Every finding on record at San Juan Care Center

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 1 (R #1) of ( R #1) resident reviewed for PASARR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.The findings are:A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses:Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest),Generalized Anxiety Disorder (feelings of fear or apprehension),Adjustment Disorder with depressed mood, identified after admission into the facility. B. Record review of R #1's PASARR Level I, dated 04/15/25, revealed the screening required the identification of mental illness diagnoses, including depression. R #1's PASARR did not include R #1's diagnosis of depression. C. On 04/07/26 at 9:30 am, during an interview, the Director of Nursing (DON) stated R #1 received the diagnosis of depression at the facility and acknowledged R #1's PASARR should have been updated following the new diagnosis. The DON stated she is responsible for completing PASARR screenings and R #1's PASARR, dated 04/15/25, was inaccurate.

Based on observation, interview, and record review, the facility failed to utilize screens in all windows of the facility to prevent pest from entering the facility. This failure had the potential to affect all residents in the facility. If the facility does not use screens in the windows, then pest could enter the facility and harm or annoy the residents. The findings are: A. Record review of the facility's Grounds and Exterior Inspection, undated, revealed the policy did not address the use of screens to prevent pests from entering the facility. B. On 06/10/25 at 10:10 am, observation revealed the following: - Three windows open in the main dining room without screens in place. - One window open in room [ROOM NUMBER] without a screen in place. - Two windows open in the Therapy room without screens in place. - One window open in room [ROOM NUMBER] without a screen in place. - An active wasp nest was present outside the Therapy windows. C. On 06/10/25 at 10:58 am and 06/11/25 at 4:20 pm, observation revealed flies in various locations throughout the facility. D. On 06/11/25 at 11:32 am, during an interview, the Administrator stated he expected the windows in the facility to have a screen present for pest control. He stated it was expected for the screens to be in good condition and without holes. He stated there was not a system for inspecting the screens, and staff were not trained to submit work orders for missing screens. He stated the maintenance staff walk the facility monthly looking for anything out of place. He stated maintenance staff check regularly for wasp nests during their monthly rounds, but he was not aware of the nests in multiple windows.

Based on observation and interview, the facility failed to ensure the ice machine drained through an air gap. This deficient practice is likely to affect all residents in the facility. If staff do not maintain the ice machine drain air gaps, then residents are at risk of foodborne illnesses. The findings are: A. On 06/11/25 at 2:45 pm, observation of the kitchen revealed the ice machine did not drain through an air gap. The drainpipe from the ice machine drained below the surface of the floor. B. On 06/11/25 at 2:47 pm, during an interview, the facility's Corporate Maintenance Director stated he was not aware the ice machine did not drain through an air gap. He stated the ice machine should drain through an air gap to prevent backflow into the ice machine.

Based on record reviews and interviews, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 1 (R #94) of 1 (R #94) resident reviewed for unnecessary medications, when staff failed to ensure the resident's as needed (PRN) psychotropic medications were not prescribed for longer than 14 days without documentation in the resident's medical record of the rationale to extend beyond 14 days. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of the facility's policies and procedures undated, revealed the facility did not have a policy on ordering psychotropic medications or Medication Regimen Review (MRR) process. B. Record review of R #94's admission record, undated, revealed the following: 1. R #94 was admitted to the facility on [DATE]. 2. R #94 had a diagnosis of malignant neoplasm of the prostate (prostate cancer). C. Record review of R #94's Hospice Written Orders, dated 06/09/25, revealed the following orders: - Lorazepam (anti-anxiety medication) 0.5 milligram (mg) tablet. Give one tablet every four hours by mouth PRN for anxiety and insomnia. The order did not have a stop date. - Haloperidol (antipsychotic medication) 2 mg/milliliter (ml) syrup. Give one ml every six hours by mouth PRN for nausea. The order did not have a stop date. D. Record review of R #94's Provider Orders, dated 06/09/25, revealed the following: - An active order to receive lorazepam oral tablet 0.5 mg. Give one tablet by mouth every four hours as needed for anxiety and insomnia. The order had a stop date documented as indefinite. - An active order to receive haloperidol oral concentrate 2 mg/ml. Give one ml by mouth every six hours as needed for nausea. The order had a stop date documented as indefinite. E. On 06/13/25 at 9:07 am, during an interview, Nurse #1 stated she entered R #94's hospice orders into R #94's electronic health record (EHR). Nurse #1 stated Hospice preferred to keep their orders without a stop date due to the nature of the patients being at the end of their lives. F. On 06/13/25 at 9:12 am, during an interview, the Director of Nursing (DON) stated she expected Nurse #1 to enter a 14-day stop date for R #94's lorazepam and haloperidol medication orders. The DON stated the facility did not have a policy on PRN psychotropic medications. She stated she referred to Federal and State regulations to guide their practice on PRN psychotropic medications. G. On 06/13/25 at 10:02 am, during an interview, the Hospice Medical Director stated he expected the following: - The hospice nurse to enter a 14-day stop date for R #94's the lorazepam and haloperidol medication orders. - The facility's nurse, who entered the order from the R #94's hospice order sheet to the R #94's EHR, to enter a 14-day stop order for both medication orders. The Hospice Medical Director stated he did not instruct the facility staff not to enter a 14-day stop date to the psychotropic orders.

Based on observation, interviews, and record review, the facility failed to: - Ensure dining room linens remained in good repair and free from stains and holes. - Maintain the facility trash and debris free. This deficient practice had the potential to affect residents who utilized the main dining area and various courtyards in the facility. If the facility fails to maintain the facility in a homelike manner, then residents may experience a diminished environment that negatively impacts their dignity and quality of life. The findings are: Dining Room Linens A. Record review of the facility's Housekeeping and Laundry policy, dated August 2020, revealed linens not in good repair are to be sorted out and discarded. B. On 06/10/25 at 8:21 a.m., observation of the main dining room revealed six red tablecloths with visible bleach stains. C. On 06/12/25 at 10:38 a.m., observation of the main dining area revealed six red tablecloths with bleach stains, and one tablecloth with a hole in it. D. On 06/12/25 at 2:59 p.m., during an interview, the Head of Housekeeping stated she requested new tablecloths. She stated it was expected for the current linens to be in good condition. E. On 06/12/25 at 3:38 p.m., during an interview, the Administrator stated it was his expectation that dining linens would not have holes or discoloration. Trash and Debris F. Record review of the facility's Grounds and Exterior Inspection policy, undated, revealed the following: - Inspect for cleanliness of grounds, especially in trash dumping area. - The policy did not instruct staff on the frequency of the inspections. G. On 06/11/25 at 11:35 am, observation revealed the following: - room [ROOM NUMBER] window had food and debris on the outside windowsill, wall, and ground outside the window. Further observation revealed the wall was visible from the main dining room. - The enclosed grill area outside the main dining room had trash on the ground. Further observation revealed the trash was visible from the main dining room and 500 hall resident rooms. - An enclosed courtyard outside the 100 hallway egress contained various medical equipment stored along the sidewalk. - An enclosed courtyard outside the 100 hallway contained a shed area with trash, paper lids, plastic, and limbs on the ground. Further observation revealed the debris was visible from the 100 hall courtyard and the main courtyard. - Cigarette waste was disposed in the handrail of an exit from the 300 hallway. H. On 06/11/25 at 11:32 am, the Administrator stated maintenance staff walked the facility monthly to look for anything out of place and garbage. He stated the resident in room [ROOM NUMBER] liked to feed the cat, and that was why there was food on the windowsill, wall, and ground. He stated it was not a homelike view for residents in dining room. The Administrator stated the medical equipment in the enclosed courtyard outside the 100 hallway was for disposal. He stated residents could come out into the enclosed area if staff were with them, and the extra equipment lined up along the sidewalk was not homelike. He stated the trash and debris around the shed was also not homelike and should be cleaned up. The Administrator stated the area outside the 300 hallway was frequented by displaced individuals, and sometime the individuals leave trash behind. He stated the facility did not have a system to check for debris left by the individuals, and the cigarette waste in the handrail was not homelike.

Based on observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment cart when they left it unattended. This deficient practice had the potential to affect all residents on the 300 Unit. If staff fail to lock an unsupervised treatment cart, then residents could obtain medical equipment which could result in injury or death. The findings are: A. On 06/09/25 at 1:33 PM, observation of the 300 Unit revealed a treatment cart unlocked and unattended. Further observation revealed the top drawer of the cart contained wound care items, such as ointments, gloves, bandages, wound cleanser, tweezers and scissors. B. On 06/09/25 at 1:36 PM, during an interview, Registered Nurse (RN) #1 stated the treatment cart was her responsibility and should be locked when unattended. She said if the treatment cart was left opened then residents could access the treatment supplies and hurt themselves. C. On 06/13/25 at 2:15 PM, during an interview, the Director of Nursing (DON) stated the treatment cart should be locked if it was not actively in use by a nurse. The DON stated it was her expectation for staff to lock the treatment cart when unattended, so residents could not open the cart and access items which could cause injury.

Based on record review, observation, and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #20) of 1 (R #20) resident. If the facility fails to implement a baseline care plan within 48 hours of admission for residents with complex needs, staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident because of medical care or lack of medical care). The findings are: A. Record review of R #20's face sheet revealed an admission date of 02/21/25. B. Record review of R #20's admission record revealed a diagnosis of chronic lung disease (a progressive respiratory condition affecting the lungs). C. On 06/09/25, at 12:24 PM during an observation, R #20 sat in her room and wore a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs), connected to an oxygen concentrator (device that concentrates the oxygen from a gas supply). D. On 06/10/25, at 3:14 pm observation revealed R #20 sat in her room and used an oxygen concentrator. E. Record review of R #20's baseline care plan, dated 02/21/25, revealed the care plan did not address the following: - Initials goals based on admission orders. - Physician orders. - The care plan did not address the resident's use of supplemental oxygen. F. On 06/09/25, during an interview, R #20's son stated his mother has used oxygen since the beginning of 2025.

Based on interview and record review, the facility failed to meet regulatory requirements when discharging 1 (R #68) of 1 (R #68) resident when staff failed to ensure proper notification was given to the resident, conduct discharge planning, and confirm of resident receipt of the discharge notice. These failures had the potential for an incomplete and unsafe discharge and increase risk of resident harm. The findings are: A. Record review of the facility's Transfer and Discharge policy, dated 10/24/22, revealed the facility must permit each resident to remain in the facility, including when a resident endangered the health or safety of others, and should not discharge the resident unless one of six regulatory criteria were met. The policy directed staff to ensure documentation was complete, involve the physician in the decision, notify the residents and/or their representative, issue a written notice, and assist with safe and appropriate discharge planning. The policy also stated residents must be informed of their right to appeal, and staff must notify the Ombudsman. B. Record review of R #68's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: - Schizoaffective disorder (a mental condition that causes both psychosis and mood problems), - Generalized anxiety disorder, - Opioid dependence (physical dependence on opioids), - Diabetes mellitus (DM; metabolic disease). C. Record review of R #68's progress notes revealed the following: - Dated 05/07/25, the resident was discharged on 05/07/25, after he threw coffee on the Assistant Director of Nursing (ADON). - Dated 05/06/25, the facility Medical Director documented the resident was no longer safe to remain in the facility due to escalating verbal and physical behaviors. - Dated 05/06/25, the Administrator documented R #68 was in jail and presumably discharged . D. On 06/12/25 at 2:25 P.M., during an interview, the Director of Nursing (DON) stated the resident was arrested on 05/06/25 for throwing coffee on the ADON, and the Administrator hand-delivered the discharge paperwork to the jail. She stated a second notice was provided to the resident on 05/07/25 when he returned to the facility. She stated the resident's physician, the facility's Medical Director, was notified of the discharge. She stated R #68 was his own responsible party. She stated the resident did not receive his medications when they discharged him, and they did not create a discharge plan with R #68. She stated it was her expectation the resident would receive a complete and appropriate discharge. E. On 06/12/25 at 2:45 P.M., during an interview, the Administrator stated the facility issued a formal discharge notice to R #68 on 05/06/25, and he personally delivered it to the jail. He stated the notice was handed to the receptionist for delivery, and he could not confirm whether the resident received it. He stated the resident returned to the facility on [DATE], and the resident stated he did not receive any paperwork while in jail. He stated he gave R #68 a copy of his discharge papers, and he verbally encouraged the resident to go to the hospital. The Administrator stated he documented the information in the administrative notes in R #68's progress notes. The Administrator stated the facility denied the resident reentry to the facility due to safety concerns. The Administrator stated the team felt comfortable with the decision based on the resident's unsafe behavior. F. On 06/12/25 at 3:00 P.M., during an interview, the Regional Nurse Consultant (RNC) stated proper discharge planning did not occur for R #68. She stated it was her expectation staff would have developed a discharge plan for R #68.

Based on record reviews and interviews, the facility failed to ensure a call light was in working order for 1 (R #1) of 1 (R #1) resident, when the staff failed to make sure the shower room call light was functional before R #1 bathed herself. If the facility is not ensuring a working call light system, then residents are unable to request immediate assistance when needed. The findings are: A. Record review of R #1's face sheet, dated 11/19/24, showed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's Electronic Health Record (EHR) undated, showed the following diagnoses: - Major joint replacement (a procedure where a damaged or diseased joint is surgically removed and replaced with an artificial one.) - After care following joint replacement surgery. - Unilateral primary osteoarthritis (chronic degeneration of the joint cartilage), - Right knee infection and inflammatory reaction (the body's response to injury, illness, or something that does not belong in the body. Characterized by heat, pain, redness, swelling, and loss of function) due to internal right knee prosthesis (an artificial device which replaces a missing body part), sequela (a condition which is the consequence of a previous disease or injury). - Pain due to internal orthopedic prosthetic devices, implants (a substance or object that is put in the body), and grafts (healthy skin, bone, or other tissue taken from one part of the body and used to replace skin, bone, or tissue in another part of the body), subsequent encounter. - Type 2 diabetes mellitus (DM2, a condition results from insufficient production of insulin) with hyperglycemia (high blood sugar.) C. Record review of the R #1's Care Plan, revealed the following: - Dated 11/25/24: - Focus: Resident was a moderate risk for falls related to knee surgery. - Interventions: Evaluate and treat as ordered or as needed. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate resident as to causes. - Dated 01/17/25: - Focus: Resident has activities of daily living (ADL) self-care performance deficit related to decreased mobility and comorbidities (the condition of having two or more diseases at the same time). - Interventions: Encourage the resident to use bell to call for assistance. Resident requires staff participation with bathing. Resident requires staff participation with transfers. D. Record review of the facility's Incident Report, dated 12/28/24, showed R #1 had an unwitnessed fall in the shower room. R #1 held the shower rail with her right hand, slipped, and hit her elbow against the wall. E. Record review of R #1's Progress Notes, dated 12/28/24, Nurse #1 documented the following: - R #1 had an unwitnessed fall in shower room. The resident stated she slipped while holding shower rail, hit her right elbow against shower wall, and slowly slid down to the floor. The resident complained of right elbow pain and tenderness when touched. Staff did not note any redness or bruising. Resident required set-up help only with shower, shower chair was in place, and towels were in place on the floor. Staff notified the Medical Director, Director of Nursing, and family. F. Record review of R #1's Discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 01/03/25, showed staff documented the following for the resident's look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS): - Resident required set-up or clean-up assistance (staff sets up or cleans up for the activity but the resident completes activity independently) for self-bathing and for transfer in and out of shower. - Resident was able to bathe self, to include washing, rinsing, and drying self. - Resident was able to get in and out of a tub/shower. G. Record review of the facility's Incident Follow-up Report, dated 01/10/25, showed the facility's administrator noted the call light in the shower room was not functional when R #1 fell on [DATE]. H. Record review of the facility's The Equipment Lifecycle System (TELS, a building management platform that helps maintenance staff with facility maintenance, life safety code inspection and testing, and asset management) revealed the following: - Dated 2024, the Maintenance Director inspected call lights on the following dates: 12/28/2024, 11/9/2024, 10/18/2024, 09/28/2024, 08/14/2024, 07/10/2024, 06/13/2024, 05/23/2024, 04/25/2024, 03/20/2024, 03/1/2024 and 01/23/2024. Further review showed the inspection reports did not show which call lights the Maintenance Director inspected or the outcomes of those inspections. - Dated 12/28/24, the Maintenance Director inspected six resident room call lights. Further review showed the record did not contain documentation to show the Maintenance Director inspected the 100 hallway shower room call light. I. On 03/17/25 at 10:02 am, during an interview, R #1's Representative stated staff notified her of R #1's fall. She stated she was worried about R #1's knee surgery, and staff informed her R #1's knee was not affected by the fall. She stated staff told her R #1 hit her right elbow against the wall but did not hit her knee. J. On 03/04/25 at 12:25 pm and 03/18/25 at 12:00 pm, during an interview with the Director of Nursing (DON), she stated maintenance staff check call lights every week for availability and functionality. She stated R #1 was able to shower and transfer herself. The DON stated the shower call light was not functional at the time of the incident. The DON stated R #1 told Certified Nursing Assistant (CNA) #1 she wanted private showers. The DON stated CNA #1 assisted R #1 with set-up for her shower on 12/28/24. The DON stated R #1 fell in the 100 hallway shower room on 12/28/24. She stated she did not expect CNA #1 to check 100 Hall shower room call light before leaving R #1 to bathe herself privately. She stated staff assume call lights work. K. On 03/04/25 at 12:20 pm and 03/18/25 at 12:00 pm, during an interview, the Maintenance Director stated he did random checks on the facility's call lights every week. He stated he inspected 100 Hall shower room on 12/28/24, but he did not remember the time of his inspection. L. On 03/04/25 at 12:00 pm, during an interview, the Administrator stated the shower room call light was not functional on 12/28/24 when R #1 fell . The Administrator stated he expected the Maintenance Director to perform random checks on the facility's call lights every week including the three shower rooms.

Based on record review and interview, the facility failed to notify the Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) when R #1's oxygen saturation (the amount of oxygen in the blood) was low and required supplemental oxygen (oxygen therapy; a therapy treatment which provides extra oxygen) through a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for change in condition. If the facility is not notifying the POA when there is a change in condition then the POA is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of the face sheet revealed that R #1 was admitted to the facility on [DATE] and was discharged on [DATE]. R #1 had the following diagnoses: - Surgical amputation below knee (surgical removal of part of the leg), - Sepsis (blood stream infection), - Type II diabetes (body is resistant to insulin and causes high blood sugar levels), - Cellulitis (serious bacterial infection of the skin) of a limb. - This is not an all inclusive list. B. Record review of R #1's change in condition evaluation note, dated 12/10/24 at 1:33 am, indicated R #1 had normal vitals with increased confusion and disorientation. The resident fell out of bed, was assessed, and did not have an injury. R #1 had shortness of breath and a cough. Staff called the on-call physician, and R #1 to receive a chest x-ray later in the day. The note did not indicate staff notified the family member (FM). C. Record review of R #1's change in condition evaluation note, dated 12/10/24 at 5:15 am, indicated the following: - R #1 had an oxygen saturation of 66 percent (%; normal saturation is between 90% and 100%). All other vitals were within normal range. - The Mental Status Evaluation Section indicated R #1 had increased confusion and disorientation. Interventions included placing R #1 on supplemental oxygen and a chest x-ray later in the day. - The Comment Section indicated resident was put on supplemental oxygen during the night and a chest x-ray was ordered. The primary nurse received report, checked on the resident, and found him with his legs hanging off the bed. The resident's nasal cannula was off. Staff took the resident's vitals, and the resident had 47% oxygen saturation on room air. Staff applied the resident's nasal cannula, and his oxygen saturation increased to 6 liters per minute (lpm). The resident's oxygen saturation came up to 66%. Resident tried to verbalize and answer questions, but he did not make sense. Emergency Medical Services (EMS) was dispatched, and the resident left with EMS for the hospital around 6:00 am. - The note did not indicate staff notified the family member. D. On 01/08/24 at 12:17 pm during an interview with R #1's FM/POA, she stated R #1 called her the night of 12/09/24, and he was calling out for help. She stated R #1 did not seem normal to her so she hung up and called the nursing station. The POA stated she asked if someone would go and check on R #1. She stated she called back twice after that and never spoke to anyone. She stated the facility did not call her about R #1's change in condition that occurred in the early morning on 12/10/24. E. On 01/09/25 at 8:30 am, during an interview with the Assistant Director of Nursing (ADON), she stated she came in at 5:00 am on 12/10/24, and the night shift nurse told her that R #1 was placed on oxygen for low saturation levels. The ADON stated she went to check on R #1, found him without his oxygen on, and he was confused. She stated she placed the oxygen on the resident, turned the oxygen up to 6 lpm, and his saturations came up to 66%. The ADON stated that was when R #1 was sent out to the hospital. She stated she called and left a message for R #1's FM/POA when he was sent to the hospital on 12/10/24 at 6:00 am. She stated she did not notify the FM/POA prior to the resident's change in condition when he started using oxygen on 12/09/24, because she was not working on 12/09/24. The ADON stated that she did not see any documentation in the resident's medical record that staff notified the FM/POA of the resident's change in condition on 12/10/24 at 1:33 am, and the night nurse did not tell her that they notified the FM/POA when the resident was placed on oxygen for low saturations. F. On 01/09/25 at 8:40 am, during an interview with Director of Nursing (DON), she stated if a resident had a change in condition then staff should notify the resident's family/POA at that time.

Based on observations and interviews the facility failed to ensure all medication carts were locked when not in use and ensure eye drops were dated when opened and not stored at the bedside for 1 (R #21) of 1 (R #21). These deficient practices will likely to result in 41 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication and allowing access to medication carts to unauthorized personnel. The findings are: Findings for unlocked medication cart. A. On [DATE], at 1:48 pm, during observation of the hall B medication cart. The medication cart looked visibly locked but was not and was accessible. B. On [DATE], at 1:50 pm, during an interview with the facility administrator, he was able to open the medication cart even though it appeared locked. The facility administrator stated the lock was broken and that it would be fixed. 47899 R #21 C. On [DATE], at 3:23 pm, during an observation of R #21's room revealed a bottle of Latanoprost solution 0.0005% (used to treat high pressure inside the eye due to glaucoma (open-angle type) or other eye diseases)that laid on R # 21's bed. The date of delivery to the facility was [DATE]. It was a little under one-fourth full. According to the manufacture instructions the medication needs to be used within six weeks of opening. The bottle did not have a date that the bottle was opened. D. On [DATE], at 2:38 pm, during an interview with the Director of Nursing (DON) confirmed that the a bottle of Latanoprost was at bedside, and the Latanoprost bottle did not have an open date. DON did confirm that R #21 did have a physician order to give the eye drops herself and to keep them at the bedside.

Based on observation and interview, the facility failed to safeguard (secure or protect) clinical record information by leaving protected health information (PHI; personal identifying information) unattended. The deficient practice has the potential to affect all residents on the 100 and 400 hall (residents were identified by the Resident Census List provided by the Administrator on 02/26/24). If the resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed (obtained or examined) by unauthorized (not having permission or approval) residents, visitors, and or staff. The findings are: R #36 A. On 02/26/24, at 3:17 pm, during an observation of medication cart computer revealed, Registered Nurse (RN) #1 left the medication cart computer screen unlocked, that showed PHI, residents name, date of birth, medications, and diagnosis for R #36 as she walked down the hall to give a health shake to R #36 . B. On 02/26/24, at 3:19 pm, during an interview with RN #1, she confirmed that she left the medication cart computer screen on when she walked down the hall to give a healthshake to R #36. C. On 02/29/24, at 2:38 pm, during an interview with the Director of Nursing (DON), confirmed when nurses' step away from their computers on the medication cart, that they (nurses) should be locking the computer screen. 48645 FACILITY D. On 02/27/24 at about 2:15 pm, during observation of the 400 hall, the treatment cart was outside a resident room [ROOM NUMBER], the laptop screen was open with resident #45's personal health information (name, date of birth, and medications) available for anyone to see.

Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #63) of 3 (R #63, R #49, and R #32) residents reviewed for respiratory care by not properly dating the oxygen tubing for the resident. This deficient practice could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (a process where water vapor becomes liquid) or becoming dirty, leading to the reduced oxygen flow. The findings are: A. On 02/27/24, at 12:09 pm, during observation of R #63, the oxygen tubing was not dated. B. Record review of R #63's physician orders dated 01/10/24, stated R #63 was prescribed oxygen 1-6 liters per minute. C. On 02/28/24, at 10:45 am, during an interview with the Director of Nursing (DON), she stated all oxygen tubing should be dated and changed weekly.

Based on record review and interview, facility failed to ensure quality of care for 1 (R #53) of 2 (R #53 and R #71) residents reviewed by not following physician's orders to obtain weekly weights. This deficient practice could likely result in residents not receiving the care and services ordered. The findings are: A. Record review of R #53's face sheet and diagnosis list within the electronic medical record (EMR) indicated that she was admitted to the facility on [DATE] with diagnoses (not an all-inclusive list) of Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) dysphagia (difficulty swallowing), and is provided nutrition via G-tube (Gastronomy tube; a tube inserted through the abdomen that creates a direct route to the stomach). B. Record review of the physician's standing order dated 01/17/2024 stated, Resident is at risk for malnutrition related to new admission and diagnosis: CVA [Cerebral Vascular Accident (stroke)]. Will weigh once weekly x (times) 4 weeks and monthly thereafter. Dietician to consult as needed, per orders. C. Record review of weights recorded in R #53's EMR include: -On 01/17/24 at 4:04 pm: 131.7 lbs. -Staff did not record a weight during the 2nd week. -On 01/30/24 at 1:50 pm: 123.2 lbs. (a 6.45% weight loss in 13 days) -On 02/01/24 at 2:11 pm: 125.0 lbs. (a 5.09% weight loss in 15 days) -Staff did not record a weight during the 4th week. D. On 02/29/24 at 10:01 am during an interview, the facility's Registered Dietician (RD) stated that the weights listed above in finding C are the only weights she is aware of for R #53, and that it appeared that facility staff did not obtain the resident's weight weekly as ordered. E. On 02/29/24 at 2:20 pm, during an interview, the Director of Nursing (DON) confirmed that weekly weights were not collected for R #53 as ordered.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 1 (R #71) of 3 (R #53, R #66, and R #71) residents reviewed for care plans by not following a planned schedule for dialysis care and by failing to include resident specific information in a goal. This deficient practice could likely result in residents not receiving the care needed to reach their highest practicable level of well-being. The findings are: Findings related to dialysis care: A. Record review of R #71's current care plan (dated 01/27/2024) indicated that the resident received dialysis (clinical purification of blood as a substitute for the normal function of the kidney) outside of the facility on Mondays, Wednesdays, and Fridays via an arteriovenous fistula (AVF: a surgically created connection between an artery and vein for use during dialysis care) on her left upper arm. The care plan included an intervention for assessing the AVF for sounds and vibrations caused by blood flowing through the fistula every shift and as needed due to risk of complications related to the AVF closing and/or excessive bleeding. B. Record review of R #71's nursing progress notes for the past week indicate that nursing staff assessed the AVF daily rather than every shift. The only documented assessment of R #71's AVF in the last week are as follows: - 2/27/24 at 9:46 am - 2/26/24 at 8:10 pm - 2/25/24 at 9:08 pm - 2/24/24 at 8:01 pm - 2/22/24 at 9:00 am - 2/21/24 at 1:39 pm C. On 02/29/24, at 2:20 pm, during an interview, the Director of Nursing (DON) stated that AVF assessments should be completed every shift and as needed as stated in the care plan, and that based off of the progress note documentation it appeared that it is only being done daily. The DON added that typically there would be an order entered into the resident's electronic medical record (EMR) so that the assessments would be tracked on the TAR (treatment administration record). Findings related to nutrition goal: D. Record review of R #71's care plan included the following goal: [PREFERRED NAME] will maintain adequate nutritional status as evidenced by maintaining weight within (X)% of (SPECIFY BASELINE), no s/sx (signs/symptoms) of malnutrition, and consuming at least (X)% of at least (X) meals daily through review date. Date Initiated: 02/08/2024 Revision on: 02/10/2024 Target Date: 04/26/2024 E. On 02/29/24, at 11:24 am, during an interview, MDS (Minimum Data Set) Nurse stated that the goal was entered by another member of the nursing staff and was not complete. This is a default goal that is supposed to be entered and then edited with the resident's information. She added that it should have already been completed with resident specific information.

Based on record review and interview, the facility failed to obtain a physician's order for dialysis (clinical purification of blood as a substitute for the normal function of the kidney) access site assessment and monitoring (ensuring the site used for dialysis remains free of complications related to excessive bleeding or closing) for 1 (R #71) of 1 (R #71) residents reviewed for dialysis care. This deficient practice could likely result in residents not receiving dialysis care and monitoring they need after dialysis treatment. The findings are: A. Record review of R #71's Electronic Medical Record (EMR) revealed that the resident was admitted to the facility on [DATE], with diagnoses (not an all-inclusive list) of end-stage renal disease (ESRD, chronic irreversible kidney failure), dependence on renal dialysis, and current use of anticoagulants (a type of medication prescribed to thin the blood and has risks associated with blood not clotting as easily). The record also included that R #71 has an AVF (arteriovenous fistula) to LUA (left upper arm) used for dialysis on Mondays, Wednesdays, and Fridays. B. Record review of facility's policy on Dialysis Care, NP-225 (undated) included expectations that the AVF be inspected for color, warmth, redness, tenderness, pain, edema (swelling), drainage, and bruit (sound of blood moving) once per shift. C. Record review of R #71's physician orders revealed the record did not contain an order for dialysis access site (AVF) monitoring every shift and PRN (as needed) after dialysis treatment. D. On 02/29/24, at 2:20 pm, during an interview, the Director of Nursing (DON) stated that AVF assessments should be completed every shift and as needed as this is typical care for all residents receiving dialysis and that a physician's order should have been entered.

Based on record review and interview, the facility failed to ensure staff maintained accurate medical records for 2 (R #1 and R #3) of 3 (R #1, R #2 and R #3) residents reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from constant pressure on the affected body part). This deficient practice could likely result in residents not receiving the care and services they need. The findings are: Findings for R #1: A. Record review of R #1's Face Sheet revealed she was admitted to the facility on [DATE], discharged on [DATE], and the record did not contain a diagnosis of pressure ulcer. B. Record review of R #1's Skin Check Assessment, dated 07/27/23, revealed a pressure wound on buttocks and coccyx (tailbone) area. C. Record review of R #1's care plan, dated 07/27/23, revealed resident's weekly wound assessment to include measurements and description of wound status. D. Record review of R #1's Transfer/Discharge Report, dated 08/03/23, revealed a diagnosis of pressure ulcer was not listed. E. On 11/16/23 at 11:20am, during an interview, the Director of Nursing (DON) stated the pressure ulcer diagnosis should have been listed on R #1's Face Sheet and her Transfer/Discharge Report. Findings for R #3: F. Record review of R #3's Face Sheet revealed she was admitted to the facility on [DATE], and the record did not contain a diagnosis of pressure ulcer. G. Record review of the facility's Weekly Pressure Injury Trending Report, dated 10/30/23, revealed a Stage II (shallow, open wound) pressure injury in R #3's intergluteal cleft area (the space between the two buttocks that starts at the tailbone and extends downward). H. Record review of R #3's quarterly Minimum Data Set (MDS; an assessment tool that measures functional capabilities and health needs for nursing home residents), dated 11/08/23, revealed under Section M - Skin Conditions, the resident had a Stage II pressure ulcer. I. Record review of R #3's Care Plan, date initiated 11/20/21, revealed the plan did not contain a diagnosis of pressure ulcer. J. On 11/16/23 at 11:24 am, during an interview, the DON stated R #3 had the pressure ulcer on her intergluteal cleft upon admission and currently had a Stage II pressure ulcer in the same area. The DON confirmed the diagnosis of pressure ulcer should be listed on R #3's Face Sheet and in the Care Plan. 47899

47899 Based on record review and and interview, the facility failed to develop a comprehensive care plan for 1 (R #2) of 3 (R #1, R #2 and R #3) residents reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from constant pressure on the affected body part). This deficient practice could likely result in residents not receiving the care and treatment needed to reach their highest well-being. The findings are: A. Record review of R #2's Face Sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: paraplegia (paralysis of the lower half of the body) and pressure ulcer of the sacral region (the bone at the base of the spine). B. Record review of R #2's Skin Only Evaluation, dated 09/19/23, revealed a Stage III (a deep wound that has broken through the top two layers of the skin and into the fatty tissue) pressure ulcer on his coccyx (tailbone). C. Record review of R #2's Care Plan, dated 09/09/23, revealed he required assistance with ADLs (activities of daily living), mobility (moving around), and transfers (moving from one position or setting to another) due to the diagnosis of paraplegia. The care plan did not contain interventions (methods to help treat or cure a medical condition or to prevent harm or improve functioning) to address repositioning of the body to prevent pressure ulcers. D. On 11/16/23 at 11:17 am, during an interview, the Director of Nursing (DON) stated R #2 should have an intervention listed on his Care Plan that instructed staff to reposition the resident to prevent pressure ulcers since the resident could not reposition himself independently due to a diagnosis of paraplegia.

Based on interview, record review, and observation, the facility failed to ensure that proper infection control practices were consistently followed. The following deficient practices could likely affect any of the 86 residents identified on the Facility Matrix provided by Administrator on 11/14/22 by allowing the spread of infectious agents [bacteria and viruses]. 1. Catheter tubing dragging on the ground under residents wheelchairs for R #'s 21, 64 and 70. 2. Catheter bag being placed on floor for R #50. 3. Laundry room not maintained in sanitary condition. 4. Residents room not sanitary after laundry The findings are: Findings related to catheter tubing: A. On 11/14/22 at 12:42 pm, an observation was made of catheter tubing dragging on the ground, under the wheelchair of R #70. R #70 was observed to have been wheeled by multiple staff and none of those staff attempted to correct the tubing dragging on the floor. B. On 11/16/22 at 12:29 pm, an observation was made of catheter tubing dragging on the ground under the wheelchairs of R #21 and R #64. C. On 11/16/22 at 12:40 pm, during an interview with the Center Nursing Executive (CNE) when it was pointed out that the catheter tubing was on floor for R #21 and R #64, CNE stated thank you. D. On 11/17/22 at 8:39 am, during an interview with Registered Nurse #5 she stated that the first thing you want to do with catheters is to make sure that it is anchored, covered, and should not be dragging on the floor. Findings for R # 50: E. On 11/15/22 at 12:14 pm, an observation was made of R #50 sitting at bedside eating his lunch while his urinary catheter bag is under the bed on the floor. F. On 11/15/22 at 12:24 pm, during an interview with Nursing Unit Manager (UM) #2 regarding why R #50's catheter bag was lying on the she revealed, yeah, we try but he always throws it there. G. On 11/15/22 at 3:56 pm and observation was made of R #50 resting in bed, his urinary catheter bag is lying on the floor. H. Record review of care plan for R #50 revealed care area focus created on 09/28/22 for urinary catheter and infection prevention related to it with no mention of interventions related to resident behavior of placing the catheter bag on the floor. Findings for laundry room: I. On 11/17/22 at 8:14 am, during an observation in the laundry room the following was noted, 1. The door between the clean and dirty areas was open, 2. The vents in the ceilings were brown spotted and dusty, 3. The ceiling light covers had significant dust in them, 4. There was no running water in the one available sink, 5. The dirty laundry area floor was bare cement. 6. The cleaned clothing was hanging uncovered. J. On 11/17/22 at 8:25 am during an interview with laundry staff person #1 she confirmed the findings in H above. Findings for resident room: K. On 11/14/22 at 12:44 pm during an interview with the facility administrator he revealed, resident room [ROOM NUMBER] had been cleaned and disinfected after a resident had been discharged . L. On 11/14/22 at 2:00 pm during observation of room [ROOM NUMBER] the following was noted, 1. Splattered brown material and a smashed mosquito over the window blind, 2. Spots of yellow, pink, and beige debris on the bed rails and frame and 3. A wheelchair with a visibly dirty pad in the seat. M. On 11/17/22 at 9:03 am during an interview Certified Nurse Assistant confirmed the findings in K above.

Based on record review, observation, and interview the facility failed to ensure that the ice-making machine was maintained in a clean and sanitary condition. This deficient practice could likely affect all 86 residents identified on the Facility Matrix provided by Administrator on 11/14/22 by not storing ice in a machine that is free from contamination and allowing the spread of bacteria and viruses. The findings are: A. On 11/16/22 at 11:02 am, during an observation of the facility's ice-making machine it was found to have hard water deposits (mineral deposits such as magnesium and calcium that can leave behind stains on surfaces) that were black in color on a bar that went across the ready-made ice in the ice machine and a black flake of unknown substance was on top of the ready made ice. B. On 11/16/22 at 11:21 am, during an interview with Central Supply (SC #1) confirmed that there was hard water deposits that were black in color on the bar that went across the ready-made ice in the machine and a black flake of unknown substance was on top of the ready-made ice. CS #1 also stated, It looks like it has not been cleaned for a while and I could not tell when the machine was last cleaned. C. On 11/16/22 at 11: 35 am, during observation of the ice machine, instructions printed on the ice machine stated, Clean when required, clean and sanitize at least 2 times a year. D. Record review of facility's logbook documentation revealed, the ice machine was last cleaned and sanitized on 09/02/22.

The facility failed to ensure that accident hazards were minimized, by neglecting to conspicuously place Wet Floor signs in a corridor which had recently been wiped with a wet mop. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K being identified on 05/24/16. The facility was notified on 05/24/16 at 9:52 am. The facility took corrective action by providing an acceptable Plan of Removal on 05/24/16 at 1:40 pm. Based on the Plan of Removal, interventions included: 1. Inservice of housekeeping staff on proper signage for wet floors. 2. Education of facility staff on the meaning of Wet Floor signs, and the necessity of redirecting residents from wet floors. 3. Assessment of ambulatory (able to walk) residents' understanding of the meaning of Wet Floor signs. All interventions showed intended completion dates of 05/24/16. Based on the Plan of Removal and interview, the IJ was lifted on 05/24/16 at 1:40 pm. This resulted in the scope and severity being reduced from level K to level E. Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, for the facility's 23 ambulatory residents (R #s 5, 12, 42, 50, 53, 62, 63, 74, 76, 80, 81, 86, 97, 105, 109, 112, 113, 117, 120, 153, 156, 157 and 160), as identified on a listing of ambulatory residents provided by the Administrator on 05/24/16. Wet Floor signs were placed next to the wall, rather than in the traffic area, of a busy corridor which had recently been mopped. This deficient practice is likely to result in significant resident injury, through avoidable slip-and-fall accidents. The findings are: A. On 05/24/16 at 9:12 am, during observation of the housekeeping staff mopping the floor in the corridor adjacent to the main dining room, the floor was observed to be wet for a distance of approximately 30 feet. The area of the wet floor was not obstructed to prevent walking on it, 2 Wet floor signs were observed to be flat against the wall and could not be read when looking down the corridor instead of in the traffic area, and no members of the housekeeping staff were in the immediate area of the wet floor. B. On 05/24/16 at 9:23 am, during interview with the Administrator, she stated that Wet Floor signs had arrows to indicate which side of the corridor floor was wet, and that the signs should have been placed so that it was clear which side of the corridor should be avoided. She stated that the housekeeper who had mopped the floor was a new hire, who had only worked at the facility for a few days, but that the housekeeper should have been educated about placement of Wet Floor signs when mopping. C. On 05/24/16 at 9:28 am, during interview with the HRM (Housekeeping Regional Manager), he stated that the wet floor signs were present on the side of the hallway, but that they should have been placed in the center of the hallway, and that there should have been one additional sign as well. He confirmed that there should be a Wet Floor sign every 15 feet. The HRM stated that the housekeeper who had mopped the floor that day was new, and that she had never been tasked with mopping floors at the facility before. He stated that he should have given her more education on the placement of signs when mopping. The HRM confirmed that, had an elderly or frail resident fallen, a serious injury could have resulted. D. On 05/24/16 at 9:32 am, during interview with Housekeeper #1, she confirmed that she had mopped the corridor floor that morning. She stated that she had worked at the facility for 2 or 3 weeks, but had never before been given the job of cleaning the floors. She stated that she had not received any training on how many signs were needed, or on their appropriate placement. She stated that she had not received any real training on the cleaning of floors at all, and that the HRM had just told her to clean the corridor floor and had quickly demonstrated how to do so. E. On 05/24/16 at 9:48 am, during interview with Licensed Practical Nurse (LPN) #1, he stated that when he checked the area after the visitor's fall, he noted that Wet Floor signs were next to the wall, rather than out in the middle of the floor. He stated that the signs were placed in a manner that would make them difficult for a person ambulating in the hallway to see. F. Record review of a document titled Housekeeping In-Service provided by the Administrator as a policy and procedure document, and dated 01/01/00, found that the Purpose section stated To review proper dry mopping and damp mopping procedures. The Damp mopping procedure section included the statements: 1. Hallways must be damp mopped half a hallway at a time. 2. Set up 'Wet Floor' signs to block off start of work area as well as halfway down the hall to show that one side is damp. G. Review of the facility's surveillance video at the time the wet floor was observed found: 1. that time stamps on the video were denoting time approximately 48 minutes faster than events were happening in real time. 2. that at time stamp 9:57, Housekeeper #1 placed Wet floor signs flat against the wall at both ends of the area to be mopped prior to mopping. Several staff members were observed to then walk through the designated area, without apparently noticing the signs. 3. that at time stamp 9:59, Housekeeper #1 began mopping the floor. The HRM then took the mop from her, and began demonstrating mopping technique. He then returned the mop to Housekeeper #1 to continue the task. The HRM did not adjust the sign placement to obstruct traffic flow at that time. 4. that at time stamp 10:00, after the housekeeper had stepped away from the wet floor area, a visitor slipped and fell on the wet floor. Immediately after observing the fall, the HRM was seen moving one of the Wet Floor signs from next to the wall to near the center of the corridor, where traffic would be diverted away from the wet area. The HRM then retrieved a third Wet floor sign, and placed it in the middle of the wet area.

Based on record review and interview, the facility failed to notify the resident's family of any mood, behaviors, adjustment issues or concerns during showers or bathing for 1 (R #59) of 2 (R #59 and #123) residents reviewed for abuse. This deficient practice likely prevented family members from making decisions regarding alternative treatment and advocating on behalf of the resident. The findings are: A. Record review of the Face Sheet dated 11/17/14, revealed the following Diagnosis: [REDACTED]. B. Record review of the Care Plan dated 02/19/15, indicated R #59 has potential for altered mood and behavior i.e. (that is); agitation, sadness, yell/sings loudly, worried, anxious d/t (due to) very confused most of time with Dx (diagnosis) Dementia. Interventions include: Assess and document any mood, behaviors and/or adjustment issues/concerns. Notify MD (medical doctor) and family as needed. C. On 03/19/15 at 10:23 am, during observation, a female could be heard screaming from inside the shower room located near the emergency exit door. The female resident was later identified as R #59. D. On 03/19/15 at 1:58 pm, during interview, Registered Nurse (RN) #2 was asked about R #59 screaming during showers. RN #2 stated, "Any time she (R #59) takes a shower, she screams. It doesn't matter who gives the shower, it doesn't matter if it's in the day or evening. She doesn't like water per her family. They said she never cared for bathing. The family doesn't want anything to help calm her, so we are honoring their wishes. The family wants her to have at least two showers a week, and we've discussed it with them." E. On 03/19/15 at 3:44 pm, during interview Family Member #1, was asked if she (Family Member #1) was aware of any issues regarding R #59 during showers. Family Member #1 stated, "No. She (R #59) has Alzheimer's and she isn't all there. No one has said anything about that, so I never question it. No one has ever said anything. All they (staff) say at the meetings (referring to care plan meetings for R #59) is 'Everything is okay, everything is fine'. They didn't say anything about her screaming." When Family Member #1 was asked if R #59 had a fear of water, Family Member #1 stated, "Not that I know of. When she was here with me she was fine. I don't know when they are showering her if they (staff) are putting water all over her. Maybe how they do it is why she is screaming. No one has asked me or told me about this. I was not aware." When asked if staff talked about medication to help calm R #59 during showers, Family Member #1 stated, "No, no one has asked or said anything about that. I've been attending all the meetings (care plan meetings) quarterly. They never brought it up, so I don't know. They say everything is fine and there have been no changes. They never asked or told me, maybe if they did, then we would have talked about it more."

Based on interview and record review, the facility failed to implement written policies and procedures for prohibiting abuse and mistreatment for 7 (R #11, 12, 25, 32, 51, 59 and 123) of 7 (R #11, 12, 25, 32, 51, 59 and 123) residents reviewed for abuse and during random observation by: 1) Not investigating complaints of abuse filed by residents and family members for R #11, 12, 25, 32, 51, 59 and 123. 2) Not implementing interventions to ensure that R #59 was not subjected to further psychological harm/distress during showers. This deficient practice had the potential to allow residents to be abused, neglected and mistreated, if the facility fails to implement policies and procedures to protect them. The findings are: A. Record review of the Abuse Prohibition Policy and Procedure dated 07/01/13 states: 1. "Facility will prohibit abuse, mistreatment, neglect...for all patients through the following: a. Prevention of occurrences b. Identification of possible incidents or allegations which need investigation. c. Investigation of incidents and allegations. d. Protection of patients during investigations. e. Reporting of incidents, investigations, and Center response to the results of their investigations. 2. "Actions to prevent abuse...Any staff member who suspects or witnesses an incident of abuse, mistreatment, neglect, injuries of unknown origin ...is to tell the abuser to stop immediately and report the incident to his or her supervisor and the DHI immediately. a. If the alleged perpetrator is an employee he or she will be immediately be removed from duty, pending investigation. b. All reports of suspected abuse must also be reported to the patient's family and attending physician. 3. "Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect...the Administrator or designee will perform the following. a. Initiate an investigation within 24 hours of an allegation of abuse b. The investigation will be thoroughly documented on the Center's investigation form and log." B. Record review of the Grievance/Concern Policy dated 06/10/13 states, "Center leadership will investigate, document and follow up on all formal concerns and grievances registered by any patient or patient representative. Social Services personnel will serve as patient advocates in the grievance/concern process...Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log...Section 4.1.2 states, for reports of abuse, follow the state-specific abuse policy...Section 5 states that the manager will: 1. Contact the person filing the grievance to acknowledge receipt 2. Investigate the grievance 3. Notify the person filing the grievance of resolution within 72 hours." C. On 03/19/15 at 2:55 pm, during interview the Social Services Director (SSD) explained that grievances or concerns are reviewed by her then she refers them to the appropriate department directors to follow up on. Concerns or issues regarding complaints or grievances are also discussed in the daily morning meeting with Administration and we try to resolve them the same day. D. Record review of facility Grievance/Concern Forms found a grievance form dated 01/20/15 signed by Family Member #3, the daughter of R #123. It stated "The night of 01/19/15, Monday night, (name of LPN #2) gave meds to my mom. She was jerking my mom around while giving meds to her. I've seen her do that to other Residents. Why is she working if she is going to be mean to elders? Please do something about it. Thanks for your understanding." E. Record review of the Grievance Log Book dated 01/01/15 to 02/28/15 revealed no resolution date for complaints of abuse made by R #25 and R #123. F. On 03/19/15 at 3:34 pm, during interview the DNS was asked to explain why two complaints of abuse regarding nursing staff that had occurred in January 2015 and February 2015 from R #25 and R #123, had no resolution date documented in the grievance log book. She (DNS) looked through the grievance binder and stated, "I can't tell you what happened to these" and then stated "It wasn't done." G. On 03/19/15 at 3:40 pm, during interview the Clinical Operations Manager confirmed the complaint investigations for ( R# 25 and R# 123) had not been completed by stating "We didn't do it." H. On 03/19/15 at 5:09 pm, during interview R #12 stated that she has had fights with Licensed Practical Nurse (LPN #2). R #12 stated that LPN #2 has made her cry by telling her (R #12) she can't have snacks. She (LPN #2) pinches and rubs too hard. R #12 stated she had filed 2 grievances against LPN #2 in February 2015 and Registered Nurse (RN #3) was told about it. I. On 03/19/15 at 3:42 pm, during interview the DNS explained that grievances/ allegations of abuse are reported to DOH (Department of Health) and investigated within 72 hours. "Any grievances with nursing and certified nursing assistants (CNAs) get personally handled by me." When asked why these grievance/concern issues were not addressed, the DNS stated, "I cannot remember seeing one of them, and I think the other one is really a resident to resident issue." The DNS admitted the grievance report regarding R #25 was assigned to her and that it was not completed. J. On 03/19/15 at 5:07 pm, during interview with R #32 when asked if he had ever been mistreated by staff, R #32 nodded his head and stated,"Yes the staff treats me badly and sometimes they talk to me badly. The 'skinny one' that comes in the evening, she doesn't treat me good. Sometimes she yells at me and sometimes she keeps saying she is too busy to help me. The staff are good, but 'skinny' is bad and I don't like her. She is mean to everyone sometimes." When asked if R #32 knew who "Skinny" was, R #32 said "No, I call her skinny. " K. On 03/20/15 at 9:00 am, during interview RN #2 stated, "If any residents or family members have any complaints, I send them to Social Services or have Social Services go down to their rooms." When RN #2 was asked if she could recall any complaints by residents or family members, she (RN #2) stated she would "Rather not comment about that." She then stated, "Complaints did occur at night, but I would not comment on this." When asked if she knew of any complaints made by residents or family members about LPN #2, RN #2 stated, "Yes...her mouth...not her treatment, but what she says. Like saying "You're already large enough and you shouldn't eat that." When RN #2 was asked if she had ever received any complaints, she (RN #2) nodded yes and stated, "I sent Social Services to the resident's room." L. On 03/20/15 at 9:29 am, during interview the SSD stated, "There were no complaints or grievances found for R #12 or R #51 in the grievance book for the present year or all of last year." M. On 03/20/15 at 9:37 am, during interview R #32 confirmed that the Director of Nursing Services (DNS) and Administrator did come and talk to him. When asked what they asked him, he stated, "The same as you did." When asked what he told them he stated, " The same as you." Then when asked if he told them about "Skinny" he stated, " Yes..I don't like her. She is bad." N. On 03/20/15 at 9:53 am, during interview with R #32 when presented with a photo ID of LPN #2, R #32 said "Yeah....yeah...Skinny, that's her, that's Skinny." O. On 03/20/15 at 11:10 am, during interview, Family Member #2 stated "(name of R # 11) complains a lot. To her, it's like they don't want to help her. They have a lot of attitude. They'll say 'I've already helped you. You should be okay.' Maybe they're short-of-staff. When they give her attitude, she gives them attitude back and it goes back and forth. She doesn't give me names. Over the weekend, one of the nurses called me and said 'Your mom is upset and is wanting to leave the facility. She keeps trying to go to the door.' I asked them 'Why is she doing that?' They said, 'She says we're being mean to her and she doesn't want to be here.' After talking to my mom, she said she was in an argument with the nurse. She says they yell at residents. Some of the residents are complaining, saying the staff says, 'Why did you pee on yourself, and why did you poop on yourself.' Most of the times her stories are true and she will defend herself." P. On 03/20/15 at 11:13 am, during interview with the Administrator regarding a grievance report received on 01/02/15 regarding resident R #59, she (Administrator) stated they (Administrator, Social Service Director and DNS) could not find the original grievance report (According to the Grievance/Concern LOG dated January 2015, R #59's family had concerns of a Licenced Nurses attitude and bruising). Q. On 03/20/15 at 12:30 pm, during interview Family Member #3 was asked about the grievance form she filed on 01/20/15. She stated that there has not been any response from the facility. She stated that she was visiting R #123 and she (R # 123) didn't want to take her medications. "My mother's roommate (R #84) told me that (name of LPN #2) had on another occasion, forced my mother to take her medication when she didn't want to. She had pushed it into my mother's mouth, and made her take it. I asked my mom if this was true, and she said that it was. Family member #3 then stated "(Name of LPN #2) is always really rude, so I try not to talk to her when I'm there. When I've asked her questions about my mom, she always just says everything is fine, but doesn't know anything specific." R. On 3/20/15 at 12:50 pm during interview regarding R #51's care, Family Member #4 stated when the family takes R #51out for dinner, LPN #2 would make comments like "Here you come, I am sure your sugar is up." FM #4 said she didn't like the comments LPN #2 would make to them and didn't like to be around her (LPN #2). "She (LPN #2) shouldn't be doing things like that. No one else ever made comments to me or the family and didn't understand where the comments were coming from. She (LPN #2) would make really unprofessional comments." Family member #4 stated that she did mention it to nursing staff and was told to see Social Services and write out a complaint, but that she had not done so. S. On 03/20/15 at 2:05 pm, during interview the SSD stated, she has had no complaints from R #51 or from Family Member #4, but remembered that Family Member #4 did have a complaint. The SSD couldn't remember what the complaint was about. The Social Service Director was unable to locate or provide the grievance reports from Family Member #4. T. On 03/20/15 at 2:18 pm, during interview with the Administrator and the DNS, when questioned (regarding R #59's grievance report dated 01/02/15 as indicated on the Grievance/Concern Log) the Administrator stated "That's the one we don't have." When asked if they recalled a conversation with R #32, the DNS stated that R #32 just told them (DNS and the Administrator) about his (R #32) shingles and no one treated him "roughly". The DNS denied that R #32 ever complained about LPN #2. When questioned regarding a grievance (assigned to the DNS as indicated on the grievance form) written and submitted by Family Member #3 of R #123 dated 01/20/15, the DNS stated, "I don't know. I got a copy of the grievance (but couldn't talk to it or why it was not investigated). I (DNS) called LPN #2 and she (LPN #2) didn't know of any situation where this happened. There was no documentation provided indicating a conversation/investigation between the DNS and LPN #2 took place. U. On 03/20/15 at 2:18 pm, during interview with the Administrator and the DNS, when questioned regarding R #59's grievance report dated 01/02/15 as indicated on the Grievance/Concern Log, the Administrator stated "That's the one we don't have." When questioned regarding a grievance (assigned to the DNS as indicated on the grievance form) written and submitted by Family Member #3 of R #123 dated 01/20/15, the DNS stated, "I don't know." During the interview the DNS could not explain why the above grievance reports were not investigated. Findings related to Resident #59: V. Record review of the Face Sheet dated 11/17/14, revealed the following Diagnosis: [REDACTED]. W. Record review of the Care Plan dated 02/19/15, indicated R #59 has potential for altered mood and behavior i.e. (that is); agitation, sadness, yell/sings loudly, worried, anxious d/t (due to) very confused most of time with Dx (diagnosis) Dementia. Interventions include: Assess and document any mood, behaviors and/or adjustment issues/concerns. Notify MD (medical doctor) and Family as needed. X. On 03/19/15 at 10:23 am, during observation, a female could be heard screaming from inside the shower room located near the emergency exit door. The female resident was later identified as R #59. Y. On 03/19/15 at 10:25 am, during interview with (CNA) #4, she was asked who was screaming in the shower room. CNA #4 stated, "That's (name of R #59). She does that." When asked if she tried to find out why R #59 screams during showers, she stated "No." When asked if that's something R #59 does during showers she stated, "Yes." When CNA #4 was asked if she asks R #59 if the water is too hot or too cold or if staff is causing her to scream, she stated "No." Z. On 03/19/15 at 10:34 am, during interview with CNA #5 and CNA #6, both confirmed that R #59 yells out during her showers all the time as soon as the water starts. CNA #5 stated, "She does that all the time." CNA #5 and CNA #6 stated that R #59 was yelling because her hair was getting wet. AA. On 03/19/15 at 1:58 pm, during interview RN #2 was asked about R #59 screaming during showers. RN #2 stated, "Anytime she (R #59) takes a shower, she screams. It doesn't matter who gives the shower, it doesn't matter if it's in the day or evening. She doesn't like water per her family. They said she never cared for bathing. The family doesn't want anything to help calm her, so we are honoring their wishes. To me, it's not a big deal. She (R #59) is not getting hurt, she just doesn't like water." RN #2 confirmed R #59 receives showers twice a week. RN #2 further stated, "The family wants her to have at least two showers a week, and we've discussed it with them." RN #2 was asked if R #59 screams for every shower, RN #2 stated "Yes. The minute the water is off, she's fine. It's only when the water is on her. Even with the bed bath it (water) bothers her. She absolutely hates it." She was asked if staff has discussed other ways of bathing R #59, RN #2 stated "No. The bed bath was as far as it went." BB. On 03/19/15 at 2:12 pm, during interview with CNA #5, when asked if R #59 screams during showers, she stated, "She has her days. Most of the time, she is yelling. She (R #59) is always cold, so you have to hurry the shower so she won't be yelling." CNA #5 was asked if R #59 refuses showers. She stated "Yes. She will say it's cold." When asked if other options have been tried, CNA #5 stated "No." She was asked if bed baths have been tried. CNA #5 stated "No. We haven't tried that. I think she would fight us more." CC. On 03/19/15 at 2:22 pm, during interview with CNA #4, when asked if R #59 screams during her shower, CNA #4 stated "All the time. It's a normal thing." She stated "I told her already that I was going to give her a shower. She (R #59) said okay. I took her clothes off, put her on the chair, I turned on the water, and I asked if the water was okay. She (R #59) said yes. Then I put shampoo on her hair and when I tried to rinse it, that's when she started screaming. It (R #59's hair) was already soapy and I had to rinse it out. She wasn't really crying, she just does that." When asked if alternatives have been tried, CNA #4 stated "She will scream for that too. She will scream for just wetting her. Even if we give her a wet wash cloth to wash her face she screams." CNA #4 was asked if R #59 refuses showers. She stated "Sometimes. She is capable of saying no. If she refuses, we ask again and maybe one time she will say yes. We keep trying, if she said no, I would come back and ask her. She will say yes eventually. When I was washing her hair she said stop, but I had to wash the soap out. I did it real quick. It (soap) was in her eyes too, she was wiping her eyes. I could of stopped, but her eyes would of burned. She's fine until she gets wet." DD. On 03/19/15 at 2:40 pm, during interview with CNA #6, she was asked if R #59 screams during showers. She stated "Yes. Right when the water hits, she will yell and scream the whole time." CNA #6 confirmed that it happens with every shower. "Right when the water hits her is when she starts yelling and screaming. Once the water hits her and even after we start washing her she yells. The first time I had to shower her, I got nervous." When asked if bed baths have been tried, CNA #6 stated "I haven't tried to give a bed bath." EE. On 03/19/15 at 3:44 pm, during phone interview Family Member #1 of R #59, was asked if she (Family Member #1) was aware of any issues regarding R #59 during showers. Family Member #1 stated, "No. She (R #59) has Alzheimer's and she isn't all there. No one has said anything about that, so I never questioned it. No one has ever said anything. All they (staff) say at the meetings (referring to care plan meetings for R #59) is 'Everything is okay, everything is fine'. They didn't say anything about her screaming." When Family Member #1 was asked if R #59 had a fear of water, Family Member #1 stated, "Not that I know of. When she was here with me, she was fine. I don't know when they are showering her if they (staff) are putting water all over her. Maybe how they do it is why she is screaming. No one has asked me or told me about this. I was not aware." When asked if staff talked about medication to help calm R #59 during showers, Family Member #1 stated, "No, no one has asked or said anything about that. I've been attending all the meetings (care plan meetings) quarterly. They never brought it up, so I don't know. They say everything is fine and there have been no changes. They never asked or told me, maybe if they did, then we would of talked about it more."

Based on observation, record review and interviews, the facility failed to ensure residents were free from verbal, physical, psychological, and psychosocial abuse in 7 (R #'s 11, 12, 25, 32, 51, 59, and 123) of 7 (R #'s 11, 12, 25, 32, 51, 59, and 123) residents reviewed for abuse and during random observation by: 1) Not investigating complaints of abuse filed by residents and family members for R #11, 12, 25, 32, 51, 59 and 123. 2) Not implementing interventions to ensure that R #59 was not subjected to further psychological harm/distress during showers. This deficient practice has the potential to cause psycological and or physical harm to residents. The findings are: Findings related to abuse complaints/grievances: A. On 03/19/15 at 2:55 pm, during interview the Social Services Director (SSD) explained that grievances or concerns are reviewed by her then she refers them to the appropriate department directors to follow up on. Concerns or issues regarding complaints or grievances are also discussed in the daily morning meeting with Administration and we try to resolve them the same day. B. Record review of facility Grievance/Concern Forms found a grievance form dated 01/20/15 signed by Family Member #3, the daughter of R #123. It stated "The night of 01/19/15, Monday night, (name of LPN #2) gave meds to my mom. She was jerking my mom around while giving meds to her. I've seen her do that to other Residents. Why is she working if she is going to be mean to elders? Please do something about it. Thanks for your understanding." C. Record review of the Grievance Log Book dated 01/01/15 to 02/28/15 revealed no resolution date for complaints of abuse made by R #25 and R #123. D. On 03/19/15 at 3:34 pm, during interview the DNS was asked to explain why two complaints of abuse regarding nursing staff that had occurred in January 2015 and February 2015 from R #25 and R #123, had no resolution date documented in the grievance log book. She (DNS) looked through the grievance binder and stated, "I can't tell you what happened to these" and then stated "It wasn't done." C. On 03/19/15 at 3:40 pm, during interview the Clinical Operations Manager confirmed the complaint investigations for ( R# 25 and R# 123) had not been completed by stating "We didn't do it." D. On 03/19/15 at 5:09 pm, during interview R #12 stated that she has had fights with Licensed Practical Nurse (LPN #2). R #12 stated that LPN #2 has made her cry by telling her (R #12) she can't have snacks. She (LPN #2) pinches and rubs too hard. R #12 stated she had filed 2 grievances against LPN #2 in February 2015 and Registered Nurse (RN #3) was told about it. E. On 03/19/15 at 3:42 pm, during interview the DNS explained that grievances/ allegations of abuse are reported to DOH (Department of Health) and investigated within 72 hours. "Any grievances with nursing and certified nursing assistants (CNAs) get personally handled by me." When asked why these grievance/concern issues were not addressed, the DNS stated, "I cannot remember seeing one of them, and I think the other one is really a resident to resident issue." The DNS admitted the grievance report regarding R #25 was assigned to her and that it was not completed. F. On 03/19/15 at 5:07 pm, during interview with R #32 when asked if he had ever been mistreated by staff, R #32 nodded his head and stated,"Yes the staff treats me badly and sometimes they talk to me badly. The 'skinny one' that comes in the evening, she doesn't treat me good. Sometimes she yells at me and sometimes she keeps saying she is too busy to help me. The staff are good, but 'skinny' is bad and I don't like her. She is mean to everyone sometimes." When asked if R #32 knew who "Skinny" was, R #32 said "No, I call her skinny. " G. On 03/20/15 at 9:00 am, during interview RN #2 stated, "If any residents or family members have any complaints, I send them to Social Services or have Social Services go down to their rooms." When RN #2 was asked if she could recall any complaints by residents or family members, she (RN #2) stated she would "Rather not comment about that." She then stated, "Complaints did occur at night, but I would not comment on this." When asked if she knew of any complaints made by residents or family members about LPN #2, RN #2 stated, "Yes...her mouth...not her treatment, but what she says. Like saying "You're already large enough and you shouldn't eat that." When RN #2 was asked if she had ever received any complaints, she (RN #2) nodded yes and stated, "I sent Social Services to the resident's room." H. On 03/20/15 at 9:29 am, during interview the SSD stated, "There were no complaints or grievances found for R #12 or R #51 in the grievance book for the present year or all of last year." I. On 03/20/15 at 9:37 am, during interview R #32 confirmed that the Director of Nursing Services (DNS) and Administrator did come and talk to him. When asked what they asked him, he stated, "The same as you did." When asked what he told them he stated, " The same as you." Then when asked if he told them about "Skinny" he stated, " Yes..I don't like her. She is bad." J. On 03/20/15 at 9:53 am, during interview with R #32 when presented with a photo ID of LPN #2, R #32 said "Yeah....yeah...Skinny, that's her, that's Skinny." K. On 03/20/15 at 11:10 am, during interview, Family Member #2 stated "(name of R # 11) complains a lot. To her, it's like they don't want to help her. They have a lot of attitude. They'll say 'I've already helped you. You should be okay.' Maybe they're short-of-staff. When they give her attitude, she gives them attitude back and it goes back and forth. She doesn't give me names. Over the weekend, one of the nurses called me and said 'Your mom is upset and is wanting to leave the facility. She keeps trying to go to the door.' I asked them 'Why is she doing that?' They said, 'She says we're being mean to her and she doesn't want to be here.' After talking to my mom, she said she was in an argument with the nurse. She says they yell at residents. Some of the residents are complaining, saying the staff says, 'Why did you pee on yourself, and why did you poop on yourself.' Most of the times her stories are true and she will defend herself." L. On 03/20/15 at 11:13 am, during interview with the Administrator regarding a grievance report received on 01/02/15 regarding resident R #59, she (Administrator) stated they (Administrator, Social Service Director and DNS) could not find the original grievance report (According to the Grievance/Concern LOG dated January 2015, R #59's family had concerns of a Licenced Nurses attitude and bruising). M. On 03/20/15 at 12:30 pm, during interview Family Member #3 was asked about the grievance form she filed on 01/20/15. She stated that there has not been any response from the facility. She stated that she was visiting R #123 and she (R # 123) didn't want to take her medications. "My mother's roommate (R #84) told me that (name of LPN #2) had on another occasion, forced my mother to take her medication when she didn't want to. She had pushed it into my mother's mouth, and made her take it. I asked my mom if this was true, and she said that it was. Family member #3 then stated "(Name of LPN #2) is always really rude, so I try not to talk to her when I'm there. When I've asked her questions about my mom, she always just says everything is fine, but doesn't know anything specific." N. On 3/20/15 at 12:50 pm during interview regarding R #51's care, Family Member #4 stated when the family takes R #51out for dinner, LPN #2 would make comments like "Here you come, I am sure your sugar is up." FM #4 said she didn't like the comments LPN #2 would make to them and didn't like to be around her (LPN #2). "She (LPN #2) shouldn't be doing things like that. No one else ever made comments to me or the family and didn't understand where the comments were coming from. She (LPN #2) would make really unprofessional comments." Family member #4 stated that she did mention it to nursing staff and was told to see Social Services and write out a complaint, but that she had not done so. O. On 03/20/15 at 2:05 pm, during interview the SSD stated, she has had no complaints from R #51 or from Family Member #4, but remembered that Family Member #4 did have a complaint. The SSD couldn't remember what the complaint was about. The Social Service Director was unable to locate or provide the grievance reports from Family Member #4. P. On 03/20/15 at 2:18 pm, during interview with the Administrator and the DNS, when questioned (regarding R #59's grievance report dated 01/02/15 as indicated on the Grievance/Concern Log) the Administrator stated "That's the one we don't have." When asked if they recalled a conversation with R #32, the DNS stated that R #32 just told them (DNS and the Administrator) about his (R #32) shingles and no one treated him "roughly". The DNS denied that R #32 ever complained about LPN #2. When questioned regarding a grievance (assigned to the DNS as indicated on the grievance form) written and submitted by Family Member #3 of R #123 dated 01/20/15, the DNS stated, "I don't know. I got a copy of the grievance (but couldn't talk to it or why it was not investigated). I (DNS) called LPN #2 and she (LPN #2) didn't know of any situation where this happened. There was no documentation provided indicating a conversation/investigation between the DNS and LPN #2 took place. Findings related to Resident #59: Q. Record review of the Face Sheet dated 11/17/14, revealed the following Diagnosis: [REDACTED]. R. Record review of the Care Plan dated 02/19/15, indicated R #59 has potential for altered mood and behavior i.e. (that is); agitation, sadness, yell/sings loudly, worried, anxious d/t (due to) very confused most of time with Dx (diagnosis) Dementia. Interventions include: Assess and document any mood, behaviors and/or adjustment issues/concerns. Notify MD (medical doctor) and Family as needed. S. On 03/19/15 at 10:23 am, during observation, a female could be heard screaming from inside the shower room located near the emergency exit door. The female resident was later identified as R #59. T. On 03/19/15 at 10:25 am, during interview with (CNA) #4, she was asked who was screaming in the shower room. CNA #4 stated, "That's (name of R #59). She does that." When asked if she tried to find out why R #59 screams during showers, she stated "No." When asked if that's something R #59 does during showers she stated, "Yes." When CNA #4 was asked if she asks R #59 if the water is too hot or too cold or if staff is causing her to scream, she stated "No." U. On 03/19/15 at 10:34 am, during interview with CNA #5 and CNA #6, both confirmed that R #59 yells out during her showers all the time as soon as the water starts. CNA #5 stated, "She does that all the time." CNA #5 and CNA #6 stated that R #59 was yelling because her hair was getting wet. V. On 03/19/15 at 1:58 pm, during interview RN #2 was asked about R #59 screaming during showers. RN #2 stated, "Anytime she (R #59) takes a shower, she screams. It doesn't matter who gives the shower, it doesn't matter if it's in the day or evening. She doesn't like water per her family. They said she never cared for bathing. The family doesn't want anything to help calm her, so we are honoring their wishes. To me, it's not a big deal. She (R #59) is not getting hurt, she just doesn't like water." RN #2 confirmed R #59 receives showers twice a week. RN #2 further stated, "The family wants her to have at least two showers a week, and we've discussed it with them." RN #2 was asked if R #59 screams for every shower, RN #2 stated "Yes. The minute the water is off, she's fine. It's only when the water is on her. Even with the bed bath it (water) bothers her. She absolutely hates it." She was asked if staff has discussed other ways of bathing R #59, RN #2 stated "No. The bed bath was as far as it went." W. On 03/19/15 at 2:12 pm, during interview with CNA #5, when asked if R #59 screams during showers, she stated, "She has her days. Most of the time, she is yelling. She (R #59) is always cold, so you have to hurry the shower so she won't be yelling." CNA #5 was asked if R #59 refuses showers. She stated "Yes. She will say it's cold." When asked if other options have been tried, CNA #5 stated "No." She was asked if bed baths have been tried. CNA #5 stated "No. We haven't tried that. I think she would fight us more." X. On 03/19/15 at 2:22 pm, during interview with CNA #4, when asked if R #59 screams during her shower, CNA #4 stated "All the time. It's a normal thing." She stated "I told her already that I was going to give her a shower. She (R #59) said okay. I took her clothes off, put her on the chair, I turned on the water, and I asked if the water was okay. She (R #59) said yes. Then I put shampoo on her hair and when I tried to rinse it, that's when she started screaming. It (R #59's hair) was already soapy and I had to rinse it out. She wasn't really crying, she just does that." When asked if alternatives have been tried, CNA #4 stated "She will scream for that too. She will scream for just wetting her. Even if we give her a wet wash cloth to wash her face she screams." CNA #4 was asked if R #59 refuses showers. She stated "Sometimes. She is capable of saying no. If she refuses, we ask again and maybe one time she will say yes. We keep trying, if she said no, I would come back and ask her. She will say yes eventually. When I was washing her hair she said stop, but I had to wash the soap out. I did it real quick. It (soap) was in her eyes too, she was wiping her eyes. I could of stopped, but her eyes would of burned. She's fine until she gets wet." Y. On 03/19/15 at 2:40 pm, during interview with CNA #6, she was asked if R #59 screams during showers. She stated "Yes. Right when the water hits, she will yell and scream the whole time." CNA #6 confirmed that it happens with every shower. "Right when the water hits her is when she starts yelling and screaming. Once the water hits her and even after we start washing her she yells. The first time I had to shower her, I got nervous." When asked if bed baths have been tried, CNA #6 stated "I haven't tried to give a bed bath." Z. On 03/19/15 at 3:44 pm, during phone interview Family Member #1 of R #59, was asked if she (Family Member #1) was aware of any issues regarding R #59 during showers. Family Member #1 stated, "No. She (R #59) has Alzheimer's and she isn't all there. No one has said anything about that, so I never questioned it. No one has ever said anything. All they (staff) say at the meetings (referring to care plan meetings for R #59) is 'Everything is okay, everything is fine'. They didn't say anything about her screaming." When Family Member #1 was asked if R #59 had a fear of water, Family Member #1 stated, "Not that I know of. When she was here with me, she was fine. I don't know when they are showering her if they (staff) are putting water all over her. Maybe how they do it is why she is screaming. No one has asked me or told me about this. I was not aware." When asked if staff talked about medication to help calm R #59 during showers, Family Member #1 stated, "No, no one has asked or said anything about that. I've been attending all the meetings (care plan meetings) quarterly. They never brought it up, so I don't know. They say everything is fine and there have been no changes. They never asked or told me, maybe if they did, then we would of talked about it more."

Based on observation, record review and interview, the facility failed to maintain a resident's highest practicable well-being by not providing pain management during a wound care dressing change for 1 of 21 sampled residents (#132) to prevent the potential for breakthrough pain during the dressing change. This deficient practice had the potential to affect five residents with pressure ulcers and receiving wound care in the facility. The findings are: A. On 01/11/11 at 10:30 am, during interview and observation of wound care and dressing change for Resident #132, a grimace was seen on the resident's face during the cleansing of the right lower extremity. The License Practical Nurse (LPN) #7 stated that she "usually address pain during dressing change and if pain is noted I will let the nurse know and then return about an hour later to do the dressing change." She also stated that she did not ask the resident about pain because she knew the resident receives pain medication in the morning. LPN #7 then asked the resident if she was in pain and the resident nodded yes. LPN #7 stated, "You're in pain all the time." B. On 01/11/11 at 10:45 am, during an interview, LPN #5 stated she gave pain medication in the morning as scheduled and had not given anything else for pain. She stated she did an assessment prior to dressing changes in case of pain medication being needed. LPN #5 stated she did not ask Resident #132 prior to the dressing change if she had any pain and the only pain medication given was at 7:00 am. C. On 01/11/10 at 6:30 pm, when Resident #132 was asked on a pain scale of 1-10 how bad her pain was, she stated that during dressing change she feels the pain was at an eight. She further stated that she tells staff about the pain during the dressing changes, but feels she gets no response to her request. D. Record review of a physician's orders [REDACTED]. E. Record review of the January 2011 Treatment Record indicated "clean wounds right lower extremities with sterile normal saline, cover with dry 4x4's wrap with Kerlix change every other day and as need when not intact." F. On 01/12/11 at 9:38 am, during interview with the Assistant Director of Nurses, she stated that her expectation would be that the site was "checked everyday and changed if needed as dressings get soiled or slip off. If the nurse does it everyday it is due to the nurses judgement that it needs to be changed." G. Review of the 12/28/10 Pharmacy Controlled Drug Receipt/Record/Disposition Form for Resident #132 indicated, "[MEDICATION NAME]/APAP 10/650 mg, one tablet by mouth one hour before dressing change and TID prn (three times a day as needed)." There was no documentation in the chart to indicate that the medication had been given for the last 4 days of December (28, 29, 30 and 31). H. During review of the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. I. Review of History and Physical notes dated 12/28/10, indicated Resident #132 was admitted to facility from hospital on [DATE] with [DIAGNOSES REDACTED]. S/P (status [REDACTED]. Type 2 Diabetes, Stroke, CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION], B-12 deficiency, obesity, [MEDICAL CONDITION] stage 2-3, [DIAGNOSES REDACTED], weakness, and deconditioning."