Every finding on record at Richland Hills Rehabilitation and Healthcare Cente

Based on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 5 residents (Resident #22) reviewed for accidents.The facility failed to ensure Resident #22's non-slip mat was placed in his wheelchair for fall prevention. This failure could place residents at risk of falls and injury. Findings included:Record review of Resident #22's Quarterly MDS assessment, dated 04/24/26, reflected the resident was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. This MDS reflected the resident had severe cognitive impairment with a BIMS score of 0, and he was dependent upon staff for assistance with all care. The MDs reflected Resident #22 had an active diagnosis of paraplegia (inability to voluntarily move or control the lower parts of the body), and he used a wheelchair.Record review of Resident #22's Comprehensive Care Plan, dated 03/30/26, reflected the resident was a fall risk related to Paraplegia, Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Right and Left-hand contracture (shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments). Goal: Will not sustain serious injury. Interventions included needed a safe environment: floors were free from spills and or clutter, adequate, glare free light; a working reachable call light, bed in lowest position. and two of the interventions were to ensure a fall mat was placed alongside the resident's bed. Resident #22 had an actual fall 05/13/26, unwitnessed, non-injury fall with the goal will not sustain serious injury. Interventions included the use of a non-slip mat which was added to the resident's wheelchair. Resident #22's last fall was 04/30/25.During an observation and interview on 05/28/26 at 9:45 AM, Resident #22 was sitting in his wheelchair heading to smoke break. Resident #22 stated he recalled the fall incident on 05/13/26. He stated he did not get hurt and had no injuries. Resident #22 stated the reason he fell was due to him sliding off his wheelchair due to the mechanical lift sling. Resident #22 stated the facility had not added anything to his wheelchair to prevent him from falling. Resident #22 stated instead of trying to readjust himself he would notify staff and they would assist with repositioning. Observation revealed Resident #22 with his sling underneath him without the use of a non-slip mat. During an interview and observation on 05/28/26 at 12:41 PM, CNA A stated she worked closely with Resident #22 but was not present during the fall. CNA A said she was notified of the fall during her next shift the day after. CNA A stated Resident #22 had the tendency to slide down while sitting in a wheelchair and staff were responsible for monitoring him for repositioning. CNA A stated there was not a non-slip mat added to his wheelchair to prevent him from sliding out of the wheelchair. Resident #22 did not have a non-slip mat on his wheelchair seat. During an interview on 05/28/26 at 1:08 PM, LVN B stated she heard about Resident #22's fall the next day at the start of her shift. LVN B stated during her assessment Resident #22 had no delayed injuries. LVN B stated she had not added any interventions to his wheelchair to keep him from sliding out the wheelchair. LVN B stated all staff were responsible for monitoring Resident #22 while he was seated in the wheelchair for repositioning. LVN B stated the monitoring was necessary to prevent him from sliding out the wheelchair and to prevent injuries. During an interview on 05/28/26 at 1:41 PM, the ADON stated Resident #22 fell while in the hallway waiting to go outside for a smoke break. The ADON stated Resident #22 utilized a mechanical lift for transfers and staff left the sling underneath him. The ADON stated Resident #22 often would try to reposition himself which created a risk for him to slide out of the wheelchair. The ADON stated it was decided to add a non-slip mat to his wheelchair to prevent him from sliding out of the wheelchair. The ADON stated she was responsible for adding the non-slip mat which she did after his fall on 05/13/26. During an observation on 05/28/26 at 2:00 PM, Resident #22 was taken to his room for incontinent care and transferred with a mechanical lift to bed. Observation of Resident #22's wheelchair did not reveal a non-slip mat. During an interview on 05/28/26 at 3:04 PM, the DON stated she had spoken with the ADON about Resident #22 having a non-slip mat added to his wheelchair. The DON stated the use of the non-slip mat was needed to prevent him from sliding out the wheelchair. The DON stated the ADON was responsible for providing the non-slip mat and responsible for educating staff to ensure it remained in his wheelchair. The DON stated the ADON would initially provide and place the non-slip mat on the wheelchair, aides were responsible to ensure the non-slip mat was in place on the wheelchair prior to transferring Resident #22 to his wheelchair daily and as needed. The DON stated when the ADON failed to place the non-slip mat on Resident #22's wheelchair placed him at risk of sliding out of his wheelchair causing potential injuries. Record review of the facility's policy titled, Fall Prevention, revised 02/2026 reflected, It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and support for daily living for 6 of 11 residents (Resident #2, Resident #7, Resident #16, Resident #48, Resident #56 and Resident #60) reviewed for safe, clean and comfortable environment. 1. The facility failed to ensure Residents #16 and #7's privacy curtain was clean and free of stains on 05/05/26. 2. The facility failed to ensure Resident #48 and Resident #60 had clean, stain-free sheets and bedding on 5/6/26. 3. The facility failed to ensure Resident #56 had clean stain-free sheets on 5/5/26 and 5/6/26. 4. The facility failed to ensure Resident #48 had good draining sink in his restroom. 5. The facility failed to ensure Resident #2 had a floor base board on the wall under her bed near the window. These failures could affect the residents by a decrease in quality of life, at risk of infections, a decline in skin integrity and an increase in bugs in resident room. Findings include: 1. Record review of Resident #16's face sheet undated reflected Resident #16 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] included diagnoses of lumbar disc displacement (pathological condition of the lumbar spine in which one of the discs which forms the lumbar spine moves out of its normal alignment) and Type 2 Diabetes (metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin). Record Review of Resident #16's quarterly MDS assessment dated [DATE] reflected he was dependent with ADLs of toileting, dressing, personal hygiene and mobility. Resident #16 had a BIMS score of 15 indicating he was cognitively intact. Record Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of partial paralysis on the right side after an unspecified type of brain injury or stroke, hypertension (high blood pressure) and diabetes. The assessment reflected no BIMS was completed for Resident #7. Observation on 05/05/26 at 10:16 AM revealed Resident #7 and Resident #16's privacy curtain had multiple stains and particles covering both sides of the privacy curtain. The privacy curtain was hanging to the right of Resident #16 while he was lying in the bed and in front of Resident #16's bed. The privacy curtain was to the left of Resident #7's end of his bed. Interview with Resident #16 revealed he stayed in bed per his preference and his privacy curtain had not been changed since he was moved to this room about 3 weeks ago. He stated his roommate (Resident #7) kept his side of the room cluttered and dirty. He stated he and his roommate preferred the privacy curtain to be closed for privacy. He stated housekeeping came into his room but had not replaced the privacy curtain. Observation on 05/05/26 at 2:51 PM revealed Resident #7 and Resident #16's privacy curtain had multiple stains and particles covering both sides of the privacy curtain. The privacy curtain was hanging to the right of Resident #16 while he was lying in the bed and in front of Resident #16's bed. Interview with CNA H revealed she had not seen the privacy curtains being changed on her hall and stated housekeeping was responsible for changing them since they had access to the privacy curtains. Interview on 05/07/2026 at 10:55 AM with Housekeeper L revealed they usually change privacy curtains every week but they have been waiting for a shipment of new privacy curtains to replace the others. She stated the last time privacy curtains have been changed was at least 2 weeks ago. Interview on 05/07/2026 at 1:48 PM with ADON D revealed housekeeping had access to privacy curtains but she was not certain if there were other privacy curtains available for replacement. She stated she could not recall the last time housekeeping had changed the privacy curtains but they should be replaced when dirty, torn or if pulled down. Interview on 05/07/2026 at 2:32 PM with DON revealed housekeeping and maintenance were responsible to ensure privacy curtains were clean and free of stains. Interview on 05/07/26 at 3:25 PM with Housekeeping Supervisor/Maintenance Director revealed the facility had clean privacy curtains in the laundry room to replace any dirty, stained or torn privacy curtains. He stated he changed the privacy curtains in resident rooms when he was made aware they needed to be changed. 2. A record review of Resident #48's Face Sheet dated 5/6/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #48 had the following pertinent diagnoses: unspecified Dementia (progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), muscle weakness, and cognitive communication deficit. A record review of Resident #48's Quarterly MDS assessment dated [DATE] did not reflect his cognitive abilities with no BIMS score. Resident #48 had functional limitations to one side of upper extremities. Resident #48 required supervision for most ADLs. A record review of Resident #48's Comprehensive Care Plan revised on 2/20/26 reflected .ADL Self Care Performance Deficit related tojoint stiffness Date Initiated: 08/30/2024 Created on: 08/30/2024 Will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score through the review date. Date Initiated: 08/30/2024 Created on: 08/30/2024Revision on: 12/16/2025 Target Date: 04/23/2026 Occupational, Physical, Speech-Language Therapy evaluation and treatment to establish functional maintenance program per physician orders Date Initiated: 12/03/2024 Created on: 12/03/2024 Revision on: 12/03/2024 Explain all procedures/tasks before starting. Date Initiated: 12/03/2024 Created on: 12/03/2024 Staff will provide the appropriate level of physical assistance with ADL's as needed due to (his/her) self-ability may fluctuate throughout the day Date Initiated: 12/03/2024 Created on: 12/03/2024 TOILET USE (TOILET TRANSFER, TOILET HYGIENE): requires assistance (SPECIFY) to: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet, to use toilet Date Initiated: 08/30/2024 Created on: 08/30/2024 Revision on: 12/03/2024 Encourage to discuss feelings about self-care deficit. Date Initiated: 12/03/2024 Created on: 12/03/2024 Encourage to participate to the fullest extent possible with each interaction.Date Initiated: 12/03/2024 Created on: 12/03/2024. Observation and interview of Resident #48 on 05/06/2026 at 11:50 a.m. reflected resident was in the restroom shaving and showed surveyor his sink was full to the top with dirty water. Resident #48 revealed the sink water did not go down by itself most days. Observation of Resident #48's bed revealed bed sheets with a large circular yellow ring and a smaller yellow ring inside of the large ring. The sheets also had other faint brownish small circles. Resident #48 stated his sheets had not been changed for 1.5 to 2 weeks. Resident # 48 stated staff did not change his sheets regularly. Observation and interview of Resident #48 on 05/06/2026 at 12:35pm revealed the sink in his restroom was half full of dirty water. Resident #48 stated he had reported the issue with the sink since he arrived at the facility over a year ago. Resident #48 stated it was a daily struggle because the sink was always full of dirty water. Resident #48 stated he last reported the issue with the sink last week and stated the Maintenance Director had used a snake to try and unclog it, but it continued to be clogged. 3. A record review of Resident #60's Face Sheet dated 5/6/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #60 had the following pertinent diagnoses: muscle weakness, cognitive communication deficit, major depressive disorder (a condition characterized by persistent sadness and loss of pleasure), irritable bowel syndrome (a disorder that causes recurrent abdominal pain, and changes in bowel habits) and anxiety disorder (a condition characterized by persistent, excessive and uncontrollable fear). A record review of Resident #60's Quarterly MDS assessment dated [DATE] reflected his cognitive abilities were intact with a BIMS score of 15. Resident #60 had no functional limitations to either side of his extremities. Resident #60 required supervision or set up for most ADLs. A record review of Resident #60's Comprehensive Care Plan revised on 3/5/26 reflected .At risk for impaired cognitive function/dementia or impaired thought processes related to Disease Process Date Initiated: 03/05/2026 Created on: 03/05/2026 Will remain oriented to (person,place, situation, time) through the review date. Date Initiated: 03/05/2026 Created on: 03/05/2026 Revision on: 05/05/2026 Target Date: 06/01/2026 COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Date Initiated: 03/05/2026Created on: 03/05/2026 Engage in simple, structured activities that avoid overly demanding tasks. Date Initiated: 03/05/2026 Created on: 03/05/2026. An interview and observation of Resident #60's room on 5/6/26 at 11:47am revealed Resident #60's bed sheets had 4 small brownish, yellow stains on them. Resident #60 stated his bed sheets were only changed once per month. 4. A record review of Resident #56's Face Sheet dated 5/6/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #56 had the following pertinent diagnoses: unspecified Dementia (a decline in mental function), muscle weakness, cognitive communication deficit, and Chronic Kidney Disease (a condition in which the kidneys are damaged and gradually lose their ability to filter waste). A record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected his cognitive abilities were severely impaired with a BIMS score of 5. Resident #56 required partial/moderate assistance, supervision or set up for most ADLs. A record review of Resident #56's Comprehensive Care Plan revised on 11/16/26 reflected .At risk for impaired cognitive function/dementia or impaired thought processes related to disease process Date Initiated: 11/17/2025 Created on: 11/17/2025 Will maintain current level of cognitive function through the review date. Date Initiated: 11/17/2025 Created on: 11/17/2025 Revision on: 02/06/2026 Target Date: 04/11/2026 COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Date Initiated: 11/17/2025Created on: 11/17/2025 Engage in simple, structured activities that avoid overly demanding tasks. Prefers: (SPECIFY ACTIVITY) Date Initiated: 11/17/2025 Created on: 11/17/2025 Revision on: 01/28/2026 Social Services to provide psychosocial support as neededDate Initiated: 11/17/2025 Created on: 11/17/2025. Observation of Resident #56's bed sheets on 05/05/2026 at 9:49 revealed resident was not in his room, however his sheets were observed to be stained with brown spots, and his pillowcase was observed with brown and red spots. Observation and interview of Resident #56 on 05/06/2026 at 9:57 AM revealed resident was lying in bed and the parts of the sheets that were visible had several tan marks on them. Resident #56 stated he did not remember the last time they changed his sheets. Observation of Resident #56's bed on 05/06/2026 at11:48am revealed his bed sheets had multiple light brown, yellowish circular stains and red small marks. An interview and observation with CNA A on 5/6/26 at 11:51am revealed he was the CNA for Resident # 48 and Resident #56. CNA A stated he changed all residents' sheets when they were visibly dirty and on shower days. CNA A observed Resident #56's sheets and stated they were dirty and needed to be changed. CNA A stated the last time he changed Resident #56's sheets was last week when he was on rotation. CNA A stated he would change Resident #56's sheets when he had his shower that day. CNA A stated Resident #56 was supposed to have a shower yesterday but he asked to have it today instead and they just showered him and were going to change his sheets. CNA A stated he was unsure if Resident #56 had his sheets changed since he changed them last week. CNA A then observed Resident #48's sheets and he stated oh there is a urine circle, I will change them right away. CNA A stated he last changed Resident #48's sheet a week ago as well. CNA A stated Resident #48 showered himself and therefore staff only saw Resident #48's sheets when he got up. CNA A stated it was the first time today Resident #48 had gotten out of the bed and therefore had not seen his sheets. CNA A stated the risk to the residents of not changing sheets regularly, particularly when they were dirty, was skin tears, infections and transmission of bacteria. An interview and observation with CNA B on 5/6/26 at 12:00 pm revealed she was the CNA for Resident #60. CNA B stated she changed all residents' sheets daily in the morning during her first round. CNA B stated at times she will change resident's sheets again throughout the day if they were visibly soiled. CNA B observed Resident #60's sheets and stated she changed his sheets this morning, but the new sheets were stained. CNA B stated she had put on clean sheets but a lot of the sheets at the facility were stained. CNA B stated she had told the Housekeeping Supervisor about the stained sheets and the need for new ones. CNA B stated putting stained sheets on residents' beds could have affected their dignity and could have made them sad or depressed. An interview and observation with the Laundry Staff on 5/6/26 at 12:12 p.m. revealed some bed sheets, placed in linen closets for resident use, were stained but clean. The Laundry Staff stated the facility was low on bed sheets and the directive was for them to discard bedsheets only when they were torn. The Laundry Staff stated some soiled bed sheets were washed over and over with extra bleach, but stains had not come off. She was unable to state how many sheets were ordered monthly but stated sheets were ordered once per month. An interview with the Housekeeping Supervisor/Maintenance Director on 5/6/26 at 12:35pm revealed he had tried to fix Resident #48's sink several times by plunging and snaking it but it continued to get clogged. The Housekeeping Supervisor/Maintenance Director stated he has been dealing with the sink issue for over 2 weeks. Housekeeping Supervisor/Maintenance Director stated Resident #48 would come to him almost daily about the issue with his sink. The Housekeeping Supervisor/Maintenance Director stated he believed he would just have to replace the plumbing to get the issue resolved. Housekeeping Supervisor/Maintenance Director stated he ordered sheets and bedding once per month. The Housekeeping Supervisor/Maintenance Director stated the Laundry Staff would let him know how many sheets to order based on how many sheets she discarded due to them being stained or having had holes. The Housekeeping Supervisor/Maintenance Director told the Laundry Staff he wanted to see the sheets before she discarded them to ensure they needed to be discarded because he only wanted the badly stained sheets discarded. The Housekeeping Supervisor/Maintenance Director stated residents should not have to sleep on bed sheets that were stained. The Housekeeping Supervisor/Maintenance Director stated he would get with the Laundry Staff and would remove all stained linen and order new ones. The Housekeeping Supervisor/Maintenance Director stated he would also do rounds daily to make sure staff were not putting stained sheets on beds. The Housekeeping Supervisor/Maintenance Director stated stained sheets could affect the residents by making them uncomfortable in their bed and making them frustrated about the condition of their sheets. An interview with the Administrator on 05/06/2026 at 1:50 PM revealed it was the responsibility of the Laundry Staff to determine how many linens the facility needed and report it to Housekeeping Supervisor/Maintenance Director. The Administrator stated expectation for linen changes was linens for residents should have been changed daily, with the shower schedule or as needed. The Administrator stated it would depend on the type of stain whether staff used a clean linen with a stain. The Administrator stated if the stain was really bad, she would have expected the staff to discard the linen and not use it, but if the stain was light and barely noticeable, she believed it was okay. The Administrator stated it would have been best practice for staff to ask residents if they felt their linens were okay when they put on sheets that were clean with stains. She stated the staff could ask the residents daily if they felt the linens were okay. The Administrator stated having dirty or stained linens could have affected the residents by making them feel uncomfortable. The Administrator stated the expectation for an issue with a resident's sink or toilet not being fixed despite repeated attempts would have been for the Housekeeping Supervisor/Maintenance Director to notify her to ensure she got it resolved. The Administrator stated the effect on the residents of having stained or dirty sheets would have been frustration or an unwillingness to sleep in their bed. 5. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of heart failure and hypertension (high blood pressure). Resident #2 had a BIMS score of 1 indicating she was severely cognitively impaired. Resident #2 was dependent with ADLs. Observation on 05/06/26 at 1:30 PM revealed there was no baseboard on the wall under Resident #2's bed which was next to the window leaving multiple cracks and white particles. Observation and interview on 05/07/26 at 3:20 PM with Housekeeping Supervisor/Maintenance Director revealed there was no base board on the wall under Resident #2's bed which was next to the window leaving multiple cracks and white particles. He stated about a month ago water had flooded from the bathroom which damaged the base board. He stated he had not gotten around to replacing the base board yet. He stated the floor base board kept the bugs from coming in from the outside. Review of facility's policy Safe/Comfortable/Homelike Environment revised 1/2022 reflected .The facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a. Cleanliness and order.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety for the facility's only kitchen. 1. The facility failed to ensure the oven and stove top were free of blackened sticky residue and stove top had working burners on 05/05/26. 2. The facility failed to ensure Dietary Manager and Dietary Aide J used proper hand hygiene during lunch meal preparation on 05/06/26. 3. The facility failed to ensure Dietary Aide J wore effective hair restraints to cover about a foot of her hair in the back during lunch meal preparation on 05/06/26. 4. The facility failed to ensure Dietary Aides K wore effective facial hair restraint to cover his mustache during lunch meal preparation on 05/06/26. 5. The facility failed to ensure Dietary Aide M wore effective facial hair restraint to cover his upper part of his beard and his mustache during lunch meal preparation on 05/06/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination.Findings included: 1. Observation on 05/05/26 at 9:34 AM revealed oven stove top had about 1 to 1.5 inch sticky black substance on the right side of the stove top. Observation of inside of the first oven revealed blackened substances and food particles covering the bottom of the stove all the way lengthwise near the oven door about 5 inches wide with about an inch thickness. There was a blackened substance in the back corners of the oven with right corner about 5 inches x 5 inches along with both sides of the bottom of the oven having a blackened substance of about 2 inches. Door of the oven had brownish, blackish substance covering the bottom covering about 2 inches to 6 inches inches. Observation of 2nd oven revealed blackish substance covering the bottom of the oven covering 3 inches on right side bottom of the oven. The inside door of 2nd oven had blackish substances and particles about 1/2 wide covering the bottom of the oven door. Both ovens had brownish, blackish substance covering the sides of the inner sides of the ovens. Interview on 05/05/26 at 9:41 AM with Dietary Manager revealed the oven and stove top were cleaned weekly. She stated the corrosion on the top of the stove and in the ovens had blackened. She stated two of the six stove burners did not work on the stove. 2. Observation on 05/06/26 at 11:08 AM revealed Dietary Manger temped the stuffed bell peppers. At 11:10 AM, Dietary Manager took gloves off and put new gloves on. She did not wash hands between glove changes. Dietary Manager was putting her gloved hands around the bell pepper with spatula to put in pan and placed the pan on the steam table. Observation on 05/06/26 at 11:16 AM revealed Dietary Aide K was wearing his facial hair restraint below his mouth not covering his mustache. He was separating out packets and pouring drink into cups. Observation on 05/06/26 at 11:18 AM revealed Dietary Aide M was wearing his facial hair restraint below his mouth not covering his mustache and about 2 inch on upper part of beard on both sides of face. Dietary Aide M took gloves off, put on new gloves and did not wash his hands. Dietary Aide M was pouring iced tea into cups. Observation on 05/06/26 at 11:20 AM revealed Dietary Aide J did not have a hair restraint covering about 1 foot of her hair in the back while in the kitchen for lunch meal preparation. Observation on 05/06/26 at 11:22 AM revealed Dietary Manager took gloves off, did not wash hands, put new gloves on and then stirred marinara sauce on stove top. She then put a tortilla in pan, opened the cheese and put cheese on the tortilla with gloved hands. Observation on 05/06/26 at 11:26 AM revealed Dietary Manager took gloves off, did not wash hands and put new gloves on. She grabbed clean bowls. Observation on 05/06/26 at 11:33 AM revealed Dietary Manager took gloves off, did not wash hands and put new gloves on. Dietary Manager was pouring marinara sauce on stuffed bell peppers. Observation on 05/06/26 at 11:36 AM revealed Dietary Manager took gloves off and put new gloves on without washing hands between glove changes. She went back to plating food touching bread and stuffed bell pepper with her gloved hands. At 11:40 AM, Dietary Manager took gloves off, put new gloves on, and did not wash hands. She plated food. Observation on 05/06/26 at 11:44 AM and 11:54 AM revealed Dietary Aide J did not wash her hands when she re-entered the Kitchen after taking a hall meal tray cart out of the kitchen. She touched the door when she re-entered the kitchen both times. Observation on 05/06/26 at 11:55 AM revealed Dietary Aide K was pouring cranberry juice into cups with his facial hair restraint below his mouth not covering his mustache. Interview on 05/06/26 at 11:59 AM with Dietary Aide K stated his facial hair restraint had fallen down. He stated he was aware it should have been covering his mustache. Interview on 05/06/26 at 12:01 PM with Dietary Aide M stated he should have washed his hands when he changed gloves before putting on the new gloves. He stated he was aware his facial restraint was not covering the upper part of his beard. Interview on 05/06/2026 at 12:05 PM with Dietary Aide J she stated she should have washed hands when she reentered the kitchen since she touched the door. Follow-up interview at 12:18 PM revealed she was not aware the back of her hair needed to be covered and thought as long as she had the front of her hair covered. Interview on 05/06/2026 at 3:12 PM with Dietary Manager she stated if she continued with same task and changed her gloves, she did not need to wash her hands between glove changes. She stated Dietary Aide J should have washed her hands when she returned back into the kitchen. She stated the importance of hand washing was not to cross contaminate and place residents at risk of bacteria. She stated hair restraints and facial hair restraints should be worn to cover loose hair only. She stated Dietary Aide J did not need to cover her hair in the back since it was not loose. She stated the importance of hair and facial hair restraints was not to contaminate the food and get loose hair in the food. She stated the facility did not have facial hair restraints to cover Dietary Aide M's full beard. She stated Dietary Aides M and K's facial hair restraints were on their faces. She stated the facility cleaned the stove and ovens weekly. The facility did not provide a policy on oven cleaning, hair restraints and hand hygiene and provided the US Food Code as their policies on 05/07/26 at 3:25 PM. Review of the Food and Drug Administration US Food Code, dated 2022, reflected 228.113. Cleaning of Equipment and Utensils.(1)Equipment food-contact surfaces.shall be clean to sight and touch. (2) The food-contact surfaces of cooking equipment.shall be kept free of encrusted grease deposits and other soil accumulations.228.114 Frequency of Cleaning. (a) Equipment food-contact surfaces and utensils. (1) Equipment food-contact surfaces and utensils shall be cleaned. Review of the Food and Drug Administration US Food Code 2022 reflected the following:-under section 2-3 Personal Cleanliness 2-301.11 Clean Condition Food Employees shall keep their hands and exposed portions of their arms clean.-under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident #2 and Resident #28) of 5 residents reviewed for ADLs. The facility failed to ensure:Resident #2 had her fingernails trimmed and cleaned on both hands on 05/06/2026.Resident #28 had his fingernails trimmed and cleaned on both hands on 05/06/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.1-Resident #2Record Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female with initial admission date of 07/22/2019. Her pertinent diagnoses included: hemiplegia (paralysis that affects one side of the body, causing severe or total loss of motor function in the arm, leg, and sometimes face) affecting right dominant side, dementia (a decline in cognitive abilities, severe enough to interfere with daily life), cerebral infarction (is a condition caused by a blockage in blood vessels supplying the brain, resulting in tissue death), and cognitive communication deficit. Her BIMS score was 01, which indicated Resident #2's cognition was severely impaired. Resident #2 was dependent on staff for her personal hygiene. Review of Resident #2 's Comprehensive Care Plan, revised 12/17/2025 reflected, Focus: [Resident #2] has ADL self-care performance deficit related to hemiplegia.Interventions: . staff will provide the level of physical assistance as needed with ADLs. An observation on 05/06/2026 at 1:57 PM revealed Resident #2 was lying in her bed. The nails on both hands were approximately 0.3cm in length extending from the tip of her fingers. The nails were discolored, tan and had yellow greenish colored residue underside. Resident #2 was confused and her answers were not pertinent to the subject. In an interview on 05/06/2026 at 2:05 PM with CNA E she stated that Nurses and CNAs were responsible for cleaning and clipping residents' fingernails as needed. CNA E stated the risks of long, dirty fingernails included skin tears and increased risk of infection. 2-Resident #28 Record review of Resident #28's face sheet, dated 05/06/26, revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Paraplegia (impairment of motor or sensory function in the lower extremities), Dysphagia (difficulty swallowing), Cognitive Communication Deficit (deficits in communication skills), Contracture Right Hand and Left Hand (hand condition causing one or more fingers to curl toward the palm), and Muscle Weakness (reduction in physical strength). Record review of Resident #28's quarterly MDS assessment, dated 03/24/2026, reflected a BIMS score of 10, which indicated moderate cognitive impairment. Section GG0103-Functional Abilities revealed Resident #28 was dependent (helper does all of the effort) for personal hygiene. Record review of Resident #28's Comprehensive Care Plan reviewed 05/06/2026 revealed an ADL Self Care Performance Deficit. Staff will provide the appropriate level of physical assistance with ADLs as needed. Record review of Resident #28's Progress Notes, from 04/06/26 to 05/06/26, reflected no notes on nail cutting/trimming. During an observation and interview on 05/06/26 at 1:45 p.m., Resident #28 was observed with long fingernails, approximately 1/8 of an inch, on his contractured left hand. Resident #28 was unable to be interviewed due to his cognitive impairment. During an interview on 05/06/26 at 1:58 p.m. the Wound Care Nurse revealed she was responsible for trimming Resident #28's nails. She stated Resident #28's nails were cut every two weeks, but he probably refused. She stated refusals were noted in the progress notes. She stated nail care was important for infection control and hygiene. In an interview on 05/07/2026 at 1:08 PM, the DON stated her expectation was that ADL care be provided as needed. She stated that CNAs were responsible for providing nail care, including trimming fingernails, unless the resident had a diagnosis of diabetes. She stated that charge nurses were responsible for monitoring this care. The DON stated that residents having long, dirty fingernails could result in skin breakdown and potential of infections. Record review of the facility policy ADL, Services to Carry Out, revised on July 2024 reflected .If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition and personal oral hygiene will be provided by qualified staff.

Based on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Resident #58) reviewed for dental services. The facility failed to refer Resident #58 for dental services after he was admitted to the facility on [DATE] despite having visibly decayed and broken teeth. This failure could affect the residents' comfort, dignity and their nutritional statusA record review of Resident #58's Face Sheet dated 5/7/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #58 had the following pertinent diagnoses: muscle weakness, cognitive communication deficit, Hypothyroidism (under active thyroid), Type 2 Diabetes (a condition in which the body cannot use insulin properly resulting in high blood sugar), moderate protein calorie malnutrition, Major Depressive Order (a condition characterized by persistent, intense sadness or loss of interest), and altered mental status (a sudden or gradual change in a person's baseline mental function). A record review of Resident #58's Quarterly MDS assessment dated [DATE] reflected a significant cognitive impairment with a BIMS score of 4. Resident #58's oral/dental status was Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). A record review of Resident #58's Comprehensive Care Plan revised on 2/16/26 reflected .Has oral/dental health problems Date Initiated: 02/16/2026 Created on: 02/16/2026 Revision on: 02/16/2026 Will be free of infection, pain or bleeding in the oral cavity by/through review date.Date Initiated: 02/16/2026 Created on: 02/16/2026 Target Date: 05/06/2026 Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/16/2026 Created on: 02/16/2026 Provide mouth care as per ADL personal hygiene.Date Initiated: 02/16/2026 Created on: 02/16/2026. Record review of Resident #58's active orders as of 5/6/26 reflected no order for dental services. Observation and interview with Resident #58 on 05/05/2026 at 9:53 a.m. revealed numerous decayed front teeth that appeared broken. Resident #58 stated he needed to see a dentist but did not know the facility could have sent him to a dentist. An interview with LVN C on 05/06/2026 at 3:07 p.m. revealed Resident #58 had never asked to see a dentist. LVN C stated Resident #28 had not complained about his teeth. LVN C stated had Resident #58 complained about his teeth she would have asked the social worker to refer him to a dentist. LVN C stated residents were referred to dental services when the resident expressed concern. LVN C stated Resident #58 had broken or decayed teeth An interview with the Social Worker on 05/06/2026 at 3:21 p.m. revealed Resident #58 was a private pay resident and therefore had not had a dental due to not having had a payor source. The Social Worker acknowledged Resident #58 had some broken teeth but noted he had not complained of any pain or requested to see a dentist. The Social Worker stated she had registered the resident upon admission for ancillary services that included dental, however due to him not having Medicaid he had not been seen by the dentist. The Social Worker stated all residents were referred to the dentist upon admission, however if the resident did not have Medicaid the dental provider would not see them. The Social Worker stated all residents should be seen by a dentist for routine and emergency services. The Social Worker stated she had not encountered a resident who had not cooperated with obtaining Medicaid and therefore had not taken alternative steps to get his dental covered. The Social Worker stated she had community resources that she could have reached out to in order to cover dental services for Resident #58. The Social Worker was unable to provide proof that Resident #58 had been referred initially to dental services or that he had been on the dental list for the past 2 months. The Social Worker stated she would put Resident #58 on the dental list for May and should be seen on 5/13/26. The Social Worker stated the risk to the resident of not receiving routine dental care was oral infections or could even result in the resident's death. An interview with ADON D on 05/07/2026 at 1:36 p.m. revealed all residents were referred to dental services, however the long-term care residents received dental service through ancillary services (contracted providers that come to the facility) and the short-term residents receive dentals from outside dental providers. ADON D stated the Social Worker was responsible for referring residents to outside dental providers or ancillary services. ADON D stated when residents were admitted to the facility the Interdisciplinary team would meet and discuss the resident's vision, dental or podiatry needs and the Social Worker would complete the referral forms for the necessary services. ADON D stated if there was an emergency need related to dental, they would request a dental visit immediately. ADON D stated the dental provider would come to the facility monthly and saw residents on their referred list. ADON D stated the expectation was that all residents were seen for routine dentals whether they had dental issues or not. ADON D stated she had seen Resident #58's decayed teeth and believed he would benefit from seeing a dentist. ADON D stated Resident #58 had not complained about dental issues but stated he should have been seen by a dentist. ADON D stated Resident #58 was at risk of further tooth decay or gingivitis (swelling of the gums) because he had not seen a dentist. An interview with the DON on 05/07/2026 at 2:26 p.m. revealed residents were referred by the Social Worker to dental services based on their insurance. The DON stated it was the responsibility of the Social Worker to refer all residents for their routine dental and for residents who their provider did not accept their insurance the facility was responsible for locating a dental provider that would accept the resident's insurance. The DON stated they would work with outside agencies to ensure the residents who had no insurance had gotten the necessary dental services. The DON stated it was the responsibility of the Social Worker to locate outside resources to pay for the dental service for residents without insurance. The DON stated all residents should have had dental but was unfamiliar with the requirements for the frequency of dental services. The DON stated even residents who do not complain about their teeth should have routine dentals while at the facility. The DON stated if a resident did not have routine dentals, they were at risk of infection, poor dental hygiene and declined health. Review of the facility's policy Dental Services revised 1/2022 reflected It is the policy of this facility to ensure that its resident who require dental services on a routine or emergency basis have access to such services without barrier.for Medicare and private pay resident, the Facility will ensure that the needed dental services are available, but may bill an additional charge for the services.if a resident is unable to pay for dental services, the Facility will attempt to find alternative funding sources or delivery systems (include other providers of dental services, such as a dental school or the provision of dental hygiene service at the Facility) so that the resident may receive the services needed to meet his/her dental needs and maintain his/her highest practicable level of well-being.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #68 and Resident #54) of 4 reviewed for infection control. 1. The facility failed to ensure MA G changed gloves and completed hand hygiene during incontinent care for Resident #68 on 5/5/26. 2. The facility failed to ensure Resident #54's mattress was free of brownish material and stains on 05/05/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.1. Record review of Resident #68's Comprehensive MDS assessment dated [DATE] reflected Resident #68 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, dementia (a decline in cognitive abilities, severe enough to interfere with daily life), and muscle weakness. Resident #68's BIMS score was 15, which indicated Resident #68's cognition was intact. The MDS assessment indicated Resident #68 required maximal assistance with toileting hygiene. Observation on 05/05/26 at 1:39 PM revealed CNA F and MA G entered Resident #68's room to provide incontinence care. Both staff washed their hands and donned gloves, MA G doubled gloves. CNA F unfastened Resident #68's brief; MA G provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. Both rolled resident on her side, CNA F supported resident when she was on her side. Resident had a large bowel movement. MA G wiped the resident's buttocks area with peri-wipes, front to back, she then removed one pair of gloves and continued to clean the resident buttocks with wipes. MA G then removed and discarded the soiled brief and soiled gloves. MA G sanitized her hands and she donned clean gloves. She continued to clean the resident's buttocks. She changed gloves without any type of hand hygiene. She put a clean brief under the resident buttocks; she applied skin barrier cream to the resident peri-area. She changed gloves without any type of hand hygiene. She rolled the resident on her back onto the clean brief. Once finished, both staff fastened the resident's brief. They covered resident and they removed and discarded gloves and washed their hands. In an interview on 05/05/26 at 1:52 PM, MA G stated she should change her gloves and perform hand hygiene when she went from dirty to clean. MA G stated failing to provide proper care would expose the residents to infections. In an interview on 05/07/26 at 1:08 PM, the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated nursing staff were trained to perform hand hygiene between change of gloves. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated she would educate all nursing staff, and she would do random rounds for monitoring. Record review of the facility's policy, Hand Washing, revised Jully 2024, reflected, . Hand Washing/hand Hygiene is generally considered the most important single procedure for preventing nosocomial infections . 2. Observation on 05/05/2026 at 12:16 PM revealed Resident #54's mattress had multiple tears down the middle about 3 ft long and smaller tears along with brownish stains on bottom half of mattress with 4 flies on his mattress. He stated he had asked to have his mattress replaced but they did not. He stated his mattress had gotten wet on 1 side so staff flipped it to other side. He stated he was told they could not replace the mattress. 5 flies on mattress. Observation on 05/05/2026 at 2:53 PM revealed Resident #54's mattress had multiple tears down the middle about 3 ft long and smaller tears along with brownish stains on bottom half of mattress with 5 flies landing on the resident's mattress. The bottom of the mattress had brownish stains about 1.5 feet long x 5 inches wide with 1/4 inch thickness. Interview with CNA H revealed she was not aware of the mattress being torn or having a brownish stain. CNA H stated the brownish stain could be feces and it should be cleaned. She stated the mattress should be replaced but she was not sure if they had more mattresses. Observation on 05/05/2026 at 2:58 PM with LVN I revealed Resident #54's mattress had multiple tears down the middle about 3 ft long and smaller tears along with brownish stains on bottom half of mattress with 5 flies landing on resident mattress. The bottom of the mattress had brownish stains about 1.5 feet long x 5 inches wide with 1/4 inch thickness. LVN I was not aware of mattress being flipped over and it should have been cleaned. She stated this was an infection control issue. She stated housekeeping should have cleaned the mattress and the facility would get a new mattress. Interview on 05/07/2026 at 2:32 PM with DON revealed housekeeping should have seen Resident #54's nasty, dirty and torn mattress. She stated housekeeping was responsible to clean mattresses daily. She stated the risk to the resident was infection control and a dignity issue. Review of facility's policy Infection Control Policy subject: Laundry Services reflected facility to assure a clean supply of linens. Under procedures: 1. Routine Handling of Soiled Linen.C. Soiled linen should be removed from resident-care areas at least daily and may need to be removed more frequently, depending on the amount of soiled linen that is generated.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for transfers with assistive devices. The facility failed to ensure staff followed Resident #1's care plan and safe transfer procedures. The facility failed to ensure CNA B used a mechanical lift with assistance from another staff person to transfer Resident #1 on 10/24/25. This failure placed residents at risk of falling, injuries and a decline in health. Findings included:Record review of Resident #1's admission record, dated 10/24/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included Weakness, Muscle Weakness, Difficulty in Walking, and Lack of Coordination. Record review of Resident #1's MDS assessment, dated 9/11/25, reflected the resident had a BIMS scored of 15 out of 15, which indicated cognition was intact. The MDS assessment under Section GG-Functional Abilities, revealed the resident needed assistance with ADLs. The MDS assessment also revealed Resident #1 required substantial assistance with sitting to stand, chair/bed-to-chair transfer and toilet transfer. Record review of Resident #1's care plan, dated initiated 7/25/24, reflected Focus: ADL Self Care Performance Deficit r/t general weakness, limited mobility, Morbid Obesity, Rhabdomyolysis (destruction of striated (long, thin parallel streaks) muscle cells). Goal: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with modified independence through review date. Interventions: Converse with resident while providing care. Explain all procedures/tasks before starting. Praise all efforts at self-care. Promote dignity by ensuring privacy. Staff will provide the level of physical assistance as needed with ADLs due to self-ability may fluctuate. TRANSFER: Requires extensive assist with 2 staff participation with transfers via [mechanical] lift. In an observation and interview on 10/24/25 at 10:05 AM, CNA B was observed alone in Resident #1's room assisting Resident #1 with a transfer from her bed to the wheelchair. CNA B was observed standing behind Resident #1, lifting her under her armpits then sitting her in the wheelchair. CNA B positioned Resident #1 in the wheelchair then adjusted her clothing. The observation further revealed no mechanical lift was used to transfer Resident #1. Resident #1 was successfully transferred into her wheelchair without any injuries. CNA B stated he should have used the mechanical lift with assistance from one staff-person for the transfer. He stated he was in a rush to get Resident #1 to therapy and was not thinking. He also stated staff were elsewhere helping other residents. In an interview on 10/24/25 at 3:23 PM, CNA B stated he got Resident #1 out bed without the use of a mechanical lift. CNA B revealed he did not follow the facility's policy regarding transfers. He also revealed he did not follow Resident #1's care plan regarding her transfer. CNA B stated it was the first time he had transferred Resident #1 alone without a mechanical lift. CNA B stated he mistakenly did not have another staff person to assist with the transfer. CNA B stated other staff were completing duties with other residents. He stated Resident #1 had to go therapy, so he was in a rush. He stated he usually transferred Resident #1 with another staff person assisting. CNA B stated by not using a mechanical lift, he and/or resident could have been hurt or injured. CNA B stated the policy for a resident unable to bear weight was that two staff-persons transferred the resident with a mechanical lift. In an interview on 10/27/25 at 9:23 AM, Resident #1 revealed CNA B usually used a mechanical lift to transfer her. She also revealed it was two staff people that did her transfer with the mechanical lift. Resident #1 stated she was not hurt during the transfer with CNA B. She stated she had never been hurt in the process of transfer. An observation on 10/27/25 at 11:15 AM, revealed Resident #1 was properly transferred with two staff using a mechanical lift. In an interview on 10/27/25 at 1:01 PM, the DON revealed she was not aware that CNA B did not utilize the mechanical lift during transfer with Resident #1. She also revealed she did not know CNA B had transferred the resident alone. The DON stated CNA B should have had another staff person and used the mechanical lift. The DON stated CNA B risked hurting the resident and/or himself. The DON also stated policy was two people assist and a mechanical lift when a resident cannot bear weight. She stated she would complete an in-service with staff. Record review of the facility's policy, no date, titled Policy: Mechanical Lift and Slings, revealed in part the following: Nursing Policy Manual Purpose: The facility will provide for the safety needs of a resident requiring the use of a mechanical lift for transfers. Guideline: 2. Two or more assistants must be used for all mechanical lift transfers.

Based on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were securely stored for 2 of 2 medication carts (Medication Cart A and B) reviewed for storage of drugs and biologicals. The facility failed to ensure medication carts A and B were locked and secured. On 10/24/25 MA A left medication cart A unlocked and unsecured. On 10/27/25 MA D left medication cart B unlocked and unsecured. This failure could place residents at risk of medication misuse or drug diversion. Findings included: On 10/24/25 at 10:01 AM, an observation revealed medication cart A was left unlocked by pulling the drawers. The medication cart was also unattended in the hall near the nurse's station, facing out into the main pathway where residents and staff were observed walking. Further observation revealed MA A was standing directly across the hall at the nurse's station near another medication cart. During an observation and interview on 10/24/25 at 10:02 AM, MA A revealed medication cart A belonged to her, and it was locked. MA A walked to the cart and pulled the drawer which revealed the medication cart was unlocked. MA A then locked the drawer on the medication cart and said, I thought I locked it. In a follow-up interview on 10/24/25 at 3:03 PM, MA A stated her medication cart was unlocked because she was distracted. She stated she thought she locked her medication cart before she walked off to retrieve something from another cart. MA A stated the risk of an unlocked and unattended medication cart was residents having access to the medications. She also stated another risk was a resident stealing the medication. She stated the top lock on the medication cart was unlocked which held over-the-counter medications. During an interview on 10/27/25 at 1:01 PM, the DON stated medication carts were supposed to be locked anytime left unattended. She stated the expectation was that staff double checked to ensure medication carts were locked. The DON stated the risk of an unattended and unlocked medication cart was a resident taking medications. On 10/27/25 at 7:30 AM, surveyor observed medication cart B near the nurse's station unlocked by pulling the opened drawer. There was also no nursing staff in attendance of the opened cart. MA D approached the surveyor. The surveyor addressed the medication cart B not being locked. MA D confirmed it was her cart and replied, I know it wasn't locked, and I know it should be locked. I was just getting my stuff; you can't hold that against me. Record review of the facility's policy, revised 07/2024, titled Policy/Procedure-Nursing Clinical with subject Medication Access and Storage/Drug Destruction, revealed in part the following: Policy: It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed to access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to keep and store confidential information as required, except when requested by an approved place or person for 1 of 1 resident (Resident #2) reviewed for unsecured confidential information on top of medication cart. The facility failed to ensure resident specific medication materials were secured for Resident #2 on 10/24/25. This failure had the potential to expose sensitive information to unauthorized individuals. Findings included:Record review of Resident #2's admission record, dated 10/7/2025, reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Acute (sudden) respiratory failure with hypoxia (inadequate supply of oxygen to body tissues), heart attack, pneumonia, candidiasis (yeast infection) of skin and nail, anoxic (complete or near absence of oxygen) brain damage, cognitive (mental process) communication deficit, tracheostomy (surgical procedure that creates a direct opening of the windpipe) status and gastrostomy (surgical procedure that creates a direct opening of the stomach) status and an indwelling (remains inside the body) urethral catheter for draining urine from the bladder. Record review of Resident #2's admission MDS assessment, dated 10/7/25, reflected no BIMS score. On 10/24/25 at 10:01 AM, surveyor observed an empty medication packet containing identifiable resident information left unattended on top of a medication cart on the long-term hallway. The medication cart was in the hallway outside resident rooms across from the nurse's station. Further observation revealed two empty medication packets on top of the medication cart which displayed, Resident #2's name, Baclofen 10mg, [Resident #2], delivery and pharmacy address. The medication cart was observed unattended for approximately 2 minutes, during the time other residents and staff had access to the hallway. During the observation, Investigator inquired which staff the cart belonged to. Medication Aide A stated it belonged to LVN C. Medication Aide A also stated she did not know where LVN C went. Medication Aide A removed Resident #2's empty medication packets and securely stored them in the medication cart. In an interview on 10/24/25 at 3:47 PM, LVN C stated she was a floor nurse. LVN C stated she administered Resident #2's medication for the G-tube and his breathing treatment. LVN C revealed she was aware she should not leave any resident's empty medication packets unattended. LVN C also revealed she had left Resident #2's empty medication packet unattended. She revealed she had pulled Resident #2's medication packets from the nurse's cart and sat them on top of the cart as a reminder to order more. She also revealed she had stepped away to place an order. LVN C revealed she had been gone for 5 minutes. LVN C stated it was the first time she had left a resident's medication packet unattended. LVN C stated her leaving any resident identifiable information unattended was a HIPAA violation. She stated someone could have walked past and seen the resident's information. In an interview on 10/27/25 at 1:01 PM, the DON revealed she was not aware that LVN C left Resident #2's empty medication packets unattended. She stated staff knew that was a violation. She stated the expectation was that staff ensured all resident information was secure. She stated someone could have walked past and looked at Resident #2's information. She stated she would complete an in-service with LVN C. Record review of the facility's notice of private practices policy, original effective date on 4/13/03 and revised date 3/1/16, revealed in part the following: Our Responsibilities: We are required to maintain the privacy and security of your protected health information

Based on observation, interview, and record review, the facility failed 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, for two residents (Resident #2 and Resident #3) of three residents reviewed for infection control. The facility failed to ensure Resident #2, who was on enhanced barrier precautions for Candidiasis (yeast infection), unspecified, received Tracheostomy care via sterile technique. The facility failed to ensure Resident #3, who was on enhanced barrier precautions for osteomyelitis (infection of bone caused by bacteria) and sacral (base of the spine) pressure ulcer received wound care using aseptic (free from microorganisms) technique. This failure placed all residents at risk for the spread of infections and decreased quality of life. Findings included:Record review of Resident #2's admission MDS assessment, dated 10/7/25, reflected he was readmitted from an acute care hospital. Record review of Resident #2's face sheet, dated 10/7/25, reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Acute (sudden) respiratory failure with hypoxia (inadequate supply of oxygen to body tissues), heart attack, pneumonia, candidiasis (yeast infection) of skin and nail, anoxic (complete or near absence of oxygen) brain damage, cognitive (mental process) communication deficit, tracheostomy (surgical procedure that creates a direct opening of the windpipe) status and gastrostomy (surgical procedure that creates a direct opening of the stomach) status and an indwelling (remains inside the body) urethral catheter for draining urine from the bladder. Record review of Resident #2's physician orders, dated 10/07/25, reflected need for change in all respiratory connecting tubes, humidifying water bottle, oxygen tubing, suction catheters, suction canisters, and masks weekly on Wednesday nights. Resident #2 was to receive tracheostomy care daily using sterile techniques and change inner trach cannula (a curved hollow tube inserted into the neck to maintain an open airway) daily with tracheostomy care. Record review of Resident #2's care plan, dated 10/7/25, reflected the resident had a deficit with activities of daily living related to limited mobility and contractures (permanent shortening of muscle, tendon, leading to fixed loss of joint motion) to upper arms and lower legs requiring assistance for turning and repositioning. Resident #2 had a risk of bleeding due to blood thinning medication administration, at risk for falls due to disease processes, potential for nutritional problems due to disease process and gastronomy (resident receives nourishment via feeding tube) status and had a potential for pressure ulcers development due to limited mobility. Record review of Resident #2's physician history and physical progress note, dated 10/14/25 at 2:30 PM, reflected the following:[Resident #2] is a poor historian due to cognitive/psychiatric impairment. Chief complaint/reason for this visit is to follow up on anoxic brain injury. [Resident #2] is in vegetative status (awake but not aware) and is tracheostomy dependent and continues with peg tube feeding. [Resident #2] had suspected tracheostomy site infection and was treated initially with intravenous (into the vein directly into the bloodstream via line) then oral (by mouth) antibiotics. [Resident #2] requires medications by mouth to be crushed and mixed with liquid to be administered via gastronomy tube directly into the stomach. Interview with the ADON on 10/27/2025 at 9:30 AM, revealed there were sufficient sterile supplies to provide care daily for one resident requiring tracheostomy care. The ADON stated she was the wound care nurse and the Infection Preventionist for the Infection Control and Prevention program for this nursing facility. LVN stated she provides all infection control in-services for all facility staff. The ADON stated she provided daily tracheostomy care on her work rotation for Resident #2. Observation of tracheostomy care on 10/27/2025 at 9:40 AM for Resident #2 revealed resident lying on his back with the head of the bed slightly elevated. Resident #2's oxygen was administered via tracheostomy tube. Resident #2 was unable to speak or make eye contact. A sign was on Resident #2's door indicating Enhanced Barrier Precautions were required for infection control. The ADON put on a personal protective gown and washed her hands. The ADON did not speak to Resident #2 to explain the procedure. The ADON gathered supplies and placed them on a clean bed over the table. The ADON put on clean gloves and proceeded to set up a sterile field (contamination free zone). The ADON opened the box of sterile contents with clean gloves and immediately contaminated the materials inside with her gloved hands. The ADON then took off the clean gloves and attempted to put on both sterile gloves. Both sterile gloves developed a tear and the ADON contaminated the sterile gloves by adding a clean glove over the sterile glove. Sterile field (contamination free zone) was not maintained during the entire process. The ADON changed gloves twice without benefit of hand hygiene that was required at each change of gloves. The ADON did not position the materials where she did not have to reach across the sterile field to discard items. When the care was completed, the ADON took off her personal protective gown incorrectly as evidenced by touching the front of the gown with bare hands. Record review of facility policy/procedure, revised 05/2007, titled Nursing Clinical for Tracheostomy Care and Cleaning Policy Number NCLN 103 reflected: It is the policy of this facility that tracheostomy care will be done a minimum of once a day or as ordered by the physician. This is a STERILE procedure. 1. Explain procedure to the resident2. Open plastic bag and cuff. Place within reach so you do not have to reach across the sterile field to discard items.3. Open tracheostomy tray, keeping contents sterile4. Set up sterile field5. Put on one sterile glove6. Remove soiled tracheostomy dressing and drop into the plastic discard bag along with soiled single glove7. Document procedure and record any pertinent information such as appearance of tracheostomy site, unusual color or odor of bronchial secretions and tolerance to the procedure. Record review of Resident #3's face sheet dated 10/27/25, reflected the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #3 had diagnoses which included: unspecified displaced fracture of the sixth cervical (neck) vertebra (bone of spine), surgical aftercare on the skin and subcutaneous (beneath the skin) tissue, hypertension (high blood pressure) and dysphasia (impairment of language due to brain damage). Record review of Resident #3's MDS assessment, dated 9/30/25, reflected he had a BIMS score of 09, which indicated he was moderately cognitively impaired. Further review of the MDS assessment under section GG functional abilities, reflected Resident #3 required supervision and moderate assistance with all activities of daily living. Record review of Resident #3's care plan, dated 10/8/25, reflected multiple complications including cervical fungal osteomyelitis and wound infection after spinal surgery. Resident #3 had an ADL deficit due to limited mobility, malnutrition, dysphagia that required tube feedings, and pressure ulcers. Record review of Resident #3's wound care orders, dated 8/25/25, revealed cleanse sacral wound with normal saline, pat dry, apply Santyl and calcium alginate and cover with dry dressing daily and as needed for soilage or dislodgement daily shift for unstageable pressure wound. Interview with the ADON on 10/24/25 at 2:15 PM prior to observation of wound care. The ADON stated she has worked at this facility since 2014. The ADON stated she provided all weekly skin assessments and wound care for residents requiring skin treatments. She also stated she provided all infection control in-services for facility staff and was the facility Infection Preventionist. The ADON stated the wound care physician came to the facility weekly, and she rounded with that physician to provide wound care treatments and note changes in wound care orders by the wound care physician. Observation of wound care for Resident #3 on 10/24/25 at 2:30 PM revealed an enhanced barrier precaution sign was on the door of Resident #3's room. No procedure in progress sign was placed on the resident's door prior to wound care. The ADON cleaned Resident #3's bedside table and gathered wound supplies and placed wax paper on the bedside table. The ADON put on a personal protective gown and washed her hands. ADON put on clean gloves then realized she did not have all the supplies she needed. She removed all PPE (personal protective equipment) left the room and finished gathering supplies. No procedure in progress sign was placed on the door. The ADON returned, washed hands and put on PPE again. She prepared the normal saline and gauze and measured out Santyl ointment. The calcium alginate powder was not at the bedside. Resident #3 was lying on a contaminated incontinence brief that was not removed prior to starting the wound care. The ADON placed the container holding gauze and normal saline on the resident's bed and contaminated the normal saline and gauze by touching the gauze to the incontinence brief prior to cleaning Resident #3's sacral wound. After cleaning the wound, she took off her gloves and put on clean gloves without cleaning her hands. She applied the Santyl and a new bandage to the sacrum area but not the calcium alginate powder. The ADON took off her gloves and applied clean gloves without washing hands again. The ADON then proceeded to provide perineal care (genitals and anus). Feces were noted on the hygienic wipes used to provide perineal care. However, complete perineal care was not provided when a clean incontinence brief was placed on Resident #3. The ADON touched Resident #3's bed covers with the same gloves worn to clean feces. The ADON then took off the gloves and removed the personal protective gown with bare hands. In an interview on 10/27/25, the ADON stated she the infection preventionist at the facility. The ADON was unaware where to get a copy of communicable diseases that must be reported to the state. The ADON was unfamiliar with the department of state health services and what resources they offer. The ADON was not able to recite how nursing communicated with housekeeping and laundry regarding infection control issues that included enhanced barrier precautions except a sign was placed on resident doors. She stated she was unfamiliar with the facility's QAPI (Quality Assurance Performance Improvement) meetings. She was unable to give the date of the facility's most recent QAPI meeting which was noted to be October 21, 2025. The ADON stated she did not attend the meeting. The ADON presented to surveyor a sheet of Infection Control Rates dated October 2025. The report showed no flu, pneumonia, or COVID immunizations were given in October 2025. The date of the last infection control in-service was documented to be 08/08/25. Record review of Resident Wound Care & Treatment Guidelines reflected: 1. Privacy must be provided during treatments. A procedure in progress sign is needed on the door. The door must be closed and the curtains pulled.2. Supplies are never placed on the bed3. Handwashing should be done as outlined in the procedure4. The resident must not be soiled when the dressing change is done5. Documentation of the treatment should be done immediately after the treatment Review of the Center for Disease Control and Prevention website, <https://www.cdc.gov/infection-control/about/index.html reflected: Recommendations for Core Practices in Infection Control. Recommendation: Consider the Core Practice Table under the category of Leadership support. Ensure that the governing body of the healthcare facility is accountable for the success of infection prevention activities. Assign one or more qualified individuals with training in infection prevention and control to manage the facility's infection prevention program.

Based on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 02/26/2025) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by leaving out the dinner roll with margarine for all diet types on 02/26/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings included: Observation on 02/26/25 at 11:30 AM of the kitchen's steamtable (foods are kept at a warm temperature) revealed the following items: chicken fried steak, peas with onions, mashed potatoes, and gravy. No dinner rolls were observed, and none were placed on the residents' trays to serve to the residents. Interview on 02/26/25 at 3:50 PM with the Dietary Supervisor revealed that the dinner rolls were not served because the Dietary Supervisor could not locate them. The Dietary Supervisor said she was not aware that the delivery truck did not deliver the rolls the previous day. The Dietary Supervisor stated that she forgot to do a substitution for the dinner rolls. The Dietary Supervisor also stated that she should have logged a substitution like a slice of bread onto the substitution log and serve it to the residents along with the margarine. The Dietary Supervisor stated the dinner roll, or a substitution was important because the residents needed their starches to prevent weight loss due to loss of nutrients that they required. The Dietary Supervisor revealed that she did not tell the residents about the change and did not post the information anywhere in the facility for residents to see. The Dietary Supervisor stated that she in-serviced on following menus on 12/05/24. Interview on 02/26/25 at 3:42 PM with the [NAME] revealed she forgot to serve the substitution for the dinner rolls. The [NAME] said that she knew they had not received the dinner rolls from the delivery truck the previous day. The [NAME] stated that if residents did not receive the dinner rolls on the menu, they could be affected by possible weight loss because they would not receive all the necessary starch and nutrition that was required by the dietician. The [NAME] also revealed that she should report the menu substitution to the Dietary Supervisor and record a substitution in the substitution logbook. The [NAME] stated that if the Dietary Supervisor was not available and a dietary item was needed, the Administrator would provide the funds, and the [NAME] would purchase the necessary items from a local grocery store. The [NAME] stated she was last in-serviced on following menus on 12/05/24. Record review of the facility's menu, dated 02/26/25, reflected for Wednesday (02/26/25) the following: Lunch-Country Fried Steak, Mashed Potatoes/Gravy, Peas with Onions, Roll/[NAME], Boston Cream Pie, Beverage. Record review of the facility's Food and Nutrition Service Menus policy, revised January 2022, reflected: Policy: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. .4. If any meal served varies from the planned menu, the change and the reason for the change are noted on the posted menu in the kitchen and/or in the record book used solely for recording such changes.

Based on observation, interview, and record review, the facility failed to prepare foods according to the established food preparation practices and safety techniques in 1 of 1 kitchen reviewed for appropriate sanitation, as evidenced by: The warewasher (dish machine) sanitizer was not dispensing sanitizer, leaving the dishes used for the afternoon meal, of 02/24/25 through afternoon meal of 02/26/25, unsanitized. This failure could place residents at risk of infection. Findings included: Observation on 02/24/25 at 6:14 PM revealed the Dishwasher ran the warewasher and then used a test strip to test the sanitizer strength. The test strip showed no sanitizer at all in the warewasher. The Dishwasher repeated the test three times. Each time the test strip showed no sanitizer. Further observation revealed the sanitizer did not appear to be coming through the tubing from the bucket of solution to the warewasher. Observation and interview on 02/25/25 at 9:30 AM revealed the warewasher was not repaired and the facility was waiting on the repairman. The Dietary Supervisor revealed that she had contacted the repairman, and that it usually took about 24 hours for the repairman to arrive to the facility. The Dietary Supervisor stated that she would be serving all meals on paper and/or plastic and utilizing the three compartment sink with the sanitizing solution until the repairman came and fixed the warewasher. Observation and interview on 02/26/25 at 10:09 AM revealed the Dietary Aide ran the warewasher, and then used a test strip to test the sanitizer strength. The test strip showed no sanitizer at all in the warewasher. The Dietary Aide stated the repairman had just left the facility within an hour previously, and the warewasher was functioning properly at that time. The Dietary Aide said it was producing 50 ppm of chlorine at that time. The Dietary Aide then said the policy for washing the dishes was that she should test the chlorine level before starting the warewasher before each meal's dishes and record the results in the log book. The Dietary Aide stated if the warewasher was not functioning at the correct temperature of chlorine level, she would report it to the Dietary Supervisor. The Dietary Aide revealed chlorine was used to sanitize the dishes to kill bacteria and other germs. The Dietary Aide said germs could make residents sick. The Dietary Aide stated she was last in-serviced on the warewasher about 90 days ago. Observation and interview on 02/26/25 at 10:55 AM with the Dietary Supervisor revealed the warewasher was not functioning properly. The Dietary Supervisor stated she had notified the repairman on 02/24/25. The Dietary Supervisor said the repairman arrived the morning of 02/25/25 and repaired the machine. She stated it was working when the repairman left, and it was now not working again. The Dietary Supervisor said she had just put in another call for him to come back to the facility. She stated when dietary equipment was not functioning properly, she reported it to the Administrator and Maintenance. The Dietary Supervisor also revealed the importance of chlorine was to kill bacteria because it prevented residents from getting illnesses. She stated that the dietary policy stated dishes were to be sanitized in the three compartment sink as well as serve the residents on disposables when the warewasher was not functioning properly. She revealed staff were in-serviced on 01/31/25 about kitchen equipment. Interview with Dishwasher X on 02/26/25 at 3:52 PM revealed he would call the Dietary Supervisor and Maintenance if the warewasher was not working properly. He stated the Dishwasher was to run a test of the machine and log the temperature and chlorine into the logbook kept near the warewasher before each meal's dishes were washed. Dishwasher X revealed the minimum chlorine ppm that the warewasher should utilize was 50 ppm. The Dishwasher stated the importance of chlorine was to kill germs, which would prevent residents from getting sick. The dishwasher said he was last in-serviced about a month ago on kitchen equipment. Observation on 02/27/25 at 12:01 PM revealed the warewasher was working properly. The Dietary Supervisor tested the warewasher using the test strips. The test strips revealed the warewasher was sanitizing at 50 ppm of chlorine. Record review of the water temperatures recorded for the dishwasher revealed a consistent water temperature of 120 degrees and chlorine of 50 ppm until 02/21/25. The entire days' logs for 02/22/25 and 02/23/25 were completed with out of order. All spaces on the form were completed on 02/24/25. All spaces on the form for 02/25/25 reflected out of order. The 02/26/25 breakfast dishes were recorded at 120 degrees and 50 ppm for chlorine, and the rest of the day had recorded on it out of order. Record review of the facility's Sanitation in Dietary policy, dated October 2007, reflected: Policy: It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner. Procedures: .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas

Based on observation, interview, and record review the facility failed to ensure residents with wounds receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 3 of 3 residents (Residents #25, #30 and #107) reviewed for wound care. 1. The facility failed to ensure Resident #25 and Resident #107 received wound care everyday as per physician orders on 02/25/25. 2. LVN A failed to update physician wound care orders in the MAR when Resident #30 was seen by the Wound Care Physician on 02/17/25. These failures placed residents at risk for infection and delay in healing of existing wounds. Findings included: 1. Record review of Resident #25's Admission MDS dated [DATE] reflected the resident was a [AGE] year-old female. Resident admitted to the facility on [DATE]. Her diagnoses included Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain). Resident #25 had a BIMS of 4 indicating her cognition was severely impaired. Record review of physician's orders dated 02/24/25 revealed Resident #25's had a skin tear to right lateral ankle. The order reflected: Cleanse right lateral ankle skin tear with NS or WC, pat dry, apply xeroform; cover with dry dressing daily and as needed for soilage or dislodgement. Observation on 02/26/25 at 4:20 PM with LVN A who was the wound care nurse, providing Resident #25 with wound care revealed she disinfected the table and left it to dry. She removed her gloves, washed her hands, and put the supplies together. She wheeled the table to Resident #25's bedside. She then washed her hands, put on gloves, and removed the old dressing on Resident #25's right ankle. The old dressing was observed to be dated 02/24/25 meaning she had missed her wound care on 02/25/25. LVN D removed her gloves, washed her hands, and put on new gloves. She cleansed the wound with normal saline, removed her gloves, washed hands, and put on new gloves and then applied xeroform and covered with a dry dressing dated 02/26/25. 2. Record review of Resident #30's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male. Resident admitted to the facility on [DATE]. His diagnoses included cellulitis (common bacterial infection of the skin and underlying tissues). Resident #30 had a BIMS of 15 indicating his cognition was intact. Record review of physician's orders dated 02/17/25 revealed Resident #30's had a wound on the left foot 4th digit. The order reflected: Left Fourth toe trauma 1.5 x 1.5 x undetermined 40% slough,20% granulation and 30% eschar and 10% epithelial. Cleanse left foot 4th digit with normal saline or wound cleanser, pat, apply xeroform and cover with dry dressing 3x/week (M/W/F) and as needed for soilage or dislodgement every day shift every Mon, Wed, Fri for trauma. Record review of Resident 30's February 2025 MAR and TAR revealed there were no new wound care orders for 02/17/2025. The old orders were to apply betadine solutions dated 02/10/25. Record review of Resident #30's Wound Care Physician's notes/assessment, dated 02/17/25, revealed the resident was assessed to have a 1.5 centimeters x 1.5 centimeters x undetermined (depth) wound on left fourth toe. The orders were to cleanse with normal saline, apply Xeroform on Mondays, Wednesdays, and Fridays and as needed and cover with dry dressing. Observation and interview on 02/24/25 at 8:05 PM revealed Resident #30 was in his room lying on his bed. He was observed to have open wounds on the medial foot and the left fourth toe and cellulitis on bilateral legs. No draining was observed. He stated staff in facility apply dressing when the wounds were weeping and when not they left them open. He stated he did not recall the last time the dressing was applied. He stated they applied betadine, but he did not mention how often. Observation and interview on 02/25/25 at 12:24 PM with LVN A, who was the facility's Wound Care Nurse, revealed there were no dressings on Resident #30's open wounds. LVN A stated Resident #30 was seen by the Wound Care Doctor on 02/17/24. She stated the doctor gave orders to cover Resident #30's wounds, but she got busy working on the floor, and she did not update the orders on the Treatment Administration record. She stated Resident #30 had not received the new wound care to date. She stated they had not been applying dressing since she forgot to update the orders. She stated she was aware he was supposed to be getting his wound care three times a week. She stated the doctors also saw the resident on 02/24/25 and some wounds were healed, but they were supposed to continue with the same orders for the left fourth toe, but she still had not updated the orders. She stated failure to update the orders made the resident miss treatments. She stated the risk for Resident #30 was that his wounds could get infected and there could be a delay in healing. She stated she was aware wound care needed to be updated once the doctor gave the orders. She denied notifying management of not having updated the orders. 3. Record review of Resident #107's Entry MDS dated [DATE] reflected the resident was a [AGE] year-old male. Resident admitted to the facility on [DATE]. His diagnoses included acute hematogenous osteomyelitis, left ankle and foot (an acute infection of the bone or bone marrow diagnosed within 2 weeks from the onset of signs and symptoms). Resident #107 had a BIMS of 14 indicating his cognition was intact. Record review of Resident #107's February 2025 MAR and TAR revealed there were wound care orders. The orders were to cleanse left medial foot surgical incision with normal saline and wound cleanser, pat dry, pack distal part of incision with iodoform ribbon, cover with Xeroform and 4x4 gauze, wrap with Kerlix and then with ACE wrap daily every day shift for surgical wound. Record review of physician's orders dated 02/15/25 revealed Resident #107's had a surgical wound on left ankle and foot. The order reflected: Cleanse left medial foot surgical incision with NS or WC, pat dry, pack distal part of incision with iodoform ribbon, cover with xeroform and 4x4 gauze, wrap with kerlix and then with ace wrap daily every day shift for surgical wound. Interview with Resident #107 on 02/26/25 at 10:36 AM revealed he was supposed to get wound care every day, but the last time he got his wound care was 02/24/25. He stated he feared his wound would get infected. Observation and interview with LVN A on 02/26/25 at 2:37 PM revealed she washed her hands and put on gloves. She opened the ACE wrap and the kerlix covering the Resident #107's wound, and it was revealed the wound dressing was dated 02/24/25. LVN A stated she last did the wound care on 02/24/25 after the Wound Care Doctor saw Resident #107. She stated she did not change the dressing on 02/25/25 for Resident #25 and Resident #107 because she was not able to finish rounding all the wounds. She stated she knew the wound care was supposed to be provided every day. She stated she did not notify management or the on-coming nurse of the wounds she had not completed changing the dressing. LVN A stated failure to perform wound care as per the physician orders could lead to infection. Interview on 02/26/25 at 3:26 PM with the DON revealed her expectation was physician orders were supposed to be updated the same day they were received. The DON stated she and ADON were supposed to follow-up and ensure the new orders were updated in the treatment administration record weekly. The DON stated it was all nurses' responsibility to ensure wound care was being provided to residents. She stated she was not aware the residents were not getting wound dressing changes because the ADON was responsible of following with nurses to ensure the wound care was being provided. She stated the ADON updated her weekly. The DON stated failure of the nurses to act upon physician orders could create a problem because every change made by the doctor was necessary for the resident's treatment. She stated failure to offer wound care to residents might cause the wounds not to heal properly and infection. Record review of the facility's Wound Care and Treatment Guidelines policy, revised May 2007, reflected: .It is the policy of this facility to provide excellent wound care to promote healing. .11.There must be a specific order for the treatment

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 2 of 2 residents (Residents #56 and #107) reviewed for intravenous fluids. The facility failed to ensure Resident #56 and Resident #107 Midline/PICC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing change was completed and the change date was documented on the dressing. Resident #56 and Resident #107 were observed without change dates and initials on 02/24/25. The failures could affect residents by placing them at risk for infections and cross-contamination due to not knowing when the dressing was last changed. Findings included: Record review of Resident #56's entry MDS assessment, dated 02/12/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses which included: Pneumonia, (lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe) and acute and subacute infective endocarditis (fatal inflammation of your heart valves' lining and sometimes heart chambers' lining). Resident #56 had had intravenous access. BIMS score not completed she was newly admitted . Record review of Resident #56's physician's orders dated 02/12/25 reflected: right upper arm midline care: change central line/midline dressing every 7 days if visible for assessment. Change dressing as needed if wet, soiled, saturated or loose. Record review of Resident #56's February 2025 TAR reflected there was documentation of midline/PICC line dressing changes dated 02/17/25 and 2/24/25. Record review of Resident #56's current care plan initiated 02/12/25 revealed IV medication was addressed with a goal of not having any complications. Interventions included monitoring for signs and symptoms of infection at the insertion site and Checking dressing at site daily. Observation and interview on 02/24/25 at 7:22 PM revealed Resident #56 was in her room, sitting on her bed. She was observed to have a midline line on her left arm, dressing, intact but looked dirty on the surface. Resident #56 stated the peripherally inserted central catheter dressing was put after the midline fell of and another midline was inserted, but she could not tell which day. Observation and interview on 02/24/25 at 8:41 PM with LVN G revealed Resident #56 had a mid-line on her left upper arm covered with a transparent dressing with no date. LVN G stated she worked with Resident #56 on 02/20/25 and themidline came out and was reinserted by the midline company. LVN G stated she was aware the dressing was supposed to be changed every 7 days. She stated she was aware she was supposed to check the dates on the dressing, but it was not the major thing to look for while administering medications she looked for infiltration and redness. She stated the risk of not having the dressing dated would be infection since the nurse will not know when to change the dressing. She could not recall having done in-service on PICC /midline dressing. Interview with LVN A on 02/25/25 at 3:18 PM revealed she was the nurse for Resident #56, when the midline was reinserted on 02/21/25. She stated she administered the 2:00 PM dose, and she did not notice the technician did not put the date on the dressing. She stated she was aware when they administered IV medication, they should check the date on the dressing and the site for infection, but she had not checked. She stated failure to check the date could lead to a resident missing the dressing change and causing infection to the site. 2. Record review of Resident #107's Entry MDS dated [DATE] reflected the resident was a [AGE] year-old male. Resident admitted to the facility on [DATE]. His diagnoses included acute hematogenous osteomyelitis, left ankle and foot (an acute infection of the bone or bone marrow diagnosed within 2 weeks from the onset of signs and symptoms). Resident #107 had a BIMS of 14 indicating his cognition was intact. He was on intravenous medication. Record review of Resident #107's physician's orders dated 02/17/25 reflected: right upper arm midline care: change central line/midline dressing every 7 days if visible for assessment. Change dressing as needed if wet, soiled, saturated or loose, one time a day every Sunday. Record review of Resident #107's February 2025 TARs revealed there was documentation of PICC line dressing changes dated 02/23/25. Record review of Resident #107's current care plan initiated 02/17/25 reflected the following focus area: On intravenous antibiotics medications rule out osteomyelitis (infection of the bone that causes inflammation and destruction of bone tissue). Goal: -Check dressing at site daily. Observation and interview on 02/24/25 at 8:03 PM revealed Resident #107 were in his room, lying on his bed. He was observed to have a midline line on his left arm, dressing, was peeling off and was not dated. Resident#107 stated that was the dressing that he left the hospital with more than a week and half ago. Observation and interview on 02/24/25 at 8:28 PM with LVN G revealed Resident #107 had a mid-line on his left upper arm covered with a transparent dressing with no date and she had not noticed. LVN G the dressing was peeling off. She stated the dressing was supposed to have date and initials of the person that changed it. LVN G stated she was aware the dressing was supposed to be changed every 7 days. She stated she was aware she was supposed to check the dates on the dressing. She stated the risk of not having the dressing dated would be infection since the nurse will not know when to change the dressing. She could not recall having done in-service on PICC /midline dressing. Interview with LVN A on 02/26/25 2:13 PM revealed she was the nurse that had changed the dressing on 02/23/25 for Resident #107, and she forgot to put the date and initials. She stated she was aware she was supposed date the dressing so that other staff would know when dressing change was done. She stated she had done training on dressing change. Interview on 02/26/25 at 3:37 PM with the DON revealed she expected staff to change the dressing every seven days to prevent infection. She stated nurse are supposed to follow the doctors order and they should also change the dressing if the midline is infiltrated and if dressing peeling off. She stated she was aware Resident #56 midline was reinserted, but she was not aware there was no date on the dressing. She stated she expected the nurses to be checking for dates when administering medications. She stated it was the responsibility of the DON and the ADON to check after the nurses and ensure all orders were being followed and dressing were being changed and dated weekly. She stated she remember it was reported to her Resident #56 and Resident #107 dressing change was done and it was looked at by the ADON and everything was okay. She stated the risk of not putting the date other staff will not be able to tell when dressing was changed and resident risk being infected. She stated she had done training with staff on labeling and putting initials on bags and tubing and on dressings. Interview with the ADON by phone was unsuccessful on 02/26/25. She did not respond, and there was no space for voicemail. Interview with the Wound Care Doctor was attempted on 02/27/25 via phone with no response prior to exit. Record review of the facility's training record reflected an in-service on PICC line dressings dated 01/22/25. The training reflected: all PICC line dressing should be changed on admission and every 7 days from last dressing change and LVN A and LVN G were not in attendance. Record review of the facility's current Midline/Picc line dressing change dated July 2013, reflected the following: The transparent dressing are changed every 7 days and sooner when it becomes loosened to the point of compromising sterility or presents a risk of accidental dislodgment of the catheter. An accumulation of moisture, fluid, blood, or exudate could also be criteria for a dressing change.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 2 of 2 residents (Resident #15 and Resident #40) reviewed for medication storage. 1. The facility failed to ensure Resident #40's 1 bottle of nitroglycerin 0.4 mg was stored in a secured place when they were stored in her room on her bed side table on 02/24/25. 2. The facility failed to ensure Resident #15's 1 bottle of 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, 1 bottle of Linzess prescription with the label peeled for whom it was prescribed to, and 1 bottle of acetaminophen 325 mg was not stored at the resident's bedside table. These failures placed residents at risk of receiving medications that were not prescribed by the doctor, overdose and reactions with other medications. Findings included: 1. Record review of Resident #40's quarterly MDS assessment, dated 01/18/25, revealed Resident #40 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had a diagnosis that included Atherosclerosis (the build-up of fats, cholesterol, and other substances in and on the artery walls). Her cognition was intact with a BIMS score of 15. Record review of Resident #40's February 2025 physician's order revealed Resident #40 did not have an order for nitroglycerin 0.4 mg tablets. Observation and interview on 02/24/2025 at 7:40 PM revealed Resident #40 was in her room. Observation revealed a bottle of nitroglycerin 0.4 mg tablets sitting on her bedside table beside the resident's bed. Resident #40 stated she used the nitroglycerin tablets herself when she had chest pains. She stated she used each after 5 minutes x 3 times. She stated she took one tablet last in January. She denied saying how she got the tablet. Observation and interview on 02/26/25 at 2:51 PM with LVN A revealed she was not aware the resident had nitroglycerin tablets in her room. LVN A stated she was not supposed to have medication in the room because she did not self-administer medication to self. LVN A stated all medications are supposed to be locked up. She stated she could not understand how she got the medications, and she does not have orders. LVN A said the risk of Resident #40 having medications in her room was she can overdose, and other resident could get hold of them. Interview on 02/26/25 at 3:19 PM with the DON revealed Resident #40 was not supposed to have nitroglycerin tablets on her bedside. The DON stated all medications were supposed to be locked up. She stated there was a time the resident had transferred to an assisted living, and she thought that was when she brought the medication. She stated she expected staff to be looking and if they see medication in resident rooms to collect and report to her. She stated the risk of having medication in the room is overdose. 2. Record review of Resident #15's Quarterly MDS, dated [DATE], reflected a [AGE] year-old male with an admitted [DATE] and a diagnosis of heart failure and malignant neoplasm of the lungs (tumors in the lungs that may spread to other parts of the body). Resident #15 had a BIMS score of 14, meaning the resident was cognitively intact. Record review of Resident #15's undated Care Plan reflected no Focus, Goal, or Intervention relating to Self-Administration of Medications. Record review of Resident #15's undated orders reflected no orders for Stool Softener with stimulant, Clear Eyes, heartburn relief tablets, allergy relief 25 mg, Linzess prescription, and acetaminophen 325mg. Observation on 02/24/25 at 7:41 PM in Resident #15's room revealed 1 bottle of 100 mg/ Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, and 1 bottle of Linzess prescription with the label peeled off whom it was prescribed to were bedside. Resident #15 was resting peacefully. Observation on 02/25/25 at 10:20 AM in Resident #15's room revealed 1 bottle 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, and 1 bottle of Linzess prescription with the label peeled off whom it was prescribed to were bedside. Resident #15 was speaking with a visitor. Observation on 02/26/25 at 3:41 PM in Resident #15's room revealed 1 bottle 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, and 1 bottle of Linzess prescription with the label peeled off whom it was prescribed to were bedside. Resident #15 was resting peacefully most of the time due to his diagnoses. Observation and interview on 02/26/25 at 4:00 PM with CNA D revealed 1 bottle 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, and 1 bottle of Linzess prescription with the label peeled off whom it was prescribed to were bedside. CNA D revealed that he worked 6:00 AM to 6:00 PM four days per week. CNA D stated that any medication not prescribed by a resident's primary care physician should be given directly to the resident's charge nurse. CNA D revealed that any resident in the facility was at risk for an overdose because residents would not know the proper dosage of each medication. CNA D said that the responsibility of continued observation of residents' rooms for medications was the nurse and CNA on duty of each shift. CNA D did not recall the last time in-service was completed on the topic of bedside medications. Observation and interview on 02/26/25 at 4:17 PM with LVN B revealed 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, 1 bottle of Linzess prescription with the label peeled off whom it was prescribed to were bedside. One additional bottle of acetaminophen 325 mg was in the resident's dresser drawer which was found by LVN B. LVN B revealed that she worked 6:00 AM to 6:00 PM four days per week. LVN B stated residents were not supposed to have OTC and prescription meds in their rooms. LVN B said Resident #15 was not supposed to self-administer medications. LVN B also said Resident #15 was at risk for overdose and allergies to the medications as well as other residents that took the medications without orders from their primary care physician. LVN B stated when medications were found bedside, the charge nurse was supposed to report it to the DON. LVN B also said the responsibility for checking residents' rooms for medications was all staff. LVN B did not recall the last in-service on medications at bedside. Interview on 02/26/25 at 4:40 PM at with the DON revealed residents were not supposed to keep OTC and prescriptions in their rooms or bedside if they had not been assessed and cleared for self-administration. The DON stated she expected her staff to observe for medications when they made rounds and when providing care. The DON said the primary risk for patients was overdose for all residents with access to OTC medications and prescription medications. The DON stated it was everyone's responsibility to look for medication in residents' rooms including management who conducted angel rounds. The DON also said she last in-serviced in December 2024 in the all-staff meeting on observation in resident rooms for medication. The DON concluded by stating she would report medication at bedside to the Administrator. Record review of the facility's Medication Access and Storage, dated May 2007, reflected: Policy: The policy of this facility to store all drugs and biological in locked compartments at proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Procedures: .2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access . 48236

Based on interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility for 1 of 2 residents (Resident #199) reviewed for facility-initiated discharges. The facility failed to permit Resident #199 to remain in the facility and discharged the resident from the facility. Resident #199 was not allowed to return to the facility following a neurologist's appointment on 12/18/24 due to the facility having the resident sign an AMA form before she left for the appointment. After refusing Resident #199 to enter back into the facility, the facility called EMS who took her to a hospital for an evaluation. The failure could affect residents by placing them at risk of not having access to adequate care in a nursing home facility. Findings included: Record review of Resident #199's MDS Nursing assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #199's diagnoses included diabetes mellitus (disease that results in too much sugar in the blood), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breath), and cognitive communication deficit (communication difficulty caused by a cognitive impairment). Resident #199's MDS did not reflect a BIMS score, which meant that she did not complete the interview. MDS also reflected that Resident #199 did not have impairment in her upper or lower extremities. Record review of Resident #199's undated care plan reflected Focus: Potential for a behavior problem. Resident signed AMA on 12/18/24. This was created by the DON. There were no care plan goals or interventions documented. Record review of Resident #199's Progress Notes, dated 02/27/25 at 1:06 PM by the ADON, reflected: RP called facility to update staff about her mother//Residents whereabouts, Resident was still at the Doctor's appointment status. RP states, I'm going to try and look for a homeless shelter for my mom, because she is not allowed to come back to my house due to a former APS case and False accusations of family members .AMA was signed and RP is aware, advice was given to RP that Resident could go to hospital for further evaluation and placement . Record review of Resident #199's Progress Notes, dated 02/27/25 at 12:19 PM by LVN C, reflected: Resident informed writer that she has a doctor's appt and needed to be there by 1300 [1:00 PM]. Writer contacted social services to inquire if there's any appt set and the social worker confirmed that there was no appt set for the resident. Resident was notified about the social services' lack of knowledge of the appt and was asked if she can reschedule the appt, so that proper transportation arrangements can be made. Resident refused stating, 'No one tells me what to do. If it's transportation, I can get my own ride so don't worry about that.' Resident was further educated about her safety and the need for her to have a facility recognized personnel to take her to the appt but insisted that she must go. At around 11 am, resident came to the station ready to leave, AMA form was presented and explained to her what it means by the ADON witnessed by writer. Resident signed the form and was picked up by her ride outside the facility. Record review of Resident #199's Progress notes, dated 02/27/25 at 12:17 PM by the ADON, reflected: Resident agitated about Dr appointment not being accommodated. Resident schedules her own appointment to Neurologist. Resident scheduled her own transportation and told staff that she will not be coming back and was yelling. Once asked where Resident was going to go Resident stated, 'I will find a hotel.' This Nurse explained to Resident that it is cold and not safe for her to be outside without assistance. This Nurse offered to re-schedule her appointment to have transportation, and a staff member accompany. Resident stated, 'I'm sick of being here,' This Nurse explained that AMA will have to be filled out if she has no plan on returning to the facility. Resident signed paper. This Nurse explained that AMA is leaving again Medical Advice if there's no plans on returning to the facility. Resident's daughter was called and told about Resident leaving facility with own transportation and signing AMA form. Daughter notified of Resident leaving and was asked to talk to her mom about the situation or if she can accompany her. Resident's RP stated, 'My mom doesn't listen to me, it's ok if she wants to leave.' Ombudsman was called. PCP was notified. Record review of Leaving Facility Against Medical Advice form, dated 12/18/24, reflected signatures from LVN C, the ADON, and Resident #199. The form reflected, I am leaving the facility against the advice of Dr. [ ] and a representative of the facility administration. The form was blank with the physician's name. The physician's signature was also missing from the form. Record review on 02/27/25 of Resident #199's Electronic Health Record reflected no 30-day discharge letter issued for Resident #199 since her admitted on 10/31/24 by staff member from the facility. Interview on 02/25/25 at 2:20 PM with the Ombudsman was attempted but was not successful. Interview on 02/26/25 at 11:48 AM with Resident's RP revealed Resident #199 had an appointment with the neurologist. The RP stated the facility told her they could not take her to the appointment that day and would have to reschedule it. The RP said Resident #199 had called a car service to pick her up and take her to the appointment. The RP stated the ADON shoved a piece of paper in front of her, and she did not know what she was signing. The RP called the facility to tell them Resident #199 was on her way back to the facility, and the results of the appointment. At that time, the RP said the facility told them they would have a police officer at the building waiting because she was not allowed back in the building. The RP stated they would be sending her out via EMS. The facility also did not release Resident #199's medications to the RP when she went to get the resident's belongings after she was discharged . Interview on 02/26/25 at 12:04 PM with Resident #199 revealed she had scheduled an appointment herself with a neurologist. Whe she returned to the facility from the appointment that same day, the resident stated she was met by the police. She stated she wanted to live at the facility. She also said she did not understand why she could not set up her own transportation to and from an appointment without being discharged from the place she chose to live. Resident #199 stated she did not receive her medications back from the facility after she was discharged . Interview on 02/26/25 at 12:05 PM with the ADON revealed she was speaking with Resident #199 when Resident #199 told her she had an appointment with a neurologist over two hours away. The ADON stated the facility could not accommodate the resident and would have to reschedule the appointment. She stated Resident #199 explained to her that she had arranged her own transportation and would stay at a hotel if she could not find a way home. The ADON then explained that going to the appointment by herself and getting her own hotel was considered leaving AMA. The ADON also stated the Resident's RP was notified. The ADON revealed Resident #199 was angry because she was already discharged from the computer system. The ADON also said she notified the police because the Resident #199 was angry and became physical with the staff. The ADON felt it was unsafe for the resident to be out alone in the winter with her diagnoses. The ADON also stated the DON was there and communicated with her during this event. Interview on 02/26/25 at 2:05 PM with the Social Services Staff revealed she was contacted the day before by Resident #199's RP. The Social Services Staff stated Resident #199's appointment was over two hours away, and she did not feel it was safe for the resident to go alone because the resident did not have a good memory. She stated the resident stated she would get a car service to take her there. The Social Services Staff said the resident said she would get a hotel if she could not find transportation back that night. She revealed the facility produced an AMA form and asked the resident to sign it before she left. The Social Services Staff stated Resident #199 came back to the facility after her appointment. She stated Resident #199 became angry when the staff told her she could not go to her room and was no longer a resident. The Social Services Staff stated the police were called, and Resident #199 was sent out by EMS to a hospital. Interview on 02/27/25 at 12:43 PM with the Administrator revealed she was not in the building the day of the incident. The Administrator stated the DON was the designee of the building on 12/18/24. The Administrator said she did not know the facility policy on residents scheduling their own doctor appointments. The Administrator also revealed she was not aware of the facility's policy on residents scheduling their own transportation to their doctor appointments. Interview on 02/27/25 at 1:39 PM with the DON revealed when she was called up to the front desk on 12/18/24, Resident #199 had already been asked to sign an AMA form. The DON stated the facility policy stated that residents must let the facility know ahead of time about appointments, so they could get a family member, or a staff member, to assist the resident with the appointment by going with them. The DON stated she overheard Resident #199 say she was not coming back. The DON revealed when Resident #199 returned from the appointment, the resident was very angry and aggressive when the ADON told her that she could not stay at the facility and must leave. The police and EMS were called, and the resident was transported to the hospital. Record review of the facility's Discharge or Transfer policy, dated July 2015, reflected: Policy: It is the policy of this facility to provide the Resident with a safe organized structured transfer and or discharge from the Facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical and psychosocial well-being. Expiration of Resident within facility is known as a Discharge. A transfer and or discharge shall be considered for the following reasons as regulated by Federal, State and other Regulatory Agencies. 1. Transfer/Discharge: Emergency 2. Transfer/Discharge: Other Healthcare Facility (Planned) 3. Transfer/Discharge: Home/Community (Planned) 4. Transfer/Discharge: Leaving Against Medical Advice .

Based on observation, interview, and record review, the facility failed to provide an ongoing program of in-room activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of 1 of 18 (Resident #46) residents reviewed for activities. The facility did not provide Resident #46 ongoing individualized in-room activities for a minimum of fifteen minutes three times per week for the period between 02/25/25 to 02/27/25. This failure could place residents who required in room activities at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #46's quarterly MDS, dated [DATE], reflected Resident #46 was a [AGE] year-old male with an initial admitted [DATE]. Resident #46's MDS reflected active diagnoses of anxiety disorder, depression, schizophrenia, profound intellectual disabilities, cognitive communication deficit, other disorders of psychological development, and morbid obesity. Resident #46's MDS also reflected that the resident is rarely/never understood. Therefore, no BIMS score could be recorded. The MDS quarterly assessment did not reflect activities for Resident #46. Resident #46's MDS reflected that he was substantial/maximal assistance for ADL's. Record review of Resident #46's undated care plan indicated Resident #46 was dependent on staff for activities, cognitive stimulation, and social interaction relating to cognitive deficits. The care plan reflected two goals: Will attend/participate in activities of choice by next review dated and will maintain involvement in cognitive stimulation, social activities as desire through review date. The care plan reflected the following interventions: Engage resident in simple, structured activities such as (Specify), all staff to converse with resident while providing care, assistance with ADLs as required during the activity, invite to scheduled activities, needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. Observation on 02/24/25 at 7:47 PM revealed Resident #46 was sitting in his bed yelling out loudly. Staff attempted to calm resident but was unsuccessful. Surveyor attempted interview but was unable due to resident's cognitive deficit. There was no evidence of activity sheets or any other type of activity in the resident's room. Observation on 02/25/25 at 10:37 AM revealed Resident #46 appeared to be sleeping in his bed. Resident's television was turned on. There was no evidence of activity sheets or any other type of activity in the resident's room besides the television for Resident #46. His breakfast tray was bedside and appeared to be partially eaten. Observation on 02/25/25 at 4:08 PM revealed Resident #46 appeared to be sleeping in his bed. Resident's television was turned on. There was no evidence of activity sheets or any other type of activity in the resident's room besides the television for Resident #46. His lunch tray was bedside but was not eaten. Observation on 02/26/25 at 9:47 AM revealed Resident #46 appeared to be sleeping in his bed. Resident's television was turned on. There was no evidence of activity sheets or any other type of activity in the resident's room besides the television for Resident #46. Resident's breakfast tray was bedside and appeared to activity have been eaten by the resident. Observation on 02/26/25 at 2:00 PM revealed Resident #46 appeared to be sleeping in his bed. Resident's television was turned on. There was no evidence of activity sheets or any other type of activity in the resident's room besides the television for Resident #46. Interview on 02/25/25 at 4:22 PM with Resident #46's RP revealed the resident was non-verbal. The RP stated the resident liked to watch cartoons and musicals. She stated Resident #46's mother had passed away, and she knew more about the resident because she had been his primary care giver his whole life. She confirmed the resident did not have a consistent sleep pattern and had not had a consistent sleep pattern when living at home. Interview on 02/27/25 at 12:56 PM with the Activities Director revealed she had been employed with the facility for about a month. The Activities Director stated PASRR services visited Resident #46 monthly. The Activities Director said she attempted a 1:1 activity with Resident #46 approximately twice per week for about 15 minutes. The Activities Director stated she attempted to play with a ball with the resident as well as puzzles. She said she ordered a fidget [NAME] type accessory for the resident. She stated Resident #46 did not respond to her attempts at activities with him. The Activities Director revealed the resident did not respond to her attempts with him at activities in his room. She stated she had not attempted to take Resident #46 outside or help him into a wheelchair. She stated he could walk when he chose to walk. The Activities Director said activities was important for the resident, so he could socialize with others and not isolate in his room. The Activities Director revealed she was not trained on how to manage residents who were IDD. The Activities Director stated she would report to the charge nurse, DON, and Administrator if the resident was refusing activities, so that she could get assistance. The Activities Director also stated she should be attempting activities three times per week with Resident #46 for 15 minutes each time as well as reach out to other sources for different activity ideas for PASRR positive residents. The Activity Director also revealed that she did not document on paper or in the EHR activity minutes or activity attempts with Resident #46. The Activity Director was unable to locate documentation for Resident #46's activities or time spent with the resident. Interview on 02/27/25 at 2:30 PM with Social Services Staff revealed Resident #46 was receiving PASRR services. She stated she was working with Texas Department of State Health Services, a parent organization of MHMR for Resident #46 and his placement. She stated MHMR felt that another facility may be a better fit. The Social Services Staff also said Resident #46 was recently approved for speech services, so he would be receiving services soon in hopes to decrease his yelling out. The Social Services Staff revealed she felt the resident was withdrawn and isolated because the facility was not meeting his needs. She stated she reported this to the Administrator in morning meetings as well as in Resident #46's care plan meetings. Interview on 02/27/25 at 2:13 PM with the DON revealed the Activities Director attempted to have a 1:1 activity with Resident #46, but it was difficult because the resident yelled out if he was awake. The DON stated the resident should interact with someone daily. The DON said the PASRR Coordinator came out regularly to visit Resident #46. The DON stated the resident was not getting his needs met which was why he continually yelled out when he was awake. She stated she would speak with the Social Services Staff and PASRR individual to discuss assisting the resident get to a place that could better meet his physical and social needs met. Interview on 02/27/25 at 2:45 PM with the Administrator revealed she was unaware how often Resident #46 received 1:1 activity with the Activities Director. The Administrator stated she would refer to the facility policy on activities and get back with me about how often residents should receive activities. The Administrator said Resident #46 liked cartoons, so staff kept his television on cartoons for him in his room. The Administrator also revealed the resident was non-verbal and did not follow instructions. The Administrator stated the resident slept often in the daytime. The Administrator stated was unaware of how missing socialization with activities would affect Resident #46. Record review of the facility's Activities Program policy, dated July 2017, reflected: Policy: Is the policy of the facility to ensure each resident has daily social, recreational, or rehabilitative activities provided and available to them. Procedures: 1. Activities are planned according to the residents' preferences, needs, and abilities. Every resident will be interviewed for preferences. 2. A calendar of activities is: a. Prepared at least one week in advance from the date the activity will be provided b. Conspicuously posted c. Reflects all substitutions in the activities provided d. Maintained on the premises for 12 months after the last scheduled activity 3. Equipment and supplies are available and accessible to accommodate each resident who chooses to participate in an activity. 4. Daily newspapers, current magazines, and a variety of reading materials are available and accessible to all residents in assisted living.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 5 residents (Resident #9) reviewed for restorative care. The facility failed to apply splint to Resident #9's left hand to reduce the risk of further loss of range of motion on 02/25/25 and 02/26/25. This failure placed ten residents on with devices for contractures at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #9's Admission Record dated 02/27/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #9's quarterly MDS assessment dated [DATE] reflected his diagnoses included unspecified dementia, stiffness of left shoulder, stiffness to left elbow, stiffness to left hand, muscle weakness, cognitive communication deficit, anxiety disorder. Resident #9's BIMS score was not complete. The MDS further revealed Section GG - Functional Abilities indicated the resident had upper and lower extremity impairment on both sides. Record review of Resident #9's Care Plan dated 12/03/25 reflected: Focus; Has limited physical mobility r/t Contractures. Goal: Will demonstrate the appropriate use of adaptive device(s) to increase mobility through the review date. Interventions: Hand splint to left hand for contracture management. Applied by therapy. Record review of Resident #9's physician order dated 11/01/24 revealed the following: Pt to wear L hand splint, applied by therapy, 5x/wk for up to 8 hours a day, for contracture management. Observation on 02/24/25 at 8:02 PM of Resident #9 lying in bed, resident was a Spanish speaker and would respond with to yes or no questions. Observed residents' both hands to be contracted. Resident denied any pain. The resident was not able to open his hand on command, and there was not a contracture management device in place. Observation on 02/25/25 at 12:34 PM revealed Resident #9 in bed watching television. There was not a contracture management device in place at the time of the observation. Resident #9 hand splint was observed to be on the floor. Resident unable to state when was the last time he had it on. Observation on 02/25/25 at 3:25 PM revealed Resident #9 was in bed watching television. There was not a contracture management device in place at the time of the observation. Resident #9 hand splint was observed to be on the floor. Observation on 02/26/25 at 10:26 AM revealed Resident #9 was in bed sleeping. There was not a contracture management device in place at the time of the observation. Resident #9 hand splint was observed to be on a chair next to resident's bed. Observation on 02/26/25 at 12:09 PM revealed Resident #9 was in watching television. There was not a contracture management device in place at the time of the observation. Resident #9 hand splint was observed to be on a chair next to resident's bed. Interview on 02/26/25 at 1:31 PM with CNA E revealed Resident #9 both hands were contracted. She stated she was unaware of any splint. She stated she has never put any splint device on his hands. She stated either the charge nurse or therapy put on a splint. CNA E observed Resident #9's splint and stated she had never put one on the resident. Interview on 02/26/25 at 1:45 PM with LVN B revealed she was the nurse assigned to Resident #9. LVN B stated Resident #9 hands were contracted and was receiving therapy services. She stated she was not aware Resident #9 required a splint. LVN B reviewed Resident #9's physician orders and stated resident had an order for a splint; however, the order states splint should be applied by therapy. LVN B stated therapy had not mentioned anything to them about applying a splint. Interview on 02/26/25 at 1:51 PM with the Dir . of Rehabilitation revealed Resident #9 was receiving OT and was discharged on [DATE]. She stated therapy was putting on Resident #9 left hand splint and was once he discharged the nurses were responsible to put the splint on. Dir. of Rehabilitation reviewed Resident #9's physician order and stated therapy forgot to discontinue the order. She stated Resident #9 order should had been updated with a new order. She stated it was the responsibility of the therapist and herself to review resident's orders when discharged from therapy. She stated Resident #9's order was missed. She stated the potential risk of not applying the splint could cause contracture to tighten. Interview on 02/27/25 at 2:00 PM with the DON revealed when a resident discharges from therapy, therapy staff will notify the nursing staff regarding any restorative care. The DON stated therapy would provide an order and, on the order, it would state who would be responsible for putting on a splint or any other devices. The DON stated she was not aware Resident #9 had an order for a splint. She stated during morning meeting she goes over any new physician orders. She stated the Director of Rehabilitation and herself were responsible for any new orders. She stated the risk of not putting on a splint could lead residents to be more contracted. On 02/27/25 at 3:00 PM, the Administrator was asked to provide the facility's policy regarding range of motion/contracture management devices or restorative care. At 4:20 PM, the Administrator stated they could not locate a policy regarding range of motion/contracture management devices or restorative care.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 2 residents (Residents #25 and #107) reviewed for wound care administration. 1. The facility failed to ensure staff accurately documented on Resident #25 and #107's MAR/TAR after performing wound care on 02/26/25. This failure could put residents at risk for treatment errors and errors in care. Findings included: 1. Record review of Resident #25's Admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female. Resident admitted to the facility on [DATE]. Her diagnoses included Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain). Resident #25 had a BIMS score of 4, indicating her cognition was severely impaired. Record review of physician's orders dated 02/24/25 revealed Resident #25 had a skin tear to right lateral ankle. The order reflected: Cleanse right lateral ankle skin tear with NS or WC, pat dry, apply xeroform; cover with dry dressing daily and as needed for soilage or dislodgement. Record review of Resident #25's Treatment administration record for February 2025 on 02/26/25 revealed wound care marked as provided on 02/25/25. 2. Record review of Resident #107's Entry MDS dated [DATE] reflected the resident was a [AGE] year-old male. Resident admitted to the facility on [DATE]. His diagnoses included acute hematogenous osteomyelitis, left ankle and foot (an acute infection of the bone or bone marrow diagnosed within 2 weeks from the onset of signs and symptoms). Resident #107 had a BIMS score of 14 indicating his cognition was intact. Record review of physician's orders dated 02/15/25 revealed Resident #107's had a surgical wound on left ankle and foot. The order reflected: Cleanse left medial foot surgical incision with NS or WC, pat dry, pack distal part of incision with iodoform ribbon, cover with xeroform and 4x4 gauze, wrap with kerlix and then with ace wrap daily every day shift for surgical wound. Record review of Resident #107's February 2025 TAR on 02/26/25 revealed wound care marked as provided on 02/25/25. Interview with Resident #107 on 02/26/25 at 10:36 AM revealed he was supposed to get wound care every day, but the last time he got his wound care was 02/24/25. He stated he was fearing the wound to get infected. Interview with LVN A on 02/26/25 at 2:37 PM revealed she was the wound care nurse. She stated she was aware she was supposed to document on the treatment administration record every time she performed wound care, but she had documented before providing care and did not provide care due to having a lot of work to do. LVN A stated both Residents #25 and #107 were supposed to get wound care every day. She stated she did not notify the oncoming nurse that she had not provided wound care. LVN A stated the failure to perform wound care per doctors' orders would lead to infections, and documenting care before providing could lead to the resident missing care. She stated she had done in-services on documenting treatment after administration. Interview on 02/27/25 at 2:28 PM with the DON revealed her expectations were for staff to document accurately on the resident's TAR after providing care, but not charting before they provide care. The DON stated she was responsible of auditing the MAR with her ADON weekly. The DON said the risk of staffs not documenting care accurately could lead to care not being provided and the wounds would deteriorate. The DON stated she had done in-services on documentation. Record review of the in-services on 02/27/25 revealed the facility offered in-service on 01/22/25 on MAR /TAR and orders and LVN A was in attendance. Record review of the facility's Physician Orders policy, revised July 2022, reflected: charting and documentation was not addressed.

Based on observation, interview, and record review, the facility failed 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 for 1 of 1 resident (Resident #31) reviewed for infection control. The facility failed to ensure LVN B put on a gown before providing g-tube medication to Resident #31, who was on Enhanced Barrier Precautions. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions and cross contamination, which could result in infections or illness. Findings included: Record review of Resident #31's quarterly MDS assessment, dated 12/22/25, reflected his diagnoses included cerebral palsy (a group of non-progressive neurological disorders that affect movement, posture, and balance) and dysphagia following cerebral infarction (difficulty swallowing that occurs after a stroke). Resident #31's BIMS score was not completed due to the resident being rarely/never understood. The MDS reflected the resident had a feeding tube. Record review of Resident #31's care plan, revised on 05/12/24, reflected: Focus: The resident requires tube feeding rule out Cerebral Palsy/Dysphagia. Goal: Will be free of aspiration through the review date. Interventions: Use Enhanced Barrier Precautions. Record review of Resident #31's physician order, dated 10/01/24, reflected enhanced barrier precautions: ppe required for high resident contact care activities. Indication: indwelling medical device gastronomy tube. Observation on 02/26/25 at 7:28 AM revealed LVN B preparing to provide Resident #31's medication. Resident #31 had a sign on the door which stated EBP and had a bin of PPE hanging on the door. LVN B conducted appropriate hand hygiene and then proceeded to don gloves. LVN B failed to don a gown. LVN B checked for residual and placement. She administered all the medications via gastronomy tube. Interview on 02/26/25 at 9:48 AM with LVN B revealed she was the nurse assigned to Resident #31. LVN B stated any resident who had a catheter, or wound were on Enhanced Barrier Precautions, and staff were required to put on PPE when providing care. She stated the reason why Resident #31 was on EBP was due to resident's g-tube. She stated the potential risk of not donning PPE would be contamination . She stated she had done training on enhanced barrier precautions. Interview on 02/26/25 at 3:15 PM with the DON revealed EBP applied to residents with wounds, catheter, and g-tubes. The DON stated her expectations were for staff to use PPE on resident on enhanced barrier. She stated the potential risk would be infection control. She stated she had done in-services on staffs on enhanced barrier. Record review of facility in-services revealed the facility did training on 01/22/25 on enhanced barrier precautions and LVN B was in attendance. Record review of the facility's Infection Prevention and Control Program policy, revised on March 2024, reflected: .3. Enhanced Barrier Precaution EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident to resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: o Indwelling medical devices include, but are not limited to central lines, peripherally inserted central catheter (PICC) lines, urinary catheters, feeding tubes, and tracheostomies .

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. CNA B failed to have assistance from another staff member when she transferred Resident #1, who required 2-person assist with transfers, via a mechanical lift resulting in Resident #1 sustaining a shoulder fracture. This failure placed residents at risk for accidents and injuries. Findings included: Review of Resident #1's face sheet, dated 11/21/23, revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the left dominant side, contracture (deformity and rigidity of joint), muscle wasting and atrophy, and history of stroke. Review of Resident #1's MDS assessment, dated 10/28/23, reflected the resident's severe cognitive impairment with a BIMS score of 5 and she required total assistance of two-person assistance for transfers. Review of Resident #1's care plan, dated 08/15/23, revealed: [Resident #1] has ADL Self Care Performance Deficit r/t immobility secondary to CVA, contracture, hemiplegia (paralysis). Will remain free of complications related to immobility, including contractures, thrombus formation (formation of blood clots), skin-breakdown, fall related injury through the next review date. Will be safe through the review. TRANSFER: Requires x2 staff participation with transfers. may use Hoyer lift. Interview on 11/21/23 at 9:06 AM with the Interim DON revealed when using the Hoyer lift, facility policy stated two people were to assist when completing transfers with the mechanical lift. The Interim DON stated CNA B did not wait for assistance from staff to use the Hoyer lift. Instead, CNA B used the lift incorrectly by using the Hoyer lift alone resulting in Resident #1's fall to the floor from her wheelchair. The Interim DON stated that CNA B was suspended pending investigation. However, CNA B called HR during her suspension and resigned. CNA B's training record revealed she was trained on Hoyer lifts during her orientation. Therefore, CNA B was aware of the correct Hoyer lift procedure prior to this Hoyer lift transfer. The Interim DON revealed staff failed to have another person present when completing the transfer with the mechanical lift per policy and procedure which resulted in a fracture (per stat x-rays and further confirmed via ER visit) to Resident # 1's shoulder. Interview on 11/21/23 at 9:21 AM with the ADON revealed that the Hoyer-lift policy reflected 2 people should always operate the Hoyer lift. The ADON stated that one person cannot operate the Hoyer lift. The ADON also said when new staff are oriented, they are provided training on the Hoyer lift. The facility provided a check-off list for the Hoyer lift that was to be completed by the aides that were training the new aides. The ADON also stated that if the new aides were uncomfortable with the process, they were instructed to let management know. When Resident #1 complained to LVN A that her shoulder hurt, LVN A called and received an order for an x-ray. When the x-ray confirmed her shoulder was a fracture, they sent her to the ER for further treatment. The ADON began re-education that day of ANE, falls, Hoyer lifts, and accidents. It was confirmed through record review CNA B did receive Hoyer lift training prior to starting her shifts after orientation. Interview on 11/21/23 at 10:03 AM revealed that LVN A was working at the time of Resident #1's injury. LVN A stated she was in the middle of med pass and saw two aides pass her and enter Resident #1's room. LVN A stated CNA C came and asked for assistance because Resident #1 was on the floor. LVN A revealed that she assessed the resident and provided care. She also confirmed that she was not asked for assistance by CNA B before the incident. She stated that she knew Resident #1 was a two person assist due to her diagnoses as did CNA B. Resident #1 was in pain, so LVN A received an order for the stat x-ray. Resident #1 was sent to the ER after the shoulder x-ray revealed a fracture. Record Review confirmed the fracture both from the stat x-ray and hospital records. LVN A revealed the facility policy reflected that Hoyer lifts require a two person assist to prevent injury. LVN A also confirmed that residents who are a two-person assist are at risk for injury when only one person assists the resident. Interview on 11/21/23 at 1:18 PM via cell phone revealed CNA B was hired on 10/26/23. CNA B revealed in her orientation she was trained to use the Hoyer lift with a 2-person assist. CNA B verbalized that Resident #1 needed assistance getting from her bed to the wheelchair. CNA B stated she did not ask her nurse for help. She stated that she asked one CNA for assistance. However, she did not wait for her to finish showering her resident, and she used the Hoyer lift alone instead of waiting for assistance because she wanted to complete dressing her residents for the day. CNA B placed Resident #1 in the wheelchair using the lift. Resident #1 fell to the floor from her wheelchair and CNA B went and got assistance. Resident #1 complained of shoulder pain, so an x-ray was obtained that revealed a fracture. Resident #1 was sent to the hospital where the shoulder fracture was confirmed and an ortho appointment was suggested. CNA B was aware her failure was not waiting for assistance from a second staff member to assist with the Hoyer lift resulting in injury to Resident #1. Review of the facility's current Nursing Clinical policy, Subject: Hoyer lift, revised May 2007 reflected: Policy: It is the policy of this facility that the Hoyer Lift will be utilized for resident transfers only. It will not be used to transport resident to another location. Assistance of two personnel will be used with Hoyer Lift

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 2 (Residents #1 and #2) of 13 residents reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not have cigarettes and a lighter in his possession. 2. The facility failed to supervise Resident #2 to prevent a burn to his right hand. These failures could place the residents at risk of further injury and harm. Findings included: Review of Resident #1's Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included urinary tract infection, muscle weakness, diabetes, and cognitive communication deficit (dificulty communicating). Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated he was cognitively intact. His Functional Status revealed he only required supervision of all his ADLs. Review of Resident #1's care plan, dated 08/11/23, revealed he was at risk of injury from smoking which included interventions of keeping smoking materials at the nurse's station, and observing while smoking. Review of Resident #2's Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on ,d+[DATE]//21 with diagnoses that included Parkinson's disease, emphysema, and diabetes. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 13, indicating he was cognitively intact. His Functional Status revealed he required extensive assistance with hygiene and dressing, and supervision only with walking. Review of Resident #2's care plan, dated 08/04/23, revealed he was at risk of injury related to smoking with interventions including monitoring while smoking. Observation and interview on 08/17/23 at 9:20 AM revealed Resident #2 had a wound to the top of his right hand that was round and scabbed over and measured approximately two centimeters wide. Resident #2 stated he burned himself with a cigarette about three weeks prior. The staff member monitoring them notified the nurse of his burn. Resident #2 stated the nurse, a male whose name he could not recall, put a bandage on the burn at that time. Resident #2 stated nothing else had been done to treat his burn. Review of Resident #2's EHR revealed no documentation of a wound to his right hand, no physician orders for wound treatment, and no medications for the wound. Review of the nurse 24 hour logs from 07/01/23 to 08/17/23 revealed no report of Resident #2 having a wound to his right hand. Observation and interview on 08/17/23 at 10:10 AM revealed Resident #1 in the smoking area with a pack of cigarettes and a lighter in his shirt pocket. Resident #1 stated he would come out to smoke all the time while he tended the flowers in the smoking area. Resident #1 stated it was easier to keep his cigarettes himself instead of having to wait on the staff. Resident #1 stated he was aware he was not supposed to keep his cigarettes, as staff kept confiscating them, but he would walk to the convenience store and buy more. Resident #1 was observed to be smoking prior to staff presence for monitoring. Observation on 08/17/23 at 10:30 AM revealed Resident #2 was being monitored by a staff member while smoking. Resident #2 was wearing his protective apron. Resident #2 had a noticable tremor to his hands, caused by his Parkinson's disease. Interview on 08/17/23 at 12:00 PM with the Administrator revealed he had been at the facility for three months, and the residents that smoked had always been a problem. He stated they were non-compliant with the smoking policy, he and the staff were constantly having to confiscate smoking materials from residents, and they would go out to smoke at non-scheduled times. The Administrator stated he was working with his corporate leaders to see what his options were. Interview on 08/17/23 at 3:00 PM LVN A revealed Resident #2 had never reported the wound on his hand to her. She admitted to documenting no skin issues on his skin assessment, but stated he was always hiding his hands because he usually had something he was not supposed to have. LVN A stated a head-to-toe assessment should include looking at the resident's skin from head-to-toe. LVN A stated failing to assess the residents could result in an injury or infection going unnoticed. Interview on 08/17/23 at 4:40 PM with the DON revealed skin assessments were done weekly by the nurses and any skin issue should be documented until it was resolved. She stated she had not been made aware of Resident #2's burn until around 2:00 PM. The DON stated she would make sure the physician was aware and see if any treatment was needed. Review of the facility's current, undated Smoking Policy revealed the facility had a designated smoking area, residents were not allowed to smoke outside of the designated smoking area, and residents were not allowed to retain any smoking materials. Residents would sign and date the policy when it was given to them. Review of information retrieved from https://www.healthline.com/health/burns#firstdegree-burn on 08/31/23 reflected: .First-degree burns would have dry peeling skin as burn heals. First-degree burns usually health within 7 to 10 days. Second-degree burns are more serious because the damage extends beyond the top layer of skin. This type burn causes the skin to blister and come extremely red and sore. Over time, thick, soft sab-like tissue called fibrinous exudate may develop over the wound. Due to the delicate nature of these wounds, keeping the area clean and bandaging it properly is required to prevent infection. Some second-degree burns take longer than three weeks to heal, but most heal within two to three weeks without scarring, but often with pigment changes to skin

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #3) of eight residents reviewed for pain management. Resident #3 had an order to receive [MEDICATION NAME] for his pain twice a day. Resident #3 had not received the [MEDICATION NAME] for approximately 31 hours. The resident stated his pain was a 10, with 10 being the worst pain he had ever experienced. He said the staff did not assess his pain. Resident #3 did not receive his [MEDICATION NAME], because it was not re-ordered in a timely manner by the facility. This failure caused Resident #3 to experience uncontrolled pain due to ineffective and untimely pain management, distressed behaviors, a decreased quality of life, and decreased quality of care. This failure could affect the facility's 38 residents, including Resident #3, who received pain management from the facility, by placing them at risk for receiving inadequate pain management. Findings included: A review of the Face Sheet (undated) revealed Resident #3 was admitted to the facility on [DATE] ("latest return" date of 08/02/10) with the following Diagnoses: [REDACTED]. A review of the annual MDS assessment, dated 01/07/11, revealed Resident #3 understood others, made himself understood and he was cognitively intact. He had feelings of depression and/or hopelessness. Resident #3 did not exhibit behaviors. He was totally dependent with transfers, and he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was incontinent of bowel and bladder. He frequently had moderate pain and was on a scheduled pain medication regimen. A review of the quarterly MDS assessment, dated 03/15/11, revealed Resident #3 understood others, made himself understood and he was cognitively intact. He had feelings of depression and/or hopelessness. Resident #3 did not exhibit behaviors. He was totally dependent with transfers, and he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was incontinent of bowel and bladder. He frequently had moderate pain and was on a scheduled pain medication regimen. Resident #3 was not interviewed regarding Cognition, Mood and Pain Status, according to the MDS assessment. The assessment reflected Resident #3 did not have pain observed or documented. A review of the Comprehensive Plan of Care, dated 01/12/11 and reviewed by the facility on 03/17/11, revealed the following regarding Resident #3: 1. Problem: Resident complains of increased pain/discomfort... Goal: ...pain/discomfort will be relieved within one hour after intervention... Approaches: a. Monitor for signs/symptoms of increased pain/discomfort... assess relief. b. Assess and document pain. ...d. Allow to verbalize feelings of pain and discomfort. 2. Problem: Resident has limited movement of legs, ankles and feet related to... Chronic Pain [MEDICAL CONDITION]. Approaches: a. Monitor for increase in... pain. b. Administer pain medications for signs and symptoms of pain as ordered by the MD. 3. Problem: Resident has Arthritis and is at risk for... increased joint pain. Resident currently takes [MEDICATION NAME] and [MEDICATION NAME]. Resident complain of pain to the knees. Goal: ...increased joint pain will be relieved within one hour of intervention... Approaches: a. Monitor for increased joint pain - give meds/treatment per order. Assess for signs of relief. 4. Problem: Resident has a history of [MEDICAL CONDITION] Joint Disease and is at risk for... increase joint pain... Resident takes pain medication. Goal: ...joint pain will be relieved within one hour of intervention... Approaches: a. Give meds per order. b. Monitor for s/s of increase joint pain. Provide treatments/meds per order. Monitor for relief. A review of the Physician order [REDACTED]. [MEDICATION NAME] - Schedule II, Tablet Sustained Release; 60 mg; amount: one tablet by mouth twice a day at 6:00 a.m., and 7:00 p.m. Special instructions: Do not crush, break, or chew. This Physician order [REDACTED]. A review of the Progress Note dated 05/25/11 revealed the following physician's note regarding Resident #3: "Palliative Care (Pain) Consult Pt c ~ (with) [AGE] years hx (history) of pain, - predominantly arthralgias (pain in joint) & then progressively neuropathic pain." On 05/27/11 at 9:20 a.m., an entrance tour was conducted with LVN A. When the surveyor was introduced to Resident #3 by LVN A, Resident #3 said to the surveyor that his pain issue had not been resolved. On 05/27/11 at 10:40 a.m., Resident #3 was interviewed while in bed in his room with the television on and continuous oxygen in use via mask. He stated he had missed three doses of his [MEDICATION NAME], the pain medication, due to the facility being out of his [MEDICATION NAME]. He stated his pain level was a "10" and his pain had been a "10" for the past eight hours. He stated the facility had been telling him for the past day his [MEDICATION NAME] was on order. He stated he took the [MEDICATION NAME] twice daily. Resident #3 had obvious difficulty speaking with the surveyor due to his pain. He was holding himself very stiffly, and he was pale and distressed. Although the TV was on, Resident #3 kept his eyes closed most of the time. On 05/27/11 at 10:50 a.m., LVN A and MA B were asked to reconcile Resident #3's medication to the MAR. When Resident #3's medications were checked against the MAR, it was revealed the resident had not been administered three doses of his [MEDICATION NAME] 60 mg tablet Sustained Release. At that time, LVN A and MA B were asked if the [MEDICATION NAME] was in the facility and available for the resident's use. After MA B stated the [MEDICATION NAME] was not in the facility, LVN A stated, "We don't have (it)...." MA B was then asked the reason Resident #3's [MEDICATION NAME] was not available for use. She stated, "The medicine was ordered a few days ago. When I came back on Tuesday (05/24/11), the re-order label was missing, so that meant that it ([MEDICATION NAME]) was ordered. But I don't know about the triplicate." A review of Medication Flowsheet dated 05/01/11 through 05/31/11 revealed the following regarding Resident #3: [MEDICATION NAME] - Schedule II, Tablet Sustained Release; 60 mg was ordered for Resident #3: 05/26/11 at 6:00 a.m. was initialed and circled by staff indicating the medication was not given. 05/26/11 at 7:00 p.m. was initialed as given indicating the medication was administered. (Note: Later interviews with LVN A and MA B confirmed it was an error because the medication was not available.) 05/27/11 at 6:00 a.m. was not initialed as given (left blank), indicating the medication was not given. The Medication Flowsheet Documentation Notes, dated 05/26/11 and 05/27/11 at 6:00 a.m., for Resident #3 reflected, "No [MEDICATION NAME] in house." A review of the Nurse's Note dated 05/26/11 revealed no documentation reflecting Resident #3's failure to receive [MEDICATION NAME] as ordered. A review of the facility's 24 Hour Report dated 05/27/11 revealed no documentation reflecting Resident #3's failure to receive [MEDICATION NAME] as ordered. A review of the facility's Pain Flow Sheet dated May 2011 revealed the following pain intensity scales: Scale B - Wong-Baker FACES Pain Rating Scale 0 - No Hurt 1 - Hurts little bit 2 - Hurts little more 3 - Hurts even more 4 - Hurts whole lot 5 - Hurts Worst Scale C 0 - No Pain 5 - Moderate Pain 10 Worst Possible Pain A review of the facility's Pain Flow Sheet dated May 2011 revealed the following pain assessments for Resident #3: 05/26/11 (6:00 a.m. to 2:00 p.m.) - Resident #3 had no pain. 05/26/11 (2:00 p.m. to 10:00 p.m.) - No documentation present. 05/26/11 (10:00 p.m. to 6:00 a.m.) - Resident #3 had no pain. 05/27/11 (6:00 a.m. to 2:00 p.m.) - Resident #3 had no pain. 05/27/11 (10:00 p.m. to 6:00 a.m.) - Resident #3 had no pain. On 05/27/11 at 11:10 a.m., an interview was conducted with the facility's only ADON. She was asked to review the Medication Flowsheet dated 05/01/11 through 05/31/11 for Resident #3 and explain why the [MEDICATION NAME] scheduled for 05/27/11 at 6:00 a.m. was left blank. She stated, "According to the documentation, the 6:00 a.m. medications were not given." She was asked why the above medication was not available for Resident #3 as ordered. The ADON stated, "Usually a medication is ordered way before it runs out." The ADON was asked to call the Pharmacy to find out when the [MEDICATION NAME] was ordered. After speaking with the Contracting Pharmacy the ADON stated, "It was ordered yesterday (05/26/11) at 11:00 p.m." On 05/27/11 at 11:30 a.m., an interview was conducted with the ADON. She was asked the facility's schedule for assessing and documenting resident pain. She stated, "The nurses document pain every shift and PRN." On 05/27/11 at 12:05 p.m., an interview was conducted with the Pharmacy Consultant. She was asked to explain the facility's procedure for refilling a Schedule II medication ([MEDICATION NAME]) and the timeframe used when reordering. She stated, "They (facility) have to have the triplicate script from the doctor. I would say it should be gotten about a week in advance." She was asked what the effect on Resident #3 could be for not receiving three doses of his scheduled [MEDICATION NAME]. She stated, "His pain level is probably not good. He could have some substantial pain." She added, "He probably has some residual effects from previous doses." The Pharmacy Consultant was asked if the facility staff notified her of their inability to obtain Resident #3's [MEDICATION NAME] in a timely manner at anytime. She stated she was not notified. The Pharmacy Consultant was asked if she could have provided assistance, if asked by the facility, to obtain the [MEDICATION NAME] medication for Resident #3. She stated, "I could have seen if they had the prescription and called the Pharmacy to try to get the medication." She was asked how long she had been the Pharmacy Consultant at this facility. She stated, "About a year." On 05/27/11 at 12:15 p.m., an interview was conducted with the DON. She was asked if she was aware Resident #3's pain medication was not available. She stated, "The three meds were not here when ya'll checked it, but they are here now. The [MEDICATION NAME] is here now." The DON was asked if she had prior knowledge Resident #3 was missing the [MEDICATION NAME]. She stated, "This morning is the first I heard of the [MEDICATION NAME]. The nurse did not give the med." The DON was asked to explain why staff signed on 05/26/11 the 6:00 a.m. dose of [MEDICATION NAME] was given. She stated, "It probably means the nurse who initialed just went down and initialed everything. That would be an error." The DON was asked who completed resident pain assessments for the facility. She stated the nurses completed the pain flow sheet. The DON was asked if she would expect her nurses to write their inability to obtain and administer resident medication on the 24 Hour Report Sheet. She stated, "I would have expected the nurse to write it in the 24 Hour Report and notify me of the problem." She was asked who was aware Resident #3 was missing the medication. The DON stated, "Two people would have known the meds were not here, the night nurse and the evening MA." The DON was asked if she had in-serviced her staff on pain assessments and medication administration. She stated staff was in-serviced 04/12/11 on assessing pain as the 5th vital sign. The DON added, "The doctor was here yesterday. I don't know why they did not reorder the medication timely." The DON was asked the facility's policy for reordering medication. She stated, "Peel the sticker off within 3-4 days of being empty. Fax to Pharmacy. For problems they should come to me immediately, and they frequently do." The DON was asked how long she had been employed at the facility, and she stated six weeks. On 05/27/11 at 12:55 p.m., Resident #3 was interviewed. He was asked if he had received a dose of his pain medication ([MEDICATION NAME]) yet today. He stated, "No, not yet." He was asked when the last time staff had asked him about his pain level. He stated, "A nurse asked last night about my pain. I told her it was an 8 then. I asked her for Tylenol for the Headache." Resident #3 stated the headache was relieved after taking the Tylenol. The resident stated staff working on the day and evening shifts on 05/26/11 did not question him about his pain. He added staff did not ask him about his pain on 05/27/11, only two surveyors did. He stated, "CNAs ask about my pain sometimes. Most of the time they don't usually ask about my pain. The nurses just come in and let me know that they are there, but they don't ask me about my pain. It's been a revolving door with the nurses." Resident #3 stated he was informed in the morning on 05/26/11 the facility had run out of his routine [MEDICATION NAME] medication. He stated he was told a nurse was supposed to order it. Resident #3 stated his pain was never completely relieved, but taking the [MEDICATION NAME] brought it down to a pain level of 3. At 1:05 p.m., Resident #3 reported his pain at a level of 10, (the worst possible pain). On 05/27/11 at 1:15 p.m., the DON was asked if Resident #3 had received his [MEDICATION NAME] yet. She stated, "He hasn't gotten it yet. I've asked the nurse (LVN A) to ask the patient if he wanted to reset his time." At that time, the DON also informed the surveyor she could not locate the documentation reflecting the date of the last in-service held on the topic of ordering/re-ordering medications. On 05/27/11 at 1:25 p.m., an interview was conducted with Resident #3, and he was asked if he had gotten his pain medication yet. He stated, "I just got the pill ([MEDICATION NAME]) at about 1:15 p.m." (Note: Approximately one hour after the [MEDICATION NAME] was in the building.) He was asked what the level of his pain was. He stated it was "still about a 10." On 05/27/11 at 1:30 p.m., LVN A was asked in the presence of the DON whether he assessed Resident #3's pain. He stated he had not. LVN A was asked by the surveyor to review the facility's Pain Flow Sheet, which revealed Resident #3 had no pain on 05/27/11 between 6:00 a.m. and 2:00 p.m. (during his tour of duty). LVN A stated he documented Resident #3 had no pain 05/27/11 between 6:00 a.m. and 2:00 p.m. but did not assess the resident's pain status. LVN A was asked if anyone documented Resident #3's pain /medication status on the 24 Hour Report record. He stated nothing was reported on the 24 Hour Report about Resident #3's medications/pain status. A review of the facility's Record of In-Service on Pain dated 04/12/11 revealed LVN A and MA B were not in attendance for this in-service. On 05/27/11 at 2:00 p.m., the DON was asked to review the pain in-service held on 04/12/11 for LVN A and MA B's name. She stated, "I don't see any of their names on the in-service record." On 05/27/11 at 2:50 p.m., an interview was conducted with MA B. She was asked if she administered [MEDICATION NAME] as ordered by the physician to Resident #3 on 05/26/11 (2:00 p.m. to 10:00 p.m. shift). She stated she had initialed the medication but did so in error. She stated the [MEDICATION NAME] was not available in the facility when she administered Resident #3's medications at 6:00 a.m. on 05/26/11. She stated she communicated to every nurse she worked with since last Monday (05/23/11) Resident #3 needed his [MEDICATION NAME] medication refilled. She stated the nurse she worked with last Wednesday (05/25/11) notified the physician, who was present at the facility, of the need for the [MEDICATION NAME] prescription (triplicate). MA B stated the physician requested the information be faxed to her office for attention. MA B added the nurse she worked with on Thursday (05/26/11) refaxed the request to the Medical Director's office for attention. MA B was asked if she notified the DON of the resident's medication reorder concern. She stated she had not. She was asked if she assessed Resident #3's pain as the 5th vital sign. She stated, "I don't remember documenting a pain assessment." On 05/27/11 at 3:15 p.m. and at 3:35 p.m., Resident #3 was interviewed while in bed in his room with the television on and only intermittent oxygen in use. He stated his pain level now as about a five as he received his [MEDICATION NAME] about two hours ago. He stated he felt much better and was able to rest comfortably. He stated when he was in pain earlier he did not enjoy watching his television, talking on the telephone to his family member, making plans for the up coming holiday weekend and conducting business. He said he had to rely on his oxygen more. Resident #3 looked better. He was relaxed, no longer pale and was able to speak easily with the surveyor. On 05/27/11 at 4:15 p.m., an interview was conducted with the Administrator and DON. The Administrator was asked if he had been notified by facility staff Resident #3's [MEDICATION NAME] was not available in the facility for routine use. The Administrator stated the staff had not notified him of the medication unavailability. On 05/27/11 at 4:00 p.m., an interview was conducted with the Medical Director. During this interview, the Medical Director stated the facility faxed a request to her office that did not contain the frequency of medication use. She stated she had to have them re-fax the request to include the frequency of use for the [MEDICATION NAME]. The Medical Director stated, "This is the first time this has happened. They have some new nurses." She added, "A lot of the patients are drug dependent and drug seeking." She further stated, "We are trying to get everything in place." A review of the facility's current Nursing Policies and Procedures dated July 2009 revealed the following: "SUBJECT: Pain Management POLICY: Qualified staff will implement the Facility Pain Management Program, including Evaluation/Reevaluation for patients/residents experiencing either acute or chronic pain. DEFINITION OF PAIN: 'Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,' (National Institute of Nursing Research, 1994). It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations, and emotions. 'Pain is whatever the experiencing person say it is, existing whenever the experiencing person say it does.' McCaffey& Beebe, 1989. PROCEDURE:... 2. Upon admission, re-admission complete Section E of Nursing Data Collection Tool. A. If pain is 'triggered' upon admission, initiate the Pain Evaluation. B. Upon completion of the 'Pain Evaluation', and pain is evident, C. Initiate the 'Pain Flow Sheet' for ongoing documentation. D. Document pain as the fifth vital sign, 1) Every shift x (times) one week, then 2) Daily time two (2) weeks, then 3) As needed, guided by individual patient need E. Initiate/update Plan of Care to address pharmacological interventions... 3. Quarterly, complete a new Nursing Data Collection Tool. A. If pain is 'triggered', then B. Complete a new pain evaluation, and if pain is evident C. Utilize the Pain Flow Sheet. D. If a new onset of pain, begin Pain Flow Sheet and document as above. E. If pain continues, continue Pain Flow Sheet. F. Update Plan of Care monitor the patient's/resident's pain status for improvement or ineffective pain management. 4. With new onset of pain, between admission and quarterly evaluations, utilize the Pain Evaluation Tool; Initiate the 'Pain Flowsheet' as determined by patient needs, following documentation parameters set forth above... 5. Utilize the standard A. Word Scale 1-10 or B. Wong Baker Faces Scale for those with cognitive impairment or non conversive, but still have capability to point or C. Pain Assessment is Advance Dementia (PAINAD), for those who have end stage dementia... 9. Appropriate staff to receive on-going in-service education a d competency testing in relation to Pain Management...." A review of the facility's current policy entitled New Orders for Schedule II Controlled Substance effective date 12/07/07, revision date 07/28/08 and 05/01/10, revealed the following: " ...Procedure 1. New orders for Schedule II controlled substances require a written prescription prior to dispensing, unless there is an "Emergency Situation." An "Emergency Situation" (as defined below. Where permitted under Applicable Law, Facility staff may fax Schedule II prescriptions for long term care residents, terminally ill residents, or where the medication is used for direct infusion (e.g., [MEDICATION NAME] drip)... 2. Physician/Prescriber should provide Pharmacy with verbal authorization for Schedule II controlled substances in cases of an "Emergency Situation." An "Emergency Situation" is one in which the prescribing practitioner determines that: 2.1 Immediate administration of the Schedule II controlled substance is necessary for proper treatment of [REDACTED]. 2.2 There is no appropriate alternative treatment available, including administration of a medication that is not a Schedule II controlled substance; and 2.3 It is not reasonable for Physician/Prescriber to provide a written prescription to be presented to the person dispensing the Schedule II controlled substance prior to the dispensing. 3. For an emergency Schedule II controlled substance order, the authorized Physician/Prescriber should provide the following information to a licensed pharmacist; 3.1 Controlled substance name; 3.2 Controlled substance dosage form; 3.3 Controlled substance strength or concentration per dosage unit; 3.4 Number of dosage units or volume to be dispensed; 3.5 Full name and address of the resident to whom the controlled substance is to be dispensed; 3.6 Name, address and DEA registration number of the prescribing practitioner; 3.7 Direction for use; and 3.8 Medical diagnosis, if required... 4. Within seven (7) days of requesting an emergency oral prescription, or sooner if required by Applicable Law, the authorized Physician/Prescriber should fax (where permitted under Applicable Law), mail, or hand deliver the prescription to the Pharmacy...." The facility's Form CMS-672 (Resident Census and Conditions of Residents), dated 05/27/11, reflected 38 residents were on a pain management program.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #3) of eight residents, reviewed for medications, was free of significant medication errors. Resident #3 did not receive his [MEDICATION NAME] twice a day as ordered by the physician. He had not received his [MEDICATION NAME] in approximately 31 hours and he rated his pain as a 10, with 10 being the worst pain he had ever experienced. The facility failed to reorder the [MEDICATION NAME] in a timely manner. This failure caused Resident #3 to experience uncontrolled pain. This failure could affect the facility's 38 residents, including Resident #3, who received pain management from the facility by placing them at risk of receiving inadequate pain management. Findings included: A review of the Face Sheet (undated) revealed Resident #3 was admitted to the facility on [DATE] ("latest return" date of 08/02/10) with the following Diagnoses: [REDACTED]. A review of the annual MDS assessment, dated 01/07/11, revealed Resident #3 understood others, made himself understood and he was cognitively intact. He had feelings of depression and/or hopelessness. Resident #3 did not exhibit behaviors. He was totally dependent with transfers, and he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was incontinent of bowel and bladder. He frequently had moderate pain and was on a scheduled pain medication regimen. A review of the quarterly MDS assessment, dated 03/15/11, revealed Resident #3 understood others, made himself understood and he was cognitively intact. He had feelings of depression and/or hopelessness. Resident #3 did not exhibit behaviors. He was totally dependent with transfers, and he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was incontinent of bowel and bladder. He frequently had moderate pain and was on a scheduled pain medication regimen. Resident #3 was not interviewed regarding Cognition, Mood and Pain Status, according to the MDS assessment. The assessment reflected Resident #3 did not have pain observed or documented. A review of the Comprehensive Plan of Care, dated 01/12/11 and reviewed by the facility on 03/17/11, revealed the following regarding Resident #3: 1. Problem: Resident complains of increased pain/discomfort... Goal: ...pain/discomfort will be relieved within one hour after intervention... Approaches: a. Monitor for signs/symptoms of increased pain/discomfort... assess relief. b. Assess and document pain. ...d. Allow to verbalize feelings of pain and discomfort. 2. Problem: Resident has limited movement of legs, ankles and feet related to... Chronic Pain [MEDICAL CONDITION]. Approaches: a. Monitor for increase in... pain. b. Administer pain medications for signs and symptoms of pain as ordered by the MD. 3. Problem: Resident has Arthritis and is at risk for... increased joint pain. Resident currently takes [MEDICATION NAME] and [MEDICATION NAME]. Resident complain of pain to the knees. Goal: ...increased joint pain will be relieved within one hour of intervention... Approaches: a. Monitor for increased joint pain - give meds/treatment per order. Assess for signs of relief. 4. Problem: Resident has a history of [MEDICAL CONDITION] Joint Disease and is at risk for... increase joint pain... Resident takes pain medication. Goal: ...joint pain will be relieved within one hour of intervention... Approaches: a. Give meds per order. b. Monitor for s/s of increase joint pain. Provide treatments/meds per order. Monitor for relief. A review of the Physician order [REDACTED]. [MEDICATION NAME] - Schedule II, Tablet Sustained Release; 60 mg; amount: one tablet by mouth twice a day at 6:00 a.m., and 7:00 p.m. Special instructions: Do not crush, break, or chew. This Physician order [REDACTED]. A review of the Progress Note dated 05/25/11 revealed the following physician's note regarding Resident #3: "Palliative Care (Pain) Consult Pt c ~ (with) [AGE] years hx (history) of pain, - predominantly arthralgias (pain in joint) & then progressively neuropathic pain." On 05/27/11 at 9:20 a.m., an entrance tour was conducted with LVN A. When the surveyor was introduced to Resident #3 by LVN A, Resident #3 said to the surveyor that his pain issue had not been resolved. On 05/27/11 at 10:40 a.m., Resident #3 was interviewed while in bed in his room with the television (TV) on and continuous oxygen in use via mask. He stated he had missed three doses of his [MEDICATION NAME], pain medication, due to the facility being out of his [MEDICATION NAME]. He stated his pain level was a "10" and his pain had been a "10" for the past eight hours. He stated the facility had been telling him for the past day his [MEDICATION NAME] was on order. He stated he took the [MEDICATION NAME] twice daily. Resident #3 had obvious difficulty speaking with the surveyor due to his pain. He was holding himself very stiffly, and he was pale and distressed. Although the TV was on, Resident #3 kept his eyes closed most of the time. On 05/27/11 at 10:50 a.m., LVN A and MA B were asked to reconcile Resident #3's medication to the MAR. When Resident #3's medications were checked against the MAR, it was revealed the resident had not been administered three doses of his [MEDICATION NAME] 60 mg tablet Sustained Release. At that time, LVN A and MA B were asked if the [MEDICATION NAME] was in the facility and available for the resident's use. After MA B stated the [MEDICATION NAME] was not in the facility, LVN A stated, "We don't have (it)...." MA B was then asked the reason Resident #3's [MEDICATION NAME] was not available for use. She stated, "The medicine was ordered a few days ago. When I came back on Tuesday (05/24/11), the re-order label was missing, so that meant that it ([MEDICATION NAME]) was ordered. But I don't know about the triplicate." A review of Medication Flowsheet dated 05/01/11 through 05/31/11 revealed the following regarding Resident #3: [MEDICATION NAME] - Schedule II, Tablet Sustained Release; 60 mg was ordered for Resident #3: 05/26/11 at 6:00 a.m. was initialed and circled by staff indicating the medication was not given. 05/26/11 at 7:00 p.m. was initialed as given indicating the medication was administered. (Note: Later interviews with LVN A and MA B confirmed it was an error because the medication was not available.) 05/27/11 at 6:00 a.m. was not initialed as given (left blank), indicating the medication was not given. The Medication Flowsheet Documentation Notes, dated 05/26/11 and 05/27/11 at 6:00 a.m., for Resident #3 reflected, "No [MEDICATION NAME] in house." A review of the Nurse's Note dated 05/26/11 revealed no documentation reflecting Resident #3's failure to receive [MEDICATION NAME] as ordered. A review of the facility's 24 Hour Report dated 05/27/11 revealed no documentation reflecting Resident #3's failure to receive [MEDICATION NAME] as ordered. A review of the facility's Pain Flow Sheet dated May 2011 revealed the following pain intensity scales: Scale B - Wong-Baker FACES Pain Rating Scale 0 - No Hurt 1 - Hurts little bit 2 - Hurts little more 3 - Hurts even more 4 - Hurts whole lot 5 - Hurts Worst Scale C 0 - No Pain 5 - Moderate Pain 10 Worst Possible Pain A review of the facility's Pain Flow Sheet dated May 2011 revealed the following pain assessments for Resident #3: 05/26/11 (6:00 a.m. to 2:00 p.m.) - Resident #3 had no pain. 05/26/11 (2:00 p.m. to 10:00 p.m.) - No documentation present. 05/26/11 (10:00 p.m. to 6:00 a.m.) - Resident #3 had no pain. 05/27/11 (6:00 a.m. to 2:00 p.m.) - Resident #3 had no pain. 05/27/11 (10:00 p.m. to 6:00 a.m.) - Resident #3 had no pain. On 05/27/11 at 11:10 a.m., an interview was conducted with the facility's only ADON. She was asked to review the Medication Flowsheet dated 05/01/11 through 05/31/11 for Resident #3 and explain why the [MEDICATION NAME] scheduled for 05/27/11 at 6:00 a.m. was left blank. She stated, "According to the documentation, the 6:00 a.m. medications were not given." She was asked why the above medication was not available for Resident #3 as ordered. The ADON stated, "Usually a medication is ordered way before it runs out." The ADON was asked to call the Pharmacy to find out when the [MEDICATION NAME] was ordered. After speaking with the Contracting Pharmacy the ADON stated, "It was ordered yesterday (05/26/11) at 11:00 p.m." On 05/27/11 at 11:30 a.m., an interview was conducted with the ADON. She was asked the facility's schedule for assessing and documenting resident pain. She stated, "The nurses document pain every shift and PRN." On 05/27/11 at 12:05 p.m., an interview was conducted with the Pharmacy Consultant. She was asked to explain the facility's procedure for refilling a Schedule II medication ([MEDICATION NAME]) and the timeframe used when reordering. She stated, "They (facility) have to have the triplicate script from the doctor. I would say it should be gotten about a week in advance." She was asked what the effect on Resident #3 could be for not receiving three doses of his scheduled [MEDICATION NAME]. She stated, "His pain level is probably not good. He could have some substantial pain." She added, "He probably has some residual effects from previous doses." The Pharmacy Consultant was asked if the facility staff notified her of their inability to obtain Resident #3's [MEDICATION NAME] in a timely manner at anytime. She stated she was not notified. The Pharmacy Consultant was asked if she could have provided assistance, if asked by the facility, to obtain the [MEDICATION NAME] medication for Resident #3. She stated, "I could have seen if they had the prescription and called the Pharmacy to try to get the medication." She was asked how long she had been the Pharmacy Consultant at this facility. She stated, "About a year." On 05/27/11 at 12:15 p.m., an interview was conducted with the DON. She was asked if she was aware Resident #3's pain medication was not available. She stated, "The three meds were not here when ya'll checked it, but they are here now. The [MEDICATION NAME] is here now." The DON was asked if she had prior knowledge Resident #3 was missing the [MEDICATION NAME]. She stated, "This morning is the first I heard of the [MEDICATION NAME]. The nurse did not give the med." The DON was asked to explain why staff signed on 05/26/11 the 6:00 a.m. dose of [MEDICATION NAME] was given. She stated, "It probably means the nurse who initialed just went down and initialed everything. That would be an error." The DON was asked who completed resident pain assessments for the facility. She stated the nurses completed the pain flow sheet. The DON was asked if she would expect her nurses to write their inability to obtain and administer resident medication on the 24 Hour Report Sheet. She stated, "I would have expected the nurse to write it in the 24 Hour Report and notify me of the problem." She was asked who was aware Resident #3 was missing the medication. The DON stated, "Two people would have known the meds were not here, the night nurse and the evening MA." The DON was asked if she had in-serviced her staff on pain assessments and medication administration. She stated staff was in-serviced 04/12/11 on assessing pain as the 5th vital sign. The DON added, "The doctor was here yesterday. I don't know why they did not reorder the medication timely." The DON was asked the facility's policy for reordering medication. She stated, "Peel the sticker off within 3-4 days of being empty. Fax to Pharmacy. For problems they should come to me immediately, and they frequently do." The DON was asked how long she had been employed at the facility, and she stated six weeks. On 05/27/11 at 12:55 p.m., Resident #3 was interviewed. He was asked if he had received a dose of his pain medication ([MEDICATION NAME]) yet today. He stated, "No, not yet." He was asked when the last time staff had asked him about his pain level. He stated, "A nurse asked last night about my pain. I told her it was an 8 then. I asked her for Tylenol for the Headache." Resident #3 stated the headache was relieved after taking the Tylenol. The resident stated staff working on the day and evening shifts on 05/26/11 did not question him about his pain. He added staff did not ask him about his pain on 05/27/11, only two surveyors did. He stated, "CNAs ask about my pain sometimes. Most of the time they don't usually ask about my pain. The nurses just come in and let me know that they are there, but they don't ask me about my pain. It's been a revolving door with the nurses." Resident #3 stated he was informed in the morning on 05/26/11 the facility had run out of his routine [MEDICATION NAME] medication. He stated he was told a nurse was supposed to order it. Resident #3 stated his pain was never completely relieved, but taking the [MEDICATION NAME] brought it down to a pain level of 3. At 1:05 p.m., Resident #3 reported his pain at a level of 10, (the worst possible pain). On 05/27/11 at 1:15 p.m., the DON was asked if Resident #3 had received his [MEDICATION NAME] yet. She stated, "He hasn't gotten it yet. I've asked the nurse (LVN A) to ask the patient if he wanted to reset his time." At that time, the DON also informed the surveyor she could not locate the documentation reflecting the date of the last in-service held on the topic of ordering/re-ordering medications. On 05/27/11 at 1:25 p.m., an interview was conducted with Resident #3, and he was asked if he had gotten his pain medication yet. He stated, "I just got the pill ([MEDICATION NAME]) at about 1:15 p.m." (Note: Approximately one hour after the medication was in the building.) He was asked what the level of his pain was. He stated it was "still about a 10." On 05/27/11 at 1:30 p.m., LVN A was asked in the presence of the DON whether he assessed Resident #3's pain. He stated he had not. LVN A was asked by the surveyor to review the facility's Pain Flow Sheet, which revealed Resident #3 had no pain on 05/27/11 between 6:00 a.m. and 2:00 p.m. (during his tour of duty). LVN A stated he documented Resident #3 had no pain 05/27/11 between 6:00 a.m. and 2:00 p.m. but did not assess the resident's pain status. LVN A was asked if anyone documented Resident #3's pain /medication status on the 24 Hour Report record. He stated nothing was reported on the 24 Hour Report about Resident #3's medications/pain status. A review of the facility's Record of In-Service on Pain dated 04/12/11 revealed LVN A and MA B were not in attendance for this in-service. On 05/27/11 at 2:00 p.m., the DON was asked to review the pain in-service held on 04/12/11 for LVN A and MA B's name. She stated, "I don't see any of their names on the in-service record." On 05/27/11 at 2:50 p.m., an interview was conducted with MA B. She was asked if she administered [MEDICATION NAME] as ordered by the physician to Resident #3 on 05/26/11 (2:00 p.m. to 10:00 p.m. shift). She stated she had initialed the medication but did so in error. She stated the [MEDICATION NAME] was not available in the facility when she administered Resident #3's medications at 6:00 a.m. on 05/26/11. She stated she communicated to every nurse she worked with since last Monday (05/23/11) Resident #3 needed his [MEDICATION NAME] medication refilled. She stated the nurse she worked with last Wednesday (05/25/11) notified the physician, who was present at the facility, of the need for the [MEDICATION NAME] prescription (triplicate). MA B stated the physician requested the information be faxed to her office for attention. MA B added the nurse she worked with on Thursday (05/26/11) refaxed the request to the Medical Director's office for attention. MA B was asked if she notified the DON of the resident's medication reorder concern. She stated she had not. She was asked if she assessed Resident #3's pain as the 5th vital sign. She stated, "I don't remember documenting a pain assessment." On 05/27/11 at 3:15 p.m. and at 3:35 p.m., Resident #3 was interviewed while in bed in his room with the television on and only intermittent oxygen in use. He stated his pain level now as about a five as he received his [MEDICATION NAME] about two hours ago. He stated he felt much better and was able to rest comfortably. He stated when he was in pain earlier he did not enjoy watching his television, talking on the telephone to his family member, making plans for the up coming holiday weekend and conducting business. He said he had to rely on his oxygen more. Resident #3 looked better. He was relaxed, no longer pale and was able to speak easily with the surveyor. On 05/27/11 at 4:15 p.m., an interview was conducted with the Administrator and DON. The Administrator was asked if he had been notified by facility staff Resident #3's [MEDICATION NAME] was not available in the facility for routine use. The Administrator stated the staff had not notified him of the medication unavailability. On 05/27/11 at 4:00 p.m., an interview was conducted with the Medical Director. During this interview, the Medical Director stated the facility faxed a request to her office that did not contain the frequency of medication use. She stated she had to have them re-fax the request to include the frequency of use for the [MEDICATION NAME]. The Medical Director stated, "This is the first time this has happened. They have some new nurses." She added, "A lot of the patients are drug dependent and drug seeking." She further stated, "We are trying to get everything in place." A review of the facility's current Nursing Policies and Procedures dated July 2009 revealed the following: "SUBJECT: Pain Management POLICY: Qualified staff will implement the Facility Pain Management Program, including Evaluation/Reevaluation for patients/residents experiencing either acute or chronic pain. DEFINITION OF PAIN: 'Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,' (National Institute of Nursing Research, 1994). It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations, and emotions. 'Pain is whatever the experiencing person say it is, existing whenever the experiencing person say it does.' McCaffey& Beebe, 1989. PROCEDURE:... 2. Upon admission, re-admission complete Section E of Nursing Data Collection Tool. A. If pain is 'triggered' upon admission, initiate the Pain Evaluation. B. Upon completion of the 'Pain Evaluation', and pain is evident, C. Initiate the 'Pain Flow Sheet' for ongoing documentation. D. Document pain as the fifth vital sign, 1) Every shift x (times) one week, then 2) Daily time two (2) weeks, then 3) As needed, guided by individual patient need E. Initiate/update Plan of Care to address pharmacological interventions... 3. Quarterly, complete a new Nursing Data Collection Tool. A. If pain is 'triggered', then B. Complete a new pain evaluation, and if pain is evident C. Utilize the Pain Flow Sheet. D. If a new onset of pain, begin Pain Flow Sheet and document as above. E. If pain continues, continue Pain Flow Sheet. F. Update Plan of Care monitor the patient's/resident's pain status for improvement or ineffective pain management. 4. With new onset of pain, between admission and quarterly evaluations, utilize the Pain Evaluation Tool; Initiate the 'Pain Flowsheet' as determined by patient needs, following documentation parameters set forth above... 5. Utilize the standard A. Word Scale 1-10 or B. Wong Baker Faces Scale for those with cognitive impairment or non conversive, but still have capability to point or C. Pain Assessment is Advance Dementia (PAINAD), for those who have end stage dementia... 9. Appropriate staff to receive on-going in-service education a d competency testing in relation to Pain Management...." A review of the facility's current policy entitled New Orders for Schedule II Controlled Substance effective date 12/07/07, revision date 07/28/08 and 05/01/10, revealed the following: " ...Procedure 1. New orders for Schedule II controlled substances require a written prescription prior to dispensing, unless there is an "Emergency Situation." An "Emergency Situation" (as defined below. Where permitted under Applicable Law, Facility staff may fax Schedule II prescriptions for long term care residents, terminally ill residents, or where the medication is used for direct infusion (e.g., [MEDICATION NAME] drip)... 2. Physician/Prescriber should provide Pharmacy with verbal authorization for Schedule II controlled substances in cases of an "Emergency Situation." An "Emergency Situation" is one in which the prescribing practitioner determines that: 2.1 Immediate administration of the Schedule II controlled substance is necessary for proper treatment of [REDACTED]. 2.2 There is no appropriate alternative treatment available, including administration of a medication that is not a Schedule II controlled substance; and 2.3 It is not reasonable for Physician/Prescriber to provide a written prescription to be presented to the person dispensing the Schedule II controlled substance prior to the dispensing. 3. For an emergency Schedule II controlled substance order, the authorized Physician/Prescriber should provide the following information to a licensed pharmacist; 3.1 Controlled substance name; 3.2 Controlled substance dosage form; 3.3 Controlled substance strength or concentration per dosage unit; 3.4 Number of dosage units or volume to be dispensed; 3.5 Full name and address of the resident to whom the controlled substance is to be dispensed; 3.6 Name, address and DEA registration number of the prescribing practitioner; 3.7 Direction for use; and 3.8 Medical diagnosis, if required... 4. Within seven (7) days of requesting an emergency oral prescription, or sooner if required by Applicable Law, the authorized Physician/Prescriber should fax (where permitted under Applicable Law), mail, or hand deliver the prescription to the Pharmacy...." The facility's Form CMS-672 (Resident Census and Conditions of Residents), dated 05/27/11, reflected 38 residents were on a pain management program.

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assure accurate acquiring, receiving and administering, to meet the needs of each resident, for one (Resident #3) of eight residents reviewed for pharmacy services. Resident #3 missed three doses of Morphine due to the staff not re-ordering the medication timely. Resident #3 rated his pain as 10, with 10 being the worst pain he had ever experienced. Resident #3 did not receive the following medication as ordered by the physician: Morphine 60 mg - Schedule II, Tablet Sustained Release on 05/26/11 at 6:00 a.m. and 7:00 p.m. and on 05/27/11 at 6:00 a.m. (Resident #3 missed three doses over approximately 31 hours). This failure caused Resident #3 to experience uncontrolled pain and ineffective pain management. This failure could affect the facility's 38 residents, including Resident #3, who received pain management from the facility by placing them at risk of receiving inadequate pain management. Findings included: A review of the Face Sheet (undated) revealed Resident #3 was admitted to the facility on [DATE] ("latest return" date of 08/02/10) with the following Diagnoses: [REDACTED]. A review of the annual MDS assessment, dated 01/07/11, revealed Resident #3 understood others, made himself understood and he was cognitively intact. He had feelings of depression and/or hopelessness. Resident #3 did not exhibit behaviors. He was totally dependent with transfers, and he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was incontinent of bowel and bladder. He frequently had moderate pain and was on a scheduled pain medication regimen. A review of the quarterly MDS assessment, dated 03/15/11, revealed Resident #3 understood others, made himself understood and he was cognitively intact. He had feelings of depression and/or hopelessness. Resident #3 did not exhibit behaviors. He was totally dependent with transfers, and he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. He was incontinent of bowel and bladder. He frequently had moderate pain and was on a scheduled pain medication regimen. Resident #3 was not interviewed regarding Cognition, Mood and Pain Status, according to the MDS assessment. The assessment reflected Resident #3 did not have pain observed or documented. A review of the Comprehensive Plan of Care, dated 01/12/11 and reviewed by the facility on 03/17/11, revealed the following regarding Resident #3: 1. Problem: Resident complains of increased pain/discomfort... Goal: ...pain/discomfort will be relieved within one hour after intervention... Approaches: a. Monitor for signs/symptoms of increased pain/discomfort... assess relief. b. Assess and document pain. ...d. Allow to verbalize feelings of pain and discomfort. 2. Problem: Resident has limited movement of legs, ankles and feet related to...Chronic Pain Neuropathy. Approaches: a. Monitor for increase in... pain. b. Administer pain medications for signs and symptoms of pain as ordered by the MD. 3. Problem: Resident has Arthritis and is at risk for... increased joint pain. Resident currently takes Lortab and Morphine. Resident complain of pain to the knees. Goal: ...increased joint pain will be relieved within one hour of intervention... Approaches: a. Monitor for increased joint pain - give meds/treatment per order. Assess for signs of relief. 4. Problem: Resident has a history of Degenerative Joint Disease and is at risk for... increase joint pain... Resident takes pain medication. Goal: ...joint pain will be relieved within one hour of intervention... Approaches: a. Give meds per order. b. Monitor for s/s of increase joint pain. Provide treatments/meds per order. Monitor for relief. A review of the Physician order [REDACTED]. Morphine - Schedule II, Tablet Sustained Release; 60 mg; amount: one tablet by mouth twice a day at 6:00 a.m., and 7:00 p.m. Special instructions: Do not crush, break, or chew. This Physician order [REDACTED]. A review of the Progress Note dated 05/25/11 revealed the following physician's note regarding Resident #3: "Palliative Care (Pain) Consult Pt c ~ (with) [AGE] years hx (history) of pain, - predominantly arthralgias (pain in joint) & then progressively neuropathic pain." On 05/27/11 at 9:20 a.m., an entrance tour was conducted with LVN A. When the surveyor was introduced to Resident #3 by LVN A, Resident #3 said to the surveyor that his pain issue had not been resolved. On 05/27/11 at 10:40 a.m., Resident #3 was interviewed while in bed in his room with the television (TV) on and continuous oxygen in use via mask. He stated he had missed three doses of his Morphine, the pain medication, due to the facility being out of his Morphine. He stated his pain level was a "10" and his pain had been a "10" for the past eight hours. He stated the facility had been telling him for the past day his Morphine was on order. He stated he took the Morphine twice daily. Resident #3 had obvious difficulty speaking with the surveyor due to his pain. He was holding himself very stiffly, and he was pale and distressed. Although the TV was on, Resident #3 kept his eyes closed most of the time. On 05/27/11 at 10:50 a.m., LVN A and MA B were asked to reconcile Resident #3's medication to the MAR. When Resident #3's medications were checked against the MAR, it was revealed the resident had not been administered three doses of his Morphine 60 mg tablet Sustained Release. At that time, LVN A and MA B were asked if the Morphine was in the facility and available for the resident's use. After MA B stated the Morphine was not in the facility, LVN A stated, "We don't have (it)...." MA B was then asked the reason Resident #3's Morphine was not available for use. She stated, "The medicine was ordered a few days ago. When I came back on Tuesday (05/24/11), the re-order label was missing, so that meant that it (Morphine) was ordered. But I don't know about the triplicate." A review of Medication Flowsheet dated 05/01/11 through 05/31/11 revealed the following regarding Resident #3: Morphine - Schedule II, Tablet Sustained Release; 60 mg was ordered for Resident #3: 05/26/11 at 6:00 a.m. was initialed and circled by staff indicating the medication was not given. 05/26/11 at 7:00 p.m. was initialed as given indicating the medication was administered. (Note: Later interviews with LVN A and MA B confirmed this was an error because the medication was not available.) 05/27/11 at 6:00 a.m. was not initialed as given (left blank), indicating the medication was not given. The Medication Flowsheet Documentation Notes, dated 05/26/11 and 05/27/11 at 6:00 a.m., for Resident #3 reflected, "No Morphine in house." A review of the Nurse's Note dated 05/26/11 revealed no documentation reflecting Resident #3's failure to receive Morphine as ordered. A review of the facility's 24 Hour Report dated 05/27/11 revealed no documentation reflecting Resident #3's failure to receive Morphine as ordered. A review of the facility's Pain Flow Sheet dated May 2011 revealed the following pain intensity scales: Scale B - Wong-Baker FACES Pain Rating Scale 0 - No Hurt 1 - Hurts little bit 2 - Hurts little more 3 - Hurts even more 4 - Hurts whole lot 5 - Hurts Worst Scale C 0 - No Pain 5 - Moderate Pain 10 Worst Possible Pain A review of the facility's Pain Flow Sheet dated May 2011 revealed the following pain assessments for Resident #3: 05/26/11 (6:00 a.m. to 2:00 p.m.) - Resident #3 had no pain. 05/26/11 (2:00 p.m. to 10:00 p.m.) - No documentation present. 05/26/11 (10:00 p.m. to 6:00 a.m.) - Resident #3 had no pain. 05/27/11 (6:00 a.m. to 2:00 p.m.) - Resident #3 had no pain. 05/27/11 (10:00 p.m. to 6:00 a.m.) - Resident #3 had no pain. On 05/27/11 at 11:10 a.m., an interview was conducted with the facility's only ADON. She was asked to review the Medication Flowsheet dated 05/01/11 through 05/31/11 for Resident #3 and explain why the Morphine scheduled for 05/27/11 at 6:00 a.m. was left blank. She stated, "According to the documentation, the 6:00 a.m. medications were not given." She was asked why the above medication was not available for Resident #3 as ordered. The ADON stated, "Usually a medication is ordered way before it runs out." The ADON was asked to call the Pharmacy to find out when the Morphine was ordered. After speaking with the Contracting Pharmacy the ADON stated, "It was ordered yesterday (05/26/11) at 11:00 p.m." On 05/27/11 at 11:30 a.m., an interview was conducted with the ADON. She was asked the facility's schedule for assessing and documenting resident pain. She stated, "The nurses document pain every shift and PRN." On 05/27/11 at 12:05 p.m., an interview was conducted with the Pharmacy Consultant. She was asked to explain the facility's procedure for refilling a Schedule II medication (Morphine) and the timeframe used when reordering. She stated, "They (facility) have to have the triplicate script from the doctor. I would say it should be gotten about a week in advance." She was asked what the effect on Resident #3 could be for not receiving three doses of his scheduled Morphine. She stated, "His pain level is probably not good. He could have some substantial pain." She added, "He probably has some residual effects from previous doses." The Pharmacy Consultant was asked if the facility staff notified her of their inability to obtain Resident #3's Morphine in a timely manner at anytime. She stated she was not notified. The Pharmacy Consultant was asked if she could have provided assistance, if asked by the facility, to obtain the Morphine medication for Resident #3. She stated, "I could have seen if they had the prescription and called the Pharmacy to try to get the medication." She was asked how long she had been the Pharmacy Consultant at this facility. She stated, "About a year." On 05/27/11 at 12:15 p.m., an interview was conducted with the DON. She was asked if she was aware Resident #3's pain medication was not available. She stated, "The three meds were not here when ya'll checked it, but they are here now. The Morphine is here now." The DON was asked if she had prior knowledge Resident #3 was missing the Morphine. She stated, "This morning is the first I heard of the Morphine. The nurse did not give the med." The DON was asked to explain why staff signed on 05/26/11 the 6:00 a.m. dose of Morphine was given. She stated, "It probably means the nurse who initialed just went down and initialed everything. That would be an error." The DON was asked who completed resident pain assessments for the facility. She stated the nurses completed the pain flow sheet. The DON was asked if she would expect her nurses to write their inability to obtain and administer resident medication on the 24 Hour Report Sheet. She stated, "I would have expected the nurse to write it in the 24 Hour Report and notify me of the problem." She was asked who was aware Resident #3 was missing the medication. The DON stated, "Two people would have known the meds were not here, the night nurse and the evening MA." The DON was asked if she had in-serviced her staff on pain assessments and medication administration. She stated staff was in-serviced 04/12/11 on assessing pain as the 5th vital sign. The DON added, "The doctor was here yesterday. I don't know why they did not reorder the medication timely." The DON was asked the facility's policy for reordering medication. She stated, "Peel the sticker off within 3-4 days of being empty. Fax to Pharmacy. For problems they should come to me immediately, and they frequently do." The DON was asked how long she had been employed at the facility, and she stated six weeks. On 05/27/11 at 12:55 p.m., Resident #3 was interviewed. He was asked if he had received a dose of his pain medication (Morphine) yet today. He stated, "No, not yet." He was asked when the last time staff had asked him about his pain level. He stated, "A nurse asked last night about my pain. I told her it was an 8 then. I asked her for Tylenol for the headache." Resident #3 stated his headache was relieved after taking the Tylenol. The resident stated staff working on the day and evening shifts on 05/26/11 did not question him about his pain. He added staff did not ask him about his pain on 05/27/11, only two surveyors did. He stated, "CNAs ask about my pain sometimes. Most of the time they don't usually ask about my pain. The nurses just come in and let me know that they are there, but they don't ask me about my pain. It's been a revolving door with the nurses." Resident #3 stated he was informed in the morning on 05/26/11 the facility had run out of his routine Morphine medication. He stated he was told a nurse was supposed to order it. Resident #3 stated his pain was never completely relieved, but taking the Morphine brought it down to a pain level of 3. At 1:05 p.m., Resident #3 reported his pain at a level of 10, (the worst possible pain). On 05/27/11 at 1:15 p.m., the DON was asked if Resident #3 had received his Morphine yet. She stated, "He hasn't gotten it yet. I've asked the nurse (LVN A) to ask the patient if he wanted to reset his time." At that time, the DON also informed the surveyor she could not locate the documentation reflecting the date of the last in-service held on the topic of ordering/re-ordering medications. On 05/27/11 at 1:25 p.m., an interview was conducted with Resident #3, and he was asked if he had gotten his pain medication yet. He stated, "I just got the pill (Morphine) at about 1:15 p.m." (Note: Approximately one hour after the medication was in the building.) He was asked what the level of his pain was. He stated it was "still about a 10." On 05/27/11 at 1:30 p.m., LVN A was asked in the presence of the DON whether he assessed Resident #3's pain. He stated he had not. LVN A was asked by the surveyor to review the facility's Pain Flow Sheet, which revealed Resident #3 had no pain on 05/27/11 between 6:00 a.m. and 2:00 p.m. (during his tour of duty). LVN A stated he documented Resident #3 had no pain 05/27/11 between 6:00 a.m. and 2:00 p.m. but did not assess the resident's pain status. LVN A was asked if anyone documented Resident #3's pain /medication status on the 24 Hour Report record. He stated nothing was reported on the 24 Hour Report about Resident #3's medications/pain status. A review of the facility's Record of In-Service on Pain dated 04/12/11 revealed LVN A and MA B were not in attendance for this in-service. On 05/27/11 at 2:00 p.m., the DON was asked to review the pain in-service held on 04/12/11 for LVN A and MA B's name. She stated, "I don't see any of their names on the in-service record." On 05/27/11 at 2:50 p.m., an interview was conducted with MA B. She was asked if she administered Morphine as ordered by the physician to Resident #3 on 05/26/11 (2:00 p.m. to 10:00 p.m. shift). She stated she had initialed the medication but did so in error. She stated the Morphine was not available in the facility when she administered Resident #3's medications at 6:00 a.m. on 05/26/11. She stated she communicated to every nurse she worked with since last Monday (05/23/11) Resident #3 needed his Morphine medication refilled. She stated the nurse she worked with last Wednesday (05/25/11) notified the physician, who was present at the facility, of the need for the Morphine prescription (triplicate). MA B stated the physician requested the information be faxed to her office for attention. MA B added the nurse she worked with on Thursday (05/26/11) refaxed the request to the Medical Director's office for attention. MA B was asked if she notified the DON of the resident's medication reorder concern. She stated she had not. She was asked if she assessed Resident #3's pain as the 5th vital sign. She stated, "I don't remember documenting a pain assessment." On 05/27/11 at 3:15 p.m. and at 3:35 p.m., Resident #3 was interviewed while in bed in his room with the television on and only intermittent oxygen in use. He stated his pain level now as about a five as he received his Morphine about two hours ago. He stated he felt much better and was able to rest comfortably. He stated when he was in pain earlier he did not enjoy watching his television, talking on the telephone to his family member, making plans for the up coming holiday weekend and conducting business. He said he had to rely on his oxygen more. Resident #3 looked better. He was relaxed, no longer pale and was able to speak easily with the surveyor. On 05/27/11 at 4:15 p.m., an interview was conducted with the Administrator and DON. The Administrator was asked if he had been notified by facility staff Resident #3's Morphine was not available in the facility for routine use. The Administrator stated the staff had not notified him of the medication unavailability. On 05/27/11 at 4:00 p.m., an interview was conducted with the Medical Director. During this interview, the Medical Director stated the facility faxed a request to her office that did not contain the frequency of medication use. She stated she had to have them re-fax the request to include the frequency of use for the Morphine. The Medical Director stated, "This is the first time this has happened. They have some new nurses." She added, "A lot of the patients are drug dependent and drug seeking." She further stated, "We are trying to get everything in place." A review of the facility's current Nursing Policies and Procedures dated July 2009 revealed the following: "SUBJECT: Pain Management POLICY: Qualified staff will implement the Facility Pain Management Program, including Evaluation/Reevaluation for patients/residents experiencing either acute or chronic pain. DEFINITION OF PAIN: 'Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,' (National Institute of Nursing Research, 1994). It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations, and emotions. 'Pain is whatever the experiencing person say it is, existing whenever the experiencing person say it does.' McCaffey& Beebe, 1989. PROCEDURE:... 2. Upon admission, re-admission complete Section E of Nursing Data Collection Tool. A. If pain is 'triggered' upon admission, initiate the Pain Evaluation. B. Upon completion of the 'Pain Evaluation', and pain is evident, C. Initiate the 'Pain Flow Sheet' for ongoing documentation. D. Document pain as the fifth vital sign, 1) Every shift x (times) one week, then 2) Daily time two (2) weeks, then 3) As needed, guided by individual patient need E. Initiate/update Plan of Care to address pharmacological interventions... 3. Quarterly, complete a new Nursing Data Collection Tool. A. If pain is 'triggered', then B. Complete a new pain evaluation, and if pain is evident C. Utilize the Pain Flow Sheet. D. If a new onset of pain, begin Pain Flow Sheet and document as above. E. If pain continues, continue Pain Flow Sheet. F. Update Plan of Care monitor the patient's/resident's pain status for improvement or ineffective pain management. 4. With new onset of pain, between admission and quarterly evaluations, utilize the Pain Evaluation Tool; Initiate the 'Pain Flowsheet' as determined by patient needs, following documentation parameters set forth above... 5. Utilize the standard A. Word Scale 1-10 or B. Wong Baker Faces Scale for those with cognitive impairment or non conversive, but still have capability to point or C. Pain Assessment is Advance Dementia (PAINAD), for those who have end stage dementia... 9. Appropriate staff to receive on-going in-service education a d competency testing in relation to Pain Management...." A review of the facility's current policy entitled New Orders for Schedule II Controlled Substance effective date 12/07/07, revision date 07/28/08 and 05/01/10, revealed the following: " ...Procedure 1. New orders for Schedule II controlled substances require a written prescription prior to dispensing, unless there is an "Emergency Situation." An "Emergency Situation" (as defined below. Where permitted under Applicable Law, Facility staff may fax Schedule II prescriptions for long term care residents, terminally ill residents, or where the medication is used for direct infusion (e.g., morphine drip)... 2. Physician/Prescriber should provide Pharmacy with verbal authorization for Schedule II controlled substances in cases of an "Emergency Situation." An "Emergency Situation" is one in which the prescribing practitioner determines that: 2.1 Immediate administration of the Schedule II controlled substance is necessary for proper treatment of [REDACTED]. 2.2 There is no appropriate alternative treatment available, including administration of a medication that is not a Schedule II controlled substance; and 2.3 It is not reasonable for Physician/Prescriber to provide a written prescription to be presented to the person dispensing the Schedule II controlled substance prior to the dispensing. 3. For an emergency Schedule II controlled substance order, the authorized Physician/Prescriber should provide the following information to a licensed pharmacist; 3.1 Controlled substance name; 3.2 Controlled substance dosage form; 3.3 Controlled substance strength or concentration per dosage unit; 3.4 Number of dosage units or volume to be dispensed; 3.5 Full name and address of the resident to whom the controlled substance is to be dispensed; 3.6 Name, address and DEA registration number of the prescribing practitioner; 3.7 Direction for use; and 3.8 Medical diagnosis, if required... 4. Within seven (7) days of requesting an emergency oral prescription, or sooner if required by Applicable Law, the authorized Physician/Prescriber should fax (where permitted under Applicable Law), mail, or hand deliver the prescription to the Pharmacy...." The facility's Form CMS-672 (Resident Census and Conditions of Residents), dated 05/27/11, reflected 38 residents were on a pain management program.