Every finding on record at Sequoyah Pointe Skilled Nursing and Therapy

On 05/13/25, a past noncompliance situation was determined to exist related to the facility's failure to provide supervision to protect residents. An incident report, dated 05/02/25, showed Resident #1 had left the facility without staff knowledge and was found by local police in a commercial establishment's parking lot approximately 400 feet from the facility. Resident #1 was returned to the facility within 30 minutes of their departure and was transferred to a secured facility two days later. Based on observation, record review, and interview the facility failed to ensure a resident with a history of elopement did not elope from the facility for 1 (#1) of 3 sampled residents reviewed for accident hazards. Corp. Nurse Consult. #1 reported five residents wandered at the facility. Findings: On 05/13/25 at 10:30 a.m., the lock on the kitchen door was observed during the initial tour. A facility document titled Elopement Risk Guideline, dated 04/2025, read in part, 1. The Elopement risk assessment is completed on all admissions, readmissions, elopements, and significant changes. Elopements and significant changes are reported to a member of the IDT [interdisciplinary team] . 2. If a resident is identified to be at risk for elopement, initiate interdisciplinary care plan accordingly and follow plan of care. A care plan focus, dated 09/27/22 and revised 05/25/23, showed Resident #1 was deemed to have a risk for elopement related to impaired safety awareness and a previous elopement at the facility. A Elopement Risk Scale form, dated 02/28/25, showed Resident #1 had a score of 8 on the assessment which indicated a low elopement risk. An annual minimum data set assessment, dated 04/16/25, showed Resident #1 had a brief interview for mental status score of 14 which indicated the resident's cognitive abilities were intact. A progress note titled Incident Note, dated 05/02/25 at 10:48 p.m. showed Resident #1 had eloped through a back door of the facility kitchen and was found about one block away at a local store parking lot. The note further showed the resident had stated they were waiting for their family member to pick them up. The note showed the resident was assessed upon return to the facility and no injuries had been identified. A progress note tilted Nurses Progress Notes, dated 05/05/25 at 5:15 p.m., showed Resident #1 had been transferred to a geriatric psychiatric unit for evaluation. A progress note titled Nurses Progress Notes, dated 05/12/25 at 1:01 p.m., showed Resident #1 remained at the geriatric psychiatric unit and would be transferred to a more secure nursing facility after discharge from the hospital. On 05/13/25 at 10:30 a.m., the kitchen door where Resident #1 had eloped was observed. The door had a keypad electronic lock on the door. On 05/14/25 at 9:27 a.m., corp. nurse consult. #1 stated Resident #1 had left the facility through a back door in the kitchen. They stated the resident had crossed a dead end street behind the facility to the parking lot of a local market. Corp. Nurse Consult. #1 stated they had gone to a house next to the facility and the occupant felt the resident was confused and called the police. They stated the police found the resident at the store and called the facility. On 05/15/25 at 11:04 a.m., the DON stated a neighbor of the facility called the police department on 05/02/25 at 4:10 p.m. and the resident was back in the facility when they started the incident report at 4:35 p.m. the same afternoon. The DON stated the resident was placed on one on one checks until they were transferred to a hospital on [DATE]. They stated the kitchen door Resident #1 had used to depart the facility had a keypad placed on it on 05/05/25. The DON stated Resident #1 made no further attempts to leave the facility prior to being transferred to the hospital. The DON stated all staff were in-serviced on elopement, and monitoring of both Resident #1 movements as well as the kitchen door. They stated this began the day the resident eloped on 05/02/25. On 05/15/25 at 1:00 p.m., the administrator supplied documentation of corrections made following the elopement including a quality assurance and performance improvement teams document, dated 05/02/25 at 4:30 p.m., that identified the problem and corrections made, staff elopement in-service attendance documents dated 05/02/25 at 5:30 p.m., and monitoring sheets of Resident #1 and the kitchen door dated 05/02/25, 05/03/25, 05/04/25, 05/05/25, 05/06/25, and 05/07/25.

Based on observation, record review, and interview, the facility failed to ensure a call light was in reach for one (#35) of 24 sampled residents observed for call lights. The administrator identified 54 residents resided in the facility. Findings: Resident #35 had diagnoses which included chronic pain. The Care Plan, dated 09/28/22, documented to place call light within reach and to encourage the resident to use it. A Quarterly Assessment, dated 12/31/24, documented Resident #35's cognition was severely impaired. It documented the resident required assistance from staff for their ADLs and mobility. On 01/06/25 at 12:50 p.m., Resident #35 was observed laying in bed in their room. Resident #35 was heard screaming out wanting clean clothes. The call light was observed clipped to the privacy curtain out of reach of the resident. An orange sign was observed on the wall next to the resident's window. The sign read, Before leaving residents room please ensure all call light button are within residents reach. CNA #2 was observed going into Resident #35's room to provide care. On 01/06/25 at 12:53 p.m., CNA #2 stated Resident #35 was blind, but was able to use their call light if staff put it in the resident's hand. On 01/06/25 at 1:05 p.m., CNA #2 confirmed the call light had not been in reach. On 01/06/25 at 2:06 p.m., Resident #35 was observed laying in bed. The call light was observed clipped to the privacy curtain. On 01/06/25 at 2:10 p.m., LPN #1 stated staff were to clip the call light to the residents' blanket if they were in bed and to keep the call light in reach. On 01/06/25 at 2:11 p.m., LPN #1 was observed to go into Resident #35's room and stated, It's not within [their] reach.

Based on record review and interview, the facility failed to develop a comprehensive care plan within 14 days of admission for one (#24) of 14 sampled residents whose care plans were reviewed. The DON identified 54 residents resided at the facility. Findings: Resident #24 was admitted to the facility on [DATE] with diagnoses which included acute kidney failure, acute cystitis with hematuria, and indwelling urinary catheter. On 01/06/25 at 2:22 p.m., no comprehensive care plan was present in the EHR nor paper chart for Resident #24. On 01/08/25 at 8:21 a.m., the ADON was asked the process for completing comprehensive care plans for new admissions. They stated care plans for residents receiving skilled services were completed by the corporate nurse within 14 days of admission. After a review of Resident #24's care plan, the ADON acknowledged it had not been completed within 14 days of admission.

Based on observation, record review and interview, the facility failed to ensure heel lift boots were in place as ordered for one (#36) of two sampled residents reviewed for pressure ulcer care. The administrator identified seven residents had orders for heel lift boots. Findings: Resident #36 had diagnoses which included left side hemiplegia. Resident #36's Order Summary Report, dated 05/03/23, documented for heel lift boots to be in place every shift for wound prevention. A Braden Scale for Predicting Pressure Sore Risk assessment, dated 12/18/24, documented Resident #36 was at high risk for developing a pressure ulcer A Quarterly Assessment, dated 12/18/24, documented Resident #36's cognition was severely impaired. It documented the resident had impairment to their upper and lower extremities. On 01/06/25 at 2:31 p.m., Resident #36 was observed laying in their bed. Heel lift boots were not observed on the resident's feet. On 01/07/25 at 7:45 a.m., Resident #36 was observed up in their geri chair in their room. Heel lift boots were not observed on the resident's feet. On 01/07/25 at 7:49 a.m., CNA #1 stated some residents use heel lift boots to prevent pressure ulcers. They stated Resident #36 utilized heel lift boots. CNA #1 observed Resident #36 and stated the resident did not have the boots on. CNA #1 stated Resident #36 was suppose to have the boots on at all times.

Based on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The administrator reported 58 residents resided in the facility. Findings: On 10/26/23 at 10:20 a.m., a tour of the kitchen was conducted. The following observations were made: a. The handwashing sink was observed to have a brown dirt like substance on the back of it. b. A sink and countertop in the dry storage area was observed to have a red sticky substance on it. c. The cabinet under the sink in the dry storage was observed to be open exposing the pipes. d. A freezer temperature was observed to be at 38 degree Fahrenheit. The freezer contained a box of corn dogs, a bag of garlic bread, and a box of tater tots. All the foods were observed not frozen. The temperature log documentation stopped on 10/04/23. e. The stove/oven was observed to have a grease film on the front and down the sides. A dried white substance was observed on the oven door and the side of the oven. f. A three compartment sink in the cooking area was observed to have a bucket under the sink catching water dripping from the pipe. g. The microwave was observed to have a dried yellow substance on the inside door and walls. h. The floor under the dishwashing machine is observed to have a white/black substance on the floor under the sink. On 10/26/23 at 10:40 a.m. the dietary supervisor was informed of the observations. The dietary supervisor reported they had informed maintenance of all the issues that need to be fixed but has not been done yet. They reported the kitchen should have be cleaned daily.

Based on observation and interview the facility failed to ensure the facility maintained a clean, odor-free, and homelike environment. The CMS 671 form, dated 10/26/23, documented 58 residents resided in the facility. Findings: A Housekeeping Policies and Procedures packet, revised 06/29/12, read in parts, .Every resident room should undergo complete wet cleaning, disinfection and deodorizing daily .Pick up all litter on resident room floor and bathroom floor .Dust mop, making sure closet and areas under furniture are included . On 10/26/23 at 1:00 p.m., the following observations were made: a. The east hallway had a strong smell of urine, b. room [ROOM NUMBER] had a strong smell of urine. A bedside commode was observed located beside the bed with a large amount of medium yellow urine observed inside the basin. The bottom of the commode basin had dark yellow and brown stains. c. room [ROOM NUMBER] had large amount of dust and food debris observed underneath and around both beds. Multiple dead cockroaches observed underneath both beds. On 10/26/23 at 1:27 p.m., Res #7 in room [ROOM NUMBER] stated the room was not cleaned well. They stated the staff swept the floor quickly but did not thoroughly clean under and around the beds and furniture. On 10/26/23 at 1:34 p.m., Housekeeper #1 stated they tried to clean every room daily. They stated they emptied trash, dusted furniture, cleaned walls and toilets, and swept and mopped the floors in every room daily on the east hall. They stated they tried to clean under the beds if they had time. They stated the CNAs were responsible for emptying and cleaning the bedside commodes. On 10/26/23 at 2:26 p.m., the administrator was made aware of the observation in room [ROOM NUMBER]. The administrator stated pest control had been spraying weekly to get rid of the cockroaches. They stated they were not aware of the dead cockroaches and debris underneath and around the beds and the room would be deep cleaned immediately. On 10/27/23 at 9:00 a.m., room [ROOM NUMBER] had a strong smell of urine. A bedside commode was observed sitting beside the bed with a large amount of yellow urine observed inside the basin. Res #34 stated they utilized the bedside commode for urination. They stated the large amount of urine observed was from multiple voids and the staff rarely emptied the commode. Res #34 stated the urine was unsightly and made the room smell bad. They stated the lack of cleaning and sanitation was an on-going problem and they would like something done about it. On 11/01/23 at 8:07 a.m., the east hallway had a strong smell of urine. room [ROOM NUMBER] had a moderate amount of dust and food debris observed under the bed by the window. One dead cockroach was observed under the bed. Two sucker wrappers and sucker sticks with pink sticky residue were observed in the bathroom floor. rooms [ROOM NUMBERS] had a moderate amount of dust and food debris observed under and around the beds by the window. On 11/02/23 at 8:37 a.m., room [ROOM NUMBER] had a strong smell of urine. A bedside commode was observed sitting beside the bed with a moderate amount of dark urine observed inside the basin. Dark brown and yellow stains were observed on the bottom of the commode basin. Res #34 stated the urine had been in the commode since last night and no staff had attempted to empty the urine out of the commode. On 11/02/23 at 8:40 a.m., CNA #4 stated they tried to empty the bedside commode at least three to four times per shift but had not emptied Res #34's commode yet this shift. They stated they tried to clean the commode daily but the basin had been stained with brown and yellow streaks for a while and would not come clean. On 11/02/23 at 12:40 p.m., the administrator was made aware of the observations on the east hall. The administrator stated the staff would be re-educated on the importance of cleaning more thoroughly and more frequently. 43023 On 10/30/23 at 1:40 p.m., a tour of the laundry room was conducted. An area on the wall by the folding table was observed to be missing sheetrock and pipes are observed to be exposed. The laundry staff was asked how long the sheetrock had been missing and they reported for awhile. They reported that there had been a leak which was fixed but the wall was not. On 10/30/23 at 2:26 p.m., an interview with the maintenance supervisor and the administrator was conducted. The maintenance supervisor reported the missing sheetrock was like that before he was hired. They were asked if the wall should have already been fixed and they reported the wall should have already been fixed.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for two (#8 and #43) of five sampled residents reviewed for bathing. The CMS 671 form, dated 10/26/23, documented 58 residents resided in the facility. Findings: 1. Res #43 was admitted with diagnoses which included respiratory failure, depressive disorders, and anxiety. An admission assessment, dated 06/07/23, documented the resident was cognitively intact and required extensive one person physical assistance with bathing. A care plan, dated 06/16/23, documented the resident was to be bathed with the physical help of one person every Monday, Wednesday, and Friday during the 7 a.m. to 3 p.m. shift. The August 2023 bathing record documented Res #43 was bathed four out of 13 opportunities. The September 2023 bathing record documented Res #43 was bathed six out of 13 opportunities. The October 2023 bathing record documented Res #43 was bathed four out of 13 opportunities. On 10/26/23 at 2:12 p.m., Res #43 stated they were upset because they often have not received their baths/showers as scheduled and they would prefer to have been bathed more often. On 11/02/23 at 8:42 a.m., CNA #4 stated all completed or refused resident baths should be documented in the electronic health record. They stated all resident refusals of baths also required a paper refusal sheet to be documented and then given to the administrator daily. On 11/02/23 at 10:45 a.m., the administrator was made aware of the lack of bathing documentation in Res #43's medical record. The administrator stated all baths should be documented in the electronic health record. They stated the staff did not document all completed baths as scheduled for Res #43 but should have. They stated Res #43 should have received baths as scheduled per their plan of care. 43023 2. Res #8 admitted to the facility with diagnoses of mood disorder due to known physiological condition, hypertension, and chronic pain. A quarterly assessment, dated 09/25/23, documented the resident's cognition was moderately impaired and required the assist of one person for bathing and transfers. A shower log, dated September 2023, documented eight of 13 opportunities for a shower were missed. A shower log, dated October 2023, documented five of 13 opportunities for a shower were missed. On 11/02/23 at 8:25 a.m., CNA #2 reported the showers were documented in the computer. On 11/02/23 at 8:30 a.m., CNA #3 reported showers were documented in the computer. On 11/02/23 at 08:36 a.m., MDS coordinator #1 reported the CNA's were supposed to fill out a refusal form if the resident refused a shower. MDS coordinator #1 reported the shower log should have documented refused if the resident refused a shower. On 11/02/23 at 10:38 a.m., no refusal forms for showers had been provided by the facility for this resident.

Based on observation and interview, the facility failed to document and retain daily staffing information for the past 18 months. The CMS 671 form, dated 10/26/23, documented a census of 58 residents. Findings: On 10/26/23 at 11:00 a.m. and throughout the survey, the white boards behind each nursing station was observed to include documentation of the census number, name and titles of the staff on duty. Staffing hours were not documented. On 11/02/23 at 11:55 a.m., the administrator reported they were not aware of the requirements to post staffing hours and retain the documentation for 18 months.

Based on observation, record review, and interview, the facility failed to ensure a resident who was physically restrained was assessed, monitored, and the restraint was used to treat a medical symptom for one (#16) of one sampled resident who was reviewed for seat belt usage. The DON identified one resident who used a seat belt. Findings: Res #16 was admitted with diagnoses which included Alzheimer's, dementia with behavioral disturbances, muscle weakness, neuropathy, macular degeneration and age-related osteoporosis. A fall risk care plan initiated on 03/21/18, documented Res #16 was at risk for falls due to requiring staff assistance with ADL's and psychotropic medication use. A non-restraint safety devices care plan initiated on 03/21/18, documented Res #16 may use an alarming self-releasing seatbelt when up in wheelchair. The care plan also documented Res #16 was able to release belt at will and upon request. A list of falls from 06/10/22 to present was provided by the DON and documented Res #16 had 11 falls. A physician order dated, 01/15/23, read in part, May use alarming self-releasing seatbelt when up in wheelchair .Resident is not aware of safety needs. Resident is able to release belt at will and upon request . The order did not incorporate a medical symptom the seat belt was used to treat. There was no restraint assessments or monitoring in the medical record. A quarterly resident assessment, dated 07/07/23, documented Res #16 was severely cognitively impaired, had not ambulated in the last seven days and required extensive assistance with ADL's. On 10/31/23 at 11:03 a.m., Res #16 was observed on 200 Hall in their wheelchair with a seat belt alarm in place. Res #16 was unable to release the seat belt upon request. On 11/01/23 at 8:50 a.m., Res #16 was observed in the dining room in their wheelchair with a seat belt alarm in place. Res #16 was unable to release the seat belt alarm upon request. On 11/01/23 at 11:50 a.m., CNA #1 reported Res #16 was unable to undo their seat belt upon request. CNA #1 reported Res #16 only released their seat belt randomly when they are active. CNA #1 reported the seat belt was in place to keep Res #16 from falling and reported Res #16 would try to get out of their wheelchair if the seat belt was not in place. On 11/02/23 at 10:05 a.m., Res #16 was in the TV area on 100 Hall in their wheelchair with a seat belt alarm in place. Res #16 was unable to release the seat belt alarm upon request. On 11/02/23 at 10:08 a.m., LPN #1 reported Res #16 is non-ambulatory and required the seat belt because they were at high risk for falls. LPN #1 reported Res #16 would be able to and attempt to get out of their wheelchair, but doing so was prevented by the seat belt being in place. LPN #1 reported they did not feel Res #16 could release the seat belt upon request. On 11/02/23 at 10:30 a.m., the DON reported Res #16 would be attempting to get out of his wheelchair if they did not have the seat belt in place. On 11/02/23 at 11:15 a.m.,. Res #16 was sitting in the TV area on 100 Hall in their wheelchair with a seat belt alarm in place. Res #16 was unable to release the seat belt alarm upon request. On 11/02/23 at 2:00 p.m., the DON and ADON reported the seat belt would be a restraint if Res #16 could not release it upon request. The DON and ADON reported no restraint assessment or documentation had been completed for Res #16.

Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#8) of one sampled residents reviewed for PASRR. The administrator reported 37 residents had mental health diagnoses. Findings: Res #8 was admitted to the facility on [DATE] with diagnoses of intellectual disabilities and mood disorder due to known physiological condition. A PASRR level I, dated 02/12/13, documented Level II cleared, eligible for admission to LTC 02/06/13. The resident record documented the resident received a new diagnosis of schizophrenia on 08/19/22. The record contained no documentation that OHCA was contacted about the new diagnosis. On 11/02/23 at 8:36 a.m., MDS #1 reported that OHCA should have been contacted about the new mental health diagnosis.

Based on observation, record review, and interview, the facility failed to update a comprehensive care plan for one (#20) of one sampled resident who was reviewed for a PEG tube. The DON reported there was one resident with a PEG tube. Findings: Res #20 was admitted with diagnoses which included dementia and anorexia. Res #20's tube feeding care plan, dated 08/25/23, documented an enteral feed order of Jevity 1.5 cal 45 ml every hour. A physician order, dated 09/04/23, documented enteral feed order of Jevity 1.5 cal 273 four times a day. On 11/02/23 at 11:55 a.m., the DON reported the care plan should have been updated because Res #20 no longer received continuous feedings.

Based on record review, observation, and interview, the facility failed to ensure residents received the necessary care to help prevent urinary tract infections for two (#2 and #3) of four residents sampled for UTIs. The Resident Census and Conditions of Residents form documented 30 residents were dependent on staff assistance for their toileting needs. Findings: 1. Res #3 had diagnoses which included chronic kidney disease. An annual assessment, dated 12/22/22, documented the resident was cognitively intact and required the extensive assistance of two people for toileting. On 02/07/23 at 12:31 p.m., Res #3 stated she was wet and was not wearing a brief. The resident was asked why her call light was not on. She stated she had turned it on around 12:00 p.m., and when someone brought her lunch tray, she was told to turn off her light and someone would be back to help. She stated she needed two people because she wanted to be pulled up in bed. The surveyor told the resident to turn her call light back on. The resident turned her call light on at that time. On 02/07/23 at 12:42 p.m., CNA #1 answered the resident's call light. The CNA was heard telling the resident to turn her call light off and when the other CNA was back from lunch they would be in to clean her up. The CNA stated it would be about 20 minutes. On 02/07/23 at 12:57 p.m., CNA #1 and CNA #2 entered the resident's room with supplies. The CNAs were observed to performed incontinent care. The resident's bed pads were soaked with urine. The resident was rolled to each side and her buttocks were cleaned and incontinent bed pads replaced. The resident was then positioned on her back and CNA #1 took one wet wipe and swiped down the right side of the residents peri area next to her thigh and then did the same on the left side with another wipe. The CNAs then replaced the resident's gown with a fresh one. The CNAs did not clean the resident's entire peri area to include the inner and outer labia. 2. Res #2 had diagnoses which included chronic kidney disease and a history of UTIs. An annual assessment, dated 02/03/22, documented the resident was cognitively intact and required the extensive assistance of two people for toileting. On 02/07/23 at 1:56 a.m., CNA #3 and CNA #4 were observed to perform incontinent care for Res #2. The resident had no brief and her sheets were soaked with urine. The resident was turned from side to side and the buttocks were cleaned and fresh linens were provided. The resident was then positioned on her back and covered with linens. The resident's front peri area was not cleaned. On 02/09/23 at 8:13 a.m., the DON was made aware of the residents' incontinent care which was observed. She stated the peri area should always be thoroughly cleaned.

Based on record review, observation, and interview, the facility failed to ensure a resident received incontinent care in a timely manner for one (#3) of three residents sampled for ADL care. The Resident Census and Conditions of Residents form documented 30 residents were dependent on staff assistance for their toileting needs. Findings: Res #3's annual assessment, dated 12/22/22, documented the resident was cognitively intact and required the extensive assistance of two people for toileting. On 02/07/23 at 12:31 p.m., Res #3 stated the only problem she had with the facility was that she had to wait a long time to get cleaned up and changed. She stated about once a shift she would get help. She stated they may answer the light but they would have me turn it off until they could get back, which was usually a long time. The resident was asked if she was soiled or wet at that time. She stated she was wet and was not wearing a brief. The resident was asked why her call light was not on. She stated she had turned it on around 12:00 p.m., and when someone brought her lunch tray, she was told to turn off her light and someone would be back to help. She stated she needed two people because she wanted to be pulled up in bed. The surveyor told the resident to turn her call light back on. The resident turned her call light on at that time. On 02/07/23 at 12:42 p.m., CNA #1 answered the resident's call light. The CNA was heard telling the resident to turn her call light off and when the other CNA was back from lunch they would be in to clean her up. The CNA stated it would be about 20 minutes. On 02/07/23 at 12:57 p.m., CNA #1 and CNA #2 entered the resident's room with supplies. The CNAs were observed to performed incontinent care. The resident's bed pads were soaked with urine. On 02/09/23 at 8:12 a.m., the DON was asked how long it should take for a resident to get help after initiating their call light. She stated within five minutes.

Based on record review and interview, the facility failed to ensure a resident was not administered a medication when the medical record indicated the resident was allergic to the medication for one (#1) of four sampled residents whose medications were reviewed. The Resident Census and Conditions of Residents documented 61 residents resided in the facility. Findings: Res #1 was admitted to the facility on [DATE] and was discharged on [DATE]. The resident's diagnosis included hyperlipidemia, athersclerotic heart disease, cerebral infarction, lack of coordination, dementia, A-Fib, and anxiety. The resident's EHR documented the resident was allergic to statin medications. A pharmacist monthly review, dated 10/09/20, documented the resident's cholesterol came back elevated, the resident was not currently on a statin, and would the physician like to add one at that time. The physician documented on the review, on 10/23/20, to add atorvastatin 20 mg a day. No mention or discussion of allergies or adverse consequences were documented on the review or in the resident's medical record. A physician order, dated 10/28/20, documented to administer atorvastatin calcium (a statin medication) 20 mg tablet at bedtime related to mixed hyperlipidemia. The order documented a discontinued date of 01/13/21. A physician order, dated 01/13/21, documented to administer atorvastatin calcium 20 mg tablet at bedtime related to atherosclerotic heart disease of native coronary artery without angina pectoris. The order documented a discontinued date of 01/21/21. The MARs from October 28th, 2020 through January 20th, 2021 documented the resident received atorvastatin calcium 20 mg once a day. A physician order, dated 04/09/21, documented to administer ezetimibe (a non-statin medication) 10 mg tablet one time a day related to mixed hyperlipidemia. The order documented a discontinued date of 04/16/21. On 02/08/23 at 4:29 p.m., the ADON stated she worked at the facility at the time when the resident was there. She stated she could not find any documentation of a discussion with the physician related to the resident's allergy to atorvastatin. She stated she believed the allergy was listed on a hospital record. She stated if the resident was not allergic to statin medication the allergy indication should have been removed from the chart. On 02/09/23 at 10:29 a.m., the pharmacist stated she was not the pharmacist who had reviewed the resident's medications. She stated she could not find any documentation of a conversation with the physician concerning the documented allergy to statin medications. On 02/09/23 at 11:40 a.m., the physician stated he did not believe the resident had a true allergy to the medication because she took it with no ill effects. The physician stated he could see the record documented an allergy to statins, but he did not have any documentation as to the reason to administer the medication with the allergy still listed on the EHR. On 02/09/23 at 12:49 p.m., the resident's representative stated the resident should not have been on the statin medication. The representative stated the medication caused the resident to have violent behaviors. The representative stated the resident had cracked a glass door in the facility and had other behaviors. The representative stated the medication was discontinued when the resident went on hospice.

Based on record review, observation, and interview, the facility failed to ensure a resident newly diagnosed with a serious mental illness was referred for a PASRR level II evaluation and failed to incorporate PASRR level II recommendations into a resident care plan for three (#3, 48, and #29) of three residents reviewed for PASRR. The administrator reported 14 residents with PASRR Level II evaluations lived in the facility. Findings: 1. Res #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level II assessment, dated 11/30/17, documented Res #3 had been found to have a serious mental illness as defined by CMS during the Pre-Admission Screening and Resident Review. The PASSAR Level II document read in parts: .Self - Monitoring of Health Services. Requires total assistance with monitoring health status due to being unaware of personal health and health risk . Self - Monitoring and scheduling of treatment Requires total assistance with monitoring and scheduling of treatments due to having poor judgement and a history of inability to comply with scheduled treatments .Medication Compliance Requires total assistance with medication compliance due to being unable to fully recognize the medication, the need for medication, and being unable to follow label instructions .Ability to Handle Financial Affairs Requires total assistance with financial affairs by [sic] due to having a history of money management problems .Ability to Communicate Needs. Requires total assistance with communicating needs due to making comments and/or requests that are often based on poor judgement and insight . An annual comprehensive resident assessment, dated 12/26/21, documented Res #3 was not considered by the state level II PASRR process to have a serious mental illness. Res #3's care plan, reviewed by the facility on 5/18/22, did not fully incorporate Res #3's PASRR Level II recommendations. On 05/25/22 at 10:41 a.m., Res #3 was observed in a wheelchair, dressed in several coats, and a stocking hat. Res #3 was sitting in the doorway of another resident's room and stated they had a sore on their chest which was being treated with antibiotics. On 05/26/22 at 2:40 p.m., the MDS coordinator stated Res #3's assessment did not include the PASRR Level II. The MDS coordinator stated the facility had not fully incorporated Res #3's PASRR Level II recommendations into the care plan. 2. Res #48 was had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/06/16, Res #48 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A level II PASRR was not completed by the facility at that time. On 02/11/20, resident #48 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A level II PASRR was not completed by the facility at that time. On 05/26/22 at 11:28 a.m., the business office manager stated they believed a PASRR II was completed in 2020 when a new medication and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level II assessment was not provided for review. Res #29 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level I, dated 04/28/21, documented the resident did not have a serious mental illness. On 07/20/21, Res #29 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/30/22, Res #29 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/01/22 at 2:01 p.m., the DON stated the facility should have called the Oklahoma Health Care Authority. On 06/01/22 at 2:02 p.m., LPN #1 stated the resident did not admit with any psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview, the facility failed to accurately assess for the presence of a PASRR level II for three (#3, 35 and #49) of 16 residents whose assessments were reviewed. The ''Resident Census and Conditions of Residents'' form documented 51 residents lived in the facility. Findings: 1. Res #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level II assessment, dated 11/30/17, documented Res #3 had been found to have a serious mental illness as defined by CMS during the Pre-Admission Screening and Resident Review. An annual comprehensive resident assessment, dated 12/26/21, documented Res #3 was not considered by the state level II PASRR level II process to have a serious mental illness. 05/26/22 at 1:40 p.m., the MDS coordinator reviewed Res #3's comprehensive assessment and reported the assessment did not document the resident was identified as requiring a PASRR level II. The MDS coordinator stated the PASRR level II should have been documented in the assessment. 2. Res #49 admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Res #49 had a PASRR II, dated 08/20/21, documented the client experienced a serious mental illness as defined by CMS. An annual assessment, dated 11/11/21, documented Res #49 did not have a PASRR II. On 05/31/22 at 12:37 p.m., MDS coordinator stated she was made aware last week the residents who have a PASRR II needed to be captured on the assessments. She looked at Res #49's last annual, dated 11/11/21, and stated the question for PASRR was marked no. She found the PASRR for Res #49 and stated he did have a level II. 3. Res #35 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR II, dated 01/07/22, documented the client experienced a serious mental illness as defined by CMS. An annual assessment, dated 01/13/22, documented Res #35 did not have a PASRR II. On 05/31/22 at 12:37 p.m., MDS coordinator stated Res #35 did have a PASRR II but it was marked no on the MDS.

Based on record review and interview, the facility failed to ensure nurse aids who had been employed greater than one year completed a performance review. The administrator reported the facility employed four CNAs who had worked at the facility for greater than one year. Findings: On 05/31/22 at 5:00 p.m., the administrator was asked to provide documentation of nurse aide competencies for any CNAs who had worked greater than one year at the facility. On 05/31/22 at 5:20 p.m., the DON and administrator reported the last skills performance reviews for CNAs had last been conducted in 2019. The administrator stated because of the pandemic and staffing issues the skill performance reviews had been overlooked.

Based on record review, observations, and interviews, the facility failed to provide sufficient staffing to ensure residents maintained their highest well-being. The Resident Census and Conditions of Residents form documented 51 residents resided in the facility. Findings: 1. On 05/25/22 at 09:01 a.m., Res #101 stated she needed help when toileting self, as she could not clean after toileting easily. Res #101 stated due to the staff not answering call lights in a timely manner, she had started to clean herself after toileting. She stated she was worried about getting a urinary tract infection because she was unable to wipe herself properly. Res #101 stated this was because the facility did not have enough staff. 2. On 05/24/22 at 12:45 p.m., a family member of Res #43 stated there was not enough staff and it frequently took a long time to get help for their loved one. 3. During a resident council meeting on 05/26/22 at 09:30 a.m., through 09:50 a.m., several residents stated the facility staff were too busy to act on resident council concerns. When asked about answering of call lights residents stated it varied between quickly to as long as three hours. On 05/26/22 at 10:18 a.m., the administrator stated the facility tried to meet the resident and staffing needs, and if needed could request additional staff from sister homes. 4. On 05/24/22 at 1:22 p.m., Res #35 stated she had been in the facility since January of 2022. She stated the staff did not change her enough and she would go all day in urine. She stated she was also not getting her showers as scheduled. Res #35 stated her shower days were Monday, Wednesday, and Friday. The resident stated she was wet at that time. She said staff came in when she used her call light but then would turn the light off and leave and did not come back for up to one and a half hours. On 05/25/22 at 8:55 a.m., Res #38 was observed laying on the bed. He was unshaven and he had long dirty fingernails. The resident stated he had not been getting his showers but recently had started getting some. He stated he liked to be clean shaven and his nails were too long and he would like them to be cut. On 06/01/22 at 10:25 a.m., Res #38 was observed sitting on the side of his bed, dressed with shoes and a hat on, the resident's nails had been cut on hands. Res #38 stated the staff cut his fingernails but did not cut his toenails and they needed cut. He stated he still needed a shower and a shave. Observed noticeable facial hair growth. 5. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the treatment administration record did not document catheter care had been performed on 04/02/22, 04/03/22, 04/07/22, 04/09/22, 04/18/22, 05/13/22, and 05/21/22. A physician order, dated 10/28/2021, documented to change suprapubic catheter drainage bag on the 1st and 15th and as needed. A review of the treatment administration record documented the suprapubic catheter drainage bags had not been changed on 04/01/2022, and 05/15/2022. A physician order, dated 03/02/22, documented to collect vital signs every shift. A review of records for April and May of 2022 did not document vital signs were not completed for one or more shifts on the following dates: 04/01/22, 4/02/22, 04/03/22, 04/06/22, 04/07/22, 04/09/22, 04/18/22, 04/24/22, 04/29/22, 04/30/22, 05/02/22, 05/07/22, 05/13/22, anad 05/21/22. 6. Resident #33 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #33's clinical record did not document this was completed for eight hours on 04/02/22, 14 hours on 04/03/22, eight hours on 04/7/22, seven hours on 04/10/22, three hours on 05/07/22, and 7 hours on 05/22/22. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #33's MAR/TAR for April and May of 22 did not document monitoring was completed on 04/02/22, 04/03/22, 04/7/22, 04/09/22, 05/07/22, and 05/21/22. On 06/01/22 at 4:00 p.m., during an interview regarding QAPI, the administrator stated staffing is an ongoing process with the QAPI meetings.

Based on record review, observation, and interview the facility failed to provide services to prevent urinary tract infections for two (#37 and #102) of two residents reviewed for indwelling urinary catheters. The Resident Census and Conditions of Residents report documented two residents who required indwelling urinary catheters. Findings: 1. Res #102 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 02/20/21, documented to clean the resident's indwelling suprapubic catheter every shift and PRN. A nurse note, dated 03/01/21, documented the resident continues IV meropenum (an antibiotic) for a [CONDITION(S)]. A quarterly assessment, dated 03/20/21, documented the resident was severely impaired with cognition, required total assistance with activities of daily living, and had an indwelling urinary catheter. ADL flow sheets for March 2021 documented the staff did not record urinary output for 15 shifts from 03/01/21 through 03/19/21. The TAR for March 2021 documented for six shifts the resident catheter was not cleaned. A care plan, last reviewed on 04/13/2, documented Res # 102 had a catheter and would show no s/s of a [CONDITION(S)] through the review date. The assessment documented to monitor output each shift. On 04/25/21 the resident was discharged . On 05/31/22 at 4:07 p.m., the DON stated a resident's catheter bag should be emptied every shift and as needed. She stated this should be documented on the output section of the ADL flow sheets. On 06/01/22 at 11:26 a.m., the DON stated the resident was prone to UTIs and on a good day his urine looked like sludge. On 06/01/22 at 11:53 a.m., the DON stated the resident did not have a [CONDITION(S)] for March of 2021. 2. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 10/28/21, documented to perform catheter care every shift and as needed with soap and water or disposable wipes. The April and May 2022 TARs did not document catheter care was performed by staff on 04/02/2022, 04/03/2022, 04/07/2022, 04/09/2022, 04/18/2022, 05/13/2022, and 05/21/2022. A physician order, dated 10/28/2021, documented to change suprapubic catheter drainage bag on the 1st and 15th and as needed. The TAR did not document the suprapubic catheter had been changed on on 04/01/22, and 05/15/2022. A physician order, dated 03/30/22, documented to administer [MEDICATION(S)] monohyd macro capsule (an antibiotic) 100mg. Give 1 capsule by mouth two times a day for [CONDITION(S)] for 5 days. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 04/01/22, documented to administer Fosfomycin Tromethamin Packet (an antibiotic) 3 gm every 72 hours for [CONDITION(S)]. A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 4/18/22, documented to administer [MEDICATION(S)] (an antibiotic) at bedtime until 05/17/22 for a urinary tract infection. A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 04/20/22, documented resident #37 was incontinent of bowel, had an indwelling catheter, and required extensive assistance with toileting. On 05/24/22 at 1:05 p.m., resident #37 stated that they had frequent [CONDITION(S)]'s, and was observed with a catheter drainage bag hanging from the bed frame. On 06/01/22 at 9:09 a.m. the DON stated blanks on MAR/TARs was a known problem especially on weekends and stated that if it was not documented there was no way to defend that it was done. On 06/01/22 at 1:01 p.m., LPN #3 stated resident #37 was not physically capable of independently completing catheter care and the care should have been documented on the TAR when it was completed.

Based on record review, observation, and interview, the facility failed to ensure dependent residents were provided assistance with bathing/showers, grooming, and incontinent care for four (#35, 38, 103, and #104) of five sampled residents reviewed for staff assistance with ADLs. The Resident Census and Conditions of Residents report documented 21 residents required assistance with bathing and 25 residents are occasionally or frequently incontinent of bladder. Findings: 1. Res #35 admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 01/14/22, documented the resident was to receive a bath one time a day on the 7 a.m. to 3 p.m. shift Monday, Wednesday, and Friday. A quarterly assessment, dated 04/10/22, documented the resident was intact with cognition and required limited assistance with personal hygiene, extensive assistance with toilet use, total assistance with bathing, and was always incontinent of bowel and bladder. A care plan, last review date 04/28/22, documented the resident was incontinent and to check every two hours and as needed for incontinence. The care plan documented to wash, rinse and dry perineum, and change clothing as needed after incontinent episodes. The care plan documented the resident needed a lift for transfers and required one staff participation in bathing. On 05/24/22 at 1:22 p.m., Res #35 stated staff did not change her enough and she will go all day in urine. She stated she was also not getting her showers as scheduled. Res #35 stated her shower days were Monday, Wednesday, and Friday. The resident stated she was wet at that time. She said staff come when she uses her call light but then turn light off and leave and do not come back for up to one and a half hours. The March 2022 ADL sheets documented the resident missed four baths out of 13 opportunities. The ADL sheets for bowel and bladder had four days of no documentation for bladder continence and three for bowel continence. The ADL sheet documented for six days there was only one entry for bladder incontinence and seven entries for bowel incontinence. The April 2022 ADL sheets did not document bowel and bladder continence for three days and for five days only one shift documented bowel and bladder continence. The May 2022 ADL sheets documented four missed baths out of 11 opportunities and one day of no documentation for bowel and bladder continence. On 05/31/22 at 3:47 p.m., CNA #1 stated she was new and was training in the facility. CNA #1 stated the CNA's try to check incontinent residents at least every hour. She stated the CNA's chart on the computer behind the nurses station and they chart at the end of the day for all ADLs. CNA #1 stated Res #35 was on the MWF bathing schedule. She stated the resident was incontinent sometimes and the resident did not get out of bed because she hurts so we changed her in the bed. On 06/01/22 at 12:08 p.m., the DON stated Res #35 will call the administrator to have someone come change her if the resident was not getting changed when she wanted it. The DON stated we try to let her know staff will get to her as soon as they can. The DON stated the call light needs to stay on until care is provided. The DON stated Resident #35 had refused at times to be changed but wanted to be changed when she wants it. 2. Res #38 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/25/22, documented the resident was intact with cognition, required total assistance with bathing and was independent with personal hygiene with one person physical assist. A care plan, review date of 05/03/22, documented Res #38 had a deficit in ADL performance due to history of stroke and required one person assist with bathing and hygiene. The care plan documented bathing/showering was M-W-F and PRN. On 05/25/22 at 8:55 a.m., Res #38 was observed laying on the bed. He was unshaven and he had long dirty fingernails. The resident stated he had not been getting his showers but recently had started getting some. He stated he liked to be clean shaven and his nails were too long and he would like them to be cut. He stated he had not asked the staff to cut his nails. Bathing schedule for Res #38 was MWF on the 3 p.m. - 11 p.m. shift and PRN. The ADL sheets for March 2022, documented the resident missed four baths out of 13 opportunities. The ADL sheets for April 2022, documented the resident missed three baths out of 13 opportunities. The ADL sheets for May 2022, documented the resident missed one bath on the 20th. On 05/31/22 at 3:52 p.m., CNA #1 stated she had not taken care of Res #38 because he had one CNA that he liked to do things for him. She stated on his chart it's documented the resident was independent with his ADLs. She stated they don't need to be asked by the resident if they need a shave or nails cut. The CNA stated they could do them if the resident was one the CNA could cut nails for. On 06/01/22 at 10:25 a.m., Res #38 was observed sitting on the side of his bed, dressed with shoes and a hat on, the resident's nails had been cut on hands. Res #38 stated the staff cut his fingernails but did not cut his toenails and they needed cut. He stated he still needed a shower and a shave. Observed noticeable facial hair growth. On 06/01/22 at 11:21 a.m., the DON stated if a bath/shower is missed on a shift the staff should let the next shift know so it can be done on the residents' bath day. She stated the resident should not have to asked to get shaved or get their nails cut. She stated the resident was not a diabetic so the CNAs can cut his nails. She stated the nurse should be checking on the residents to make sure care is performed. 3. Res #103 admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was no longer at the facility at the time of survey. A quarterly assessment, dated 07/18/21, documented the resident was intact with cognition, required extensive assistance with bathing, and toileting did not occur during the look back period. The assessment documented rejection of care occurred daily. The assessment documented the resident was always incontinent of bowel and bladder. A care plan, review date 07/18/21, documented the following: Res #103 had an ADL self care performance deficit related to impaired balance. Res #103 had the option of when to bathe and what kind of bath to take, with scheduled days suggested, but had the option to change as he/she chooses. Res #103's bath days were M-W-F on the 7-3 shift. Res #103 required total assist with one staff participation with bathing. Res #103 required extensive assistance with one to two staff participation to use the toilet. Res # 103 required extensive assistance with one staff participation for personal hygiene. The care plan documented Res #103 often refused scheduled medications and to get up in her chair. The care plan did not document the resident refused incontinent care or bathing. Nurse notes were reviewed for April 4th to April 19th of 2021. The notes documented the resident refused to get out of the bed and did not document the resident refused ADL care. A nurse note, dated 04/15/21 at 9:46 p.m., documented an indwelling catheter was placed as requested by the resident to facilitate skin healing. ADL sheets for April 2021 documented scheduled baths were Tuesday, Thursday, and Saturday. The ADL sheet documented the resident had five missed baths out of 13 opportunities that month. ADL sheet for April 2021 documented bowel and bladder incontinence was not documented on one day, which was before the resident received a catheter. Bowel and bladder incontinence was only documented once a day for seven days before the catheter was placed. On 06/01/22 at 10:05 a.m., the DON stated the staff were to check and change every hour and the resident would refuse care. 4. Res #104 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #104's ADL flow sheets, dated 04/21/21 through 04/28/21, documented Res #104 had not received a bath and had not been checked for bladder incontinence for 15 shifts out of 23 shifts. An admission assessment, dated 04/28/22, documented Res #104 was intact in cognition, required extensive assistance with toileting, and had not been bathed. A review of Res #104's ADL flow sheets, dated 04/29/21 through 05/31/21, documented Res #104 had not received a bath and had not been checked for bladder incontinence for 81 shifts out of 102 shifts. A care plan for Res #104, last reviewed on 02/11/22, read in part .Monitor/document bladder and bowel function. If incontinent monitor/document for appropriate bowel and bladder training program and implement . On 06/01/22 at 11:34 a.m., the DON stated Res #104 was no longer in the facility. On 06/01/22 at 12:44 p.m., the DON reviewed Res #104's ADL flow sheets and confirmed the facility did not document they provided bathing or regular bladder incontinence care during the dates of 04/21/21 through 05/31/21. The DON stated if it was not documented it was not done.

Based on observation, record review, and interview, it was determined the facility failed to prevent the development of two facility acquired pressure ulcers for one (#59) of five sampled residents whose clinical records were reviewed for pressure ulcers. This resulted in harm to resident #59. The director of nurses (DON) identified two additional residents with pressure ulcers. The facility Resident Census and Conditions of Residents form, dated 01/30/17, documented 77 residents resided in the facility. Findings; Resident #59 had [DIAGNOSES REDACTED]. The facility's Skin and Wound Care Guidelines documented; Skin Integrity/Wound Care Purpose .To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and developing interventions Risk Assessment Policy .2. Residents identified at risk ( .Scale (score) of 18 or less) will be assessed on admission then on a weekly basis. Document this assessment on the Skin at Risk sheet . Protocol for At Risk patients . Moderate Risk (13 to 14) (score) Turning schedule, use foam wedges for .lateral positioning, pressure-reduction support surface, maximal remobilization, protect heels, manage moisture, nutrition, friction and shear The resident's initial plan of care, dated 09/26/16, documented; .Skin Integrity .Braden Scale Score 14, obtain pressure cushion for chair and or wheelchair if needed, assist with turning and repositioning to meet the resident's needs. Use pillows as needed to float heels and for positioning A facility admission pressure ulcer risk assessment, dated 09/26/16, documented the resident had a score of 14. A nurse's admission note, dated 09/26/16 at 5:37 p.m., documented the resident required the use of a wheel chair, required assistance with bed mobility, and she refused to eat and/or get out of bed. A facility Skin/Wound Note, dated 09/26/16 at 6:43 p.m., documented three reddened areas to right buttock, which measured 0.3 centimeters (cm) in circumference, no open areas were noted. The resident's admission assessment, dated 10/05/16, documented the resident required extensive assistance with two staff members for bed mobility, limited assistance with two staff for transfers, the resident had impaired mobility on one lower extremity. She used a wheelchair, was at risk of developing pressure ulcers, and was always incontinent of bladder and bowel. The assessment also documented the resident did not have pressure ulcers when she was admitted to the facility. A facility Skin/Wound note, dated 11/05/16, documented the resident had acquired two new pressure ulcers to her heels. The right heel had a stage three pressure ulcer which measured 1.5 cm x 1.5 cm. The wound base had pink/red tissue with brown slough. The physician's orders [REDACTED]. The wound note also documented the resident had acquired an unstageable pressure ulcer to her left heel. The wound bed had a dry brown stable scab measuring 1.7 cm x 3.0 cm. Dr. (Named physician) was notified of the new areas. He issued a new order to apply Skin Prep to the left heel pressure ulcer, cover with ABD, and wrap with Kerlix dressing every day. The resident's care plan, initiated on 11/14/16, documented; Focus Pressure ulcer to the left heel . Interventions .Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Focus Pressure to right heel . Interventions . Cleanse with Microsyn wound cleaner, apply Santyl, cover with ABD and Kerlix as ordered. (Named resident) kicks off her Spenco boots. Staff to trial Pro-Heel-X boots. A facility Skin/Wound note, dated 11/17/16, documented the right heel had a stage three pressure ulcer which measured 1 cm x 1 cm. The wound base had pink/red tissue. The order was to cleanse with wound cleaner, apply Santyl, cover with ABD and Kerlix every day. The wound note also documented the pressure ulcer on her left heel was unstageable and had a brown stable scab measuring 0.3 cm x 0.8 cm. Dr. (Named physician) was notified of the new areas. They were to apply Skin Prep to the left heel pressure ulcer, cover with ABD pad, and wrap with Kerlix dressing every day. A facility Skin/Wound note, dated 11/23/16, documented the right heel had a stage three pressure ulcer which measured 1 cm x 1.2 cm. The wound base had pink/red tissue. They were to cleanse with wound cleaner, apply Santyl cover, with ABD and Kerlix every day. The wound note also documented the pressure ulcer on her left heel was unstageable and had a brown stable scab measuring 0.5 cm x 0.7 cm. Dr. (Named physician) was notified of the new areas. They were to apply Skin Prep to the left heel pressure ulcer, cover with ABD pad, and wrap with Kerlix dressing every day. A facility Skin/Wound note, dated 11/30/16, documented the right heel had a stage three pressure ulcer which measured 0.3 cm x 0.5 cm. The wound base had pink/red tissue. They were to cleanse with wound cleaner, apply Santyl, cover with ABD and Kerlix every day. The wound note also documented the pressure ulcer on her left heel was closed. They were to apply Skin Prep to the left heel pressure ulcer, cover with ABD pad, and wrap with Kerlix dressing every day. A facility Skin/Wound note, dated 12/07/16, documented the right heel had a stage three pressure ulcer which measured 0.8 cm x 1.4 cm. The wound base was a scab. They were to apply Skin prep, wrap with ABD and Kerlix. A facility Skin/Wound note, dated 12/15/16, documented the right heel had a stage three pressure ulcer which measured 0.8 cm x 1.4 cm. The wound base was a scab. They were to apply Skin prep, wrap with ABD and Kerlix. A facility Skin/Wound note, dated 12/21/16, documented the right heel had a stage three pressure ulcer which measured 0.8 cm x 1.1 cm. The wound base was a scab. They were to apply Skin prep, wrap with ABD and Kerlix. A facility Skin/Wound note, dated 12/28/16, documented the right heel had a stage three pressure ulcer which measured 0.8 cm x 1.1 cm. The wound base was a scab. They were to apply Skin prep, wrap with ABD and Kerlix. The November 2016, shower schedule, prior to the discovery of the pressure ulcers, documented the resident had received a shower on 11/02 and 11/04. There was no documentation of skin assessments having been performed at the time of the showers. A facility Skin/Wound note, dated 01/04/17, documented the right heel had a stage three pressure ulcer which measured 1. cm x 1.3 cm. The scab had lifted from the wound bed and a purple area remained. They were to apply Skin prep, wrap with ABD and Kerlix. A facility Skin/Wound note, dated 01/13/17, documented the right heel had a stage three pressure ulcer which measured 1. cm x 1.3 cm. The wound bed appeared purple and closed. They were to apply Skin prep, wrap with ABD and Kerlix. The assessment comment at the bottom of the wound note documented the resident did not like pressure relief boots on while in bed, but did wear them sometimes while in bed and up in the chair. The resident did allow a pillow under her lower legs at times to elevate her heels. A facility Skin/Wound note, dated 01/19/17, documented the right heel had a stage three pressure ulcer which measured 1. cm x 0.5 cm. The wound bed appeared a purple/grayish color. They were to apply Skin prep, wrap with ABD and Kerlix. The assessment comment at the bottom of the wound note documented the resident did not like pressure relief boots on while in bed, but did wear them sometimes while in bed and up in the chair. The resident did allow a pillow under her lower legs at times, to elevate heels. A facility Skin/Wound note, dated 01/26/17, documented the right heel had a stage three pressure ulcer which measured 1. cm x 0.5 cm. The wound bed appeared purple and closed. They were to apply Skin prep, wrap with ABD and Kerlix. The assessment comment at the bottom of the wound note documented the resident did not like pressure relief boots on while in bed, but did wear them sometimes while in bed and when up in the chair. The resident did allow a pillow under her lower legs at times to elevate her heels. On 01/30/17 from 8:00 a.m., until 11:15 a.m., the resident was observed to be in bed on her right side. The resident did not have positioning pillows to help with pressure relief; her heels were not off loaded, and she was not wearing boots. She frequently yelled out for help. At 8:45 a.m., and 10:15 a.m., a staff member entered the resident's room and asked her if she needed anything. The resident stated she did not. No repositioning was provided. A facility Skin/Wound note, dated 02/02/17, documented the right heel had a stage three pressure ulcer which measured 0.8 cm x 0.5 cm. The wound bed appeared light purple in color and closed. They were to apply Skin prep, wrap with ABD and Kerlix. The assessment comment at the bottom of the wound note documented the resident did not like pressure relief boots on while in bed, but did wear them sometimes while in bed and when up in the chair. The resident did allow a pillow under her lower legs at times to elevate her heels. The clinical record contained no documentation of skin assessments having been performed, for approximately six weeks. The resident was admitted on [DATE], without pressure ulcers and her facility acquired pressure ulcers were not detected until 11/05/16. When the pressure ulcers were first noted, one wound was a stage III and one was unstageable. On 02/01/17 at 11:36 a.m., certified medication aide (CMA) #2 was interviewed about the resident's assistance requirements with activities of daily living (ADLs) and pressure ulcers. She was asked if she ever provided direct care to the resident. She stated she did. She stated the resident's ADL requirements haven't changed much. The CMA stated the resident had always required the assistance of one or two staff members for transferring and repositioning. She added the resident had always been incontinent. The CMA was asked if positioning pillows had been utilized prior to the development of the pressure ulcers. She stated she wasn't sure. On 02/01/17 at 1:42 p.m., the corporate nurse was interviewed about the facility pressure ulcer policy. She was asked if residents with a risk score of 18 or less were to have weekly skin assessments. She stated per their policy, a resident with a Braden score of 18 or less, would be assessed on a weekly basis with the weekly at risk skin evaluation form. On 02/01/16 at 4:15 p.m., wound care was observed for the right heel. The wound area was purple, the skin was intact, and per the licensed practical nurse (LPN) the discolored area was approximately 1.0 cm x 0.5 cm. The LPN stated she had applied boots prior to the development of pressure ulcers, but the resident would kick them off. She stated the resident would complain of pain in her heels and her boots would be off. The nurse stated she would tell everyone to keep the resident's boots on. She was asked where that was documented. She stated on the wound sheets or nurses' notes. She was asked if wound sheets would have been created prior to the development of wounds. She stated probably not. She was asked if she had been doing skin assessments prior to the development of the pressure ulcers. She stated she had not. She was asked if positioning pillows or other interventions had been put in place prior to the development of the pressure ulcers. The LPN stated she thought the resident had been repositioned every two hours. She wasn't sure if it was documented. The wound nurse was asked when she first became aware of the pressure ulcers She stated on 11/05/16. She wasn't sure how she became aware of the pressure ulcers. On 02/02/17 at 9:18 a.m., the DON, administrator, and the corporate nurse were asked to provide documentation of skin assessments having been provided from 09/26/16 through 11/05/16. They stated the resident had not had weekly skin assessments. They were asked why weekly skin assessments had not been performed. They stated they were unsure why the wound nurse had fallen behind, but at some point they found out she had fallen behind with the assessments, and they started helping her to catch up. They were asked if the resident had been repositioned every two hours and/or positioning pillows utilized. The DON stated the resident could reposition herself and didn't require repositioning from staff. They were asked what type of mattress was on the resident's bed. They stated all of their residents were on pressure relieving mattresses. The were asked if it was a low air loss mattress. They stated they would provide the name of the mattress. They provided information that documented the resident was on a foam layered mattress. The manufacture advertised the mattress provided weight distribution. The description did not contain documentation the mattress was recommended for use on a resident who had developed pressure ulcers. On 02/07/17 at 8:39 a.m., the resident was observed in bed with her weight shifted to her right hip. She was asked if she was able to roll to her left side. She attempted to transfer weight to the other side, but was unable to do so. She did not have boots on or positioning pillows in place.

Based on observation, record review, and interviews, it was determined the facility failed to assess, monitor, and intervene for effective pain management for one (#99) of three sampled residents who were reviewed for pain. The resident experienced consistent, severe to excruciating pain of the left arm which had not been managed by the pain management program. This resulted in harm to the resident. The Resident Census and Conditions of Residents form, dated 01/30/17, documented 35 residents were currently on a pain management program. The director of nursing (DON) identified 28 residents who had orders for as needed (PRN) schedule II pain medications for their pain management. The facility also failed to manage blood sugar levels in a manner to promote the resident's health for two (#21 and #94) of two sampled diabetic residents whose blood sugar levels were reviewed. This was evidenced by frequent and/or daily administration of a short acting insulin based on the results of fingerstick blood sugar (FSBS) tests. This resulted in harm to both residents due to putting them at risk of having diabetic complications (kidney function, infections, eye disorders, etc.) due to poor insulin control. The DON provided a facility report which documented seventeen residents in the facility had sliding scale orders used to manage elevated blood sugars. Findings: A facility policy titled, Pain Orientation (Recognition), documented, .Things to know about pain .Many residents experience pain that can impair mobility, disturb sleep, cause depression, or diminish quality of life. However, many of those residents may not be able to communicate their condition. Staff should therefore be aware of potential signs that a resident is experiencing pain and notify appropriate personnel so that it may be addressed if you think a resident is in pain report it to the nurse . .pay attention to the following signs .there are a number of ways that staff may observe the signs of pain .eyes see they are in pain .ears hear they are in pain .if a resident frowns, grimaces, or appears uncomfortable .restless, fidgety, guarding, agitated or depressed .groaning, moaning, or crying . A facility policy titled, Pain Management, documented, .pharmacological therapy .for these types of interventions, contact the resident's physician for the prescribed medication regimen . A facility policy titled, Pain Assessment', documented, .pain assessment is an ongoing process .assessment of the cognitively impaired .if the resident is unable to respond, chronic pain may very well be present if the following behaviors are manifested .facial expressions, grimacing, frowning .vocal expressions calling out, crying, screaming, moaning . 1. Resident #99 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] gel 160 mg (milligrams) / 5 milliliters (ml) give 650 mg via peg (percutaneous [MEDICAL CONDITION] gastrostomy) tube every four hours as needed for pain. The order was first written on 09/14/16, and changed to [MEDICATION NAME] liquid give 650 mg via peg tube every four hours PRN for pain on 09/15/16. [MEDICATION NAME] tablet 7.5 - 325 mg give one tablet via peg tube every six hours PRN for pain. The order was written on admission and changed to two tablets for 15 mg on 09/15/16. The GLC (Grace Living Center) Pain Assessment, dated 09/14/16, the day the resident was admitted , did not document the resident had any pain at the time and that the resident was non-verbal. An order administration note, dated 09/17/16, documented, [MEDICATION NAME] tablet 7.5 - 325 mg .every six hours PRN for pain rating of 6 - 10 via numerical scale patient pointed out 8/10 for pain level . An order administration note, dated 09/19/16, documented, [MEDICATION NAME] tablet 7.5 - 325 mg .every six hours PRN for pain rating of 6 - 10 via numerical scale hurting all over . The admission assessment, dated 09/21/16, documented the resident was severely impaired in cognitive skills for daily decision making, had no speech, and required extensive assistance with bed mobility, dressing, and toilet use. The assessment further documented the resident had pain at the time of the assessment at a moderate level, and received PRN medication in the last five days. The assessment documented the resident's pain occurred occasionally. A care plan, dated 09/26/16, documented, Focus: (Resident) has acute/chronic pain . Goal (Resident) will not have an interruption in normal activities due to pain Interventions .Administer [MEDICATION NAME] as ordered . Administer [MEDICATION NAME] (specify medication) as per orders. Give 1/2 hour before treatments or care . Administer [MEDICATION NAME] as ordered by the physician . Anticipate the (Resident's) need for pain relief and respond immediately to any complaint of pain . Evaluate the effectiveness of pain interventions . Monitor/document for probable cause of each pain episode. Remove/limit causes where possible . Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphasia; nausea; vomiting; dizziness and falls. Report occurrences to the physician . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Provide (Resident) and family with information about pain and options available for pain management. Discuss and record preferences . The GLC (Grace Living Center) Pain Assessment, dated 09/30/16, documented the resident currently had pain, had pain in the past few months that began about three months ago. The assessment additionally documented the resident had pain every day at horrible, excruciating levels rated at 8 -1 0, based on the facial expression scale on the form. The pain was rated at the greatest level of ten and the least at three. The site of the pain was documented as the upper and lower extremities of her left side. The current pain medication or treatment was documented as [MEDICATION NAME], which provided relief at a level of five (on a scale of 0-10 with ten being no relief). A review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was not administered at all. The resident received pain medication eight times between 09/14/16 and 09/27/16. A physician's progress note, dated 10/03/16, did not address the resident's pain she was having on a daily basis. The GLC (Grace Living Center) Pain Assessment, dated 10/14/16, documented the resident currently had pain, had pain in the past few months that began about three months ago. The resident had constant pain at horrible, excruciating levels rated at 8 - 10, based on the facial expression scale on the form. The pain was rated at the greatest level of ten, on a scale of 0-10. The left arm was indicated as the location of the pain and movement made the pain worse. The current pain medication or treatment was documented as [MEDICATION NAME] 7.5 milligrams, which provided relief at a level of three (on a scale of 0-10 with ten being no relief). A physician's progress note, dated 10/18/16, did not address the resident's pain she was having on a daily basis. A review of the MAR for October 2016, documented the resident received her [MEDICATION NAME] 43 times. The resident's pain was rated at a seven, four times, at eight, twelve times, at nine, eight times, and the pain was not rated at all, eleven times. The [MEDICATION NAME] was administered twice during the month. The resident was out of the facility in the hospital, from 10/05/16 through 10/13/16. An order administration note, dated 11/30/16, documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .every six hours as needed for pain two tabs = (equals) 15 mg arm . A review of the MAR for November 2016, documented the resident received her [MEDICATION NAME] 67 times. The resident's pain was rated a ten, twenty times; nine, twelve times; eight, eleven times; and seven, three times. The [MEDICATION NAME] was administered once during the month. A care plan, last updated 12/14/16, documented, Interventions . Resident is flip flopping in the bed now. She needs monitored and repositioned at least every 2 hrs (hours) .Treat pain as per orders prior to treatment/turning etc. to ensure comfort . An order administration note, dated 12/03/16 at 1:09 a.m., documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .left arm res (resident) crying . An order administration note, dated 12/03/16 at 11:52 a.m. documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .arm hurting . A physician's progress note, dated 12/15/16, did not address the resident's pain. An order administration note, dated 12/17/16 at 11:28 a.m., documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .hurting arm . An order administration note, dated 12/17/16 at 7:30 p.m., documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .arm . An order administration note, dated 12/18/16 at 2:53 a.m., documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet . A quarterly, assessment, dated 12/22/16, documented the resident was severely impaired with cognitive skills for daily decision making, and had altered level of consciousness. The resident had range of motion deficits to one side of the upper and lower extremities. The assessment further documented the resident received PRN pain medications, with non-verbal indicators or signs of pain occurring daily, such as facial expressions. The GLC (Grace Living Center) Pain Assessment, dated 12/30/16, documented the resident currently had pain, that started greater than three months ago. The pain was rated at a 7 - 8 based on the facial expression pain scale. The current pain medication or treatment was documented as [MEDICATION NAME] 7.5 - 325 - 15 mg via peg tube every six hours PRN and [MEDICATION NAME] gel 160 mg/5 ml every four hours PRN. The assessment documented the medication relieved pain at a level of seven (on a scale of 0-10 with ten being no relief). A physician's progress note, dated 12/30/16, did not address the resident's daily pain that was not being relieved by medication. A review of the MAR for December 2016, documented the resident received her [MEDICATION NAME] 43 times. The resident's pain was rated a ten, ten times; nine, five times; eight, eighteen times; and seven, two times. The [MEDICATION NAME] was administered once during the month. The resident was out of the facility in the hospital, from 12/22/16 through 12/30/16. An order administration note, dated 01/23/17, documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .arm hurting . A review of the MAR for January 2017, documented the resident received her [MEDICATION NAME] 46 times. The resident's pain was rated at a ten, nine times; twice at a nine; and twenty-six times at an eight; the [MEDICATION NAME] was not administered during the month. There was no additional documentation, after 12/30/16, that the facility had assessed the resident's daily pain and her current pain management program. There was no documentation the facility had notified and consulted with the physician about the resident's current pain management not relieving the pain. The resident continued to experience severe to excruciating pain. On 01/30/17 at 10:44 a.m., certified nurse aide (CNA) #1 was observed repositioning the resident. When the aide moved the resident's left arm, the resident cried out loudly. The CNA stated to the resident she knew she had a lot of pain, because of her left arm. She then asked the resident if the pain was in her left arm. The resident nodded her head to indicate, Yes. When the aide was finished repositioning the resident she told her she would check to see if the resident could get some pain medication. The nurse aide was asked about the resident's pain. She stated when they repositioned the resident and moved her left arm she would cry out in a lot in pain. She then stated she would cry and scream a lot whether they were working with her or not. The aide was observed leaving the room and entering another resident's room. She did notify the nurse or the CMA about the pain the resident was experiencing. The MAR indicated [REDACTED]. On 01/31/17 at 4:23 p.m., the resident was observed in bed with facial grimacing. She was asked if she was in pain and she nodded her head to indicate Yes. She was asked if the pain was in her left arm and she again nodded, Yes. A review of the MAR indicated [REDACTED]. A nurse's progress note dated 01/31/17 at 12:30 p.m., documented, CNA repositioned resident who was lying on her L (left) arm. Arm historically has limited passive ROM (range of motion). Resident grimaced and was crying. RN (registered nurse) then assisted CNA with repositioning, and supported arm with pillows . Resident is able to communicate her discomfort with facial expression. An interview was conducted on 02/01/17 at 2:32 p.m., with RN #1. She was asked to describe the resident. She stated the resident had a stroke, craniotomy, and tried to talk through her tracheotomy. She then stated the resident had a lot of pain on the left side, especially the arm. She added the resident had pain when you moved or repositioned her. She was asked to describe the pain. She stated, She cries a lot, so I would give it at least an eight. She then stated they knew how bad the pain was because of her non-verbal cues such as crying and grimacing. She was asked what interventions were in place for the resident's pain. She stated, Pain medication, [MEDICATION NAME], and elevate the left arm. She was asked what pain medications the resident received. She stated the resident had a PRN [MEDICATION NAME] and Tylenol. She was asked what the frequency of the medication was and how effective it was. She stated the resident received two [MEDICATION NAME] every six hours and Tylenol every four hours as needed. She then stated, It works pretty good. She then added the medication did not last long. She was asked to review the MARS for the pain medications. She looked at the records then stated, That is quite a bit being used. She then added the resident's pain was not being managed very well. She was asked if the physician had been notified of the usage of the pain medications and the resident's pain after administering the medication. She stated she had not contacted the physician and she was not sure about the other nurses because she only worked on the weekends. She then stated, I do think the doctor should be made aware of the use. An interview was conducted on 02/01/17 at 2:52 p.m., with CNA #2. He was asked to describe the resident. He stated the resident was unable to ambulate and was always in a great deal of pain when you moved her. He then stated when you walk by to check on her a lot of times, she will be crying because of her left arm hurting. He was asked how often the resident experienced the pain. He stated each day when he was working with her and when she was wiggling in her bed. He stated she would be in pain two to three times in an eight hour shift. He was asked how bad the resident's pain was. He stated, You can read her face and according to her face and tears, it's pretty bad. He was asked if the resident had anything to help with the pain. He stated she did, but it didn't seem to work well. An interview was conducted on 02/01/17 at 3:07 p.m., with CNA #1. She was asked how often the resident was in pain. She stated, The resident is in pain every day. She then added it's her left arm and side whenever it's moved or worked with. She was asked how she knew the resident was in pain. She stated by the resident's facial expressions and verbal throat noises. She then stated, By her facial expressions and crying, the pain is a nine. The aide then stated she wanted to cry at times because she knew the resident was in a lot of pain because of her facial expressions. She then stated, She will grab us and try to push us away because of the pain. She was asked if the resident had any medication that helped with the pain. She stated the resident had medication, but it didn't seem to work. An interview was conducted on 02/01/17 at 4:31 p.m., with the DON. Present during the interview was the corporate RN. The DON was asked what interventions were in place for the resident's pain. She stated, [MEDICATION NAME], and [MEDICATION NAME] PRN. She was asked if there were any non-pharmacological interventions in place. She stated, Reposition her and getting her up in the geri-chair. She was asked if the resident had any pain while being repositioned. She stated, Not when I have been in there. She was then asked to verify the frequency of pain medication used by the resident. She confirmed the numbers listed above for both the [MEDICATION NAME] and [MEDICATION NAME] administered to the resident. She was asked if the staff had informed her of the resident's daily pain. She stated she had been told about the grimacing and guarding of her body. She then stated the staff had talked to her about the facial cues and indicators of a lot of pain. She was asked where the pain was located. She stated she would have to look and see where it was coming from. She was asked if the physician had been notified of the daily pain and the frequency of the pain medication required. She looked through the chart and stated she did not see any documentation the physician had been notified and the physician had not addressed pain in his progress notes. She then stated she thought the resident should be on routine instead of PRN pain medication. The DON stated the facility policy for completing pain assessments, was on admission, quarterly, readmission, and with new pain. She was asked what level of pain the resident was in and if the facility had completed further assessments for better pain management. She stated, We cannot know what her pain is, because she cannot communicate. She then looked through the chart and stated there were no further assessments. 2. Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. A laboratory test dated 04/07/16, for a hemoglobin A1C (a test to measure what percentage of your hemoglobin is coated with sugar), documented the results were elevated at 10.5 mg/dl (milligrams/deciliter). The normal range was 4.0 - 5.6 mg/dl. A laboratory test dated 07/07/16, for a hemoglobin A1C, documented the results were elevated at 9.1 mg/dl. The normal range was 4.0 - 5.6 mg/dl. A Dietary Consultant Report dated 07/19/16, documented, Reentry nutritional assessment complete. Moderate risk r/t (related to) dx. (diagnosis) polypharmacy, out of bed w (with) assist. LCS (low concentrated sweets) diet, regular texture, thin liquids. PO (by mouth) intake 75-100% (percentage), expected to meet nutritional needs. BMI (body mass index) 55, [MEDICAL CONDITION]. No skin breakdown. Continue to monitor wt (weight) status and PO intake. No changes needed. Nutritional Recommendations No changes needed. Continue plan of care. This was signed by the physician. There were no other dietary consults located in the resident's clinical record or provided by the facility. A laboratory test dated 10/04/16, for a hemoglobin A1C, documented the results were elevated at 8.6 mg/dl. The normal range was 4.0 - 5.6 mg/dl. A laboratory test dated 10/07/16, for a hemoglobin A1C, documented the results were elevated at 8.7 mg/dl. The normal range was 4.0 - 5.6 mg/dl. The November 2016, Medication Administration Record [REDACTED]. The resident's care plan dated 11/20/16, documented, Focus Potential for injury r/t (related to) Diabetes Mellitus. Goal (Resident) will be free from any s/sx (signs/symptoms) of [MEDICAL CONDITION] through the review date. Interventions .Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. FSBS as ordered by MD and follow sliding scale using [MEDICATION NAME] R insulin . Monitor compliance with diet and document any problems . A quarterly assessment dated [DATE], documented the resident exhibited no behaviors, had an active [DIAGNOSES REDACTED]. The December 2016, MAR indicated [REDACTED]. On 12/29/16 at 12:00 p.m., and 12/09/16, 12/12/16, 12/19/16, and 12/30/16, at 4:00 p.m. The resident was administered SS insulin 119 times out of 124 opportunities, for the month of December 2017. A laboratory test dated 01/03/17, for a hemoglobin A1C, documented the results were elevated at 8.7 mg/dl. The normal range was 4.0 - 5.6 mg/dl. The January 2017, MAR indicated [REDACTED].m, therefore, no sliding scale (SS) insulin was required. There was no documentation that FSBS testing was performed and/or whether SS insulin was required, on 01/23/17 and 01/27/17, at 12:00 p.m., and on 01/19/17 at 8:00 p.m. The resident was administered SS insulin 120 times out of 124 opportunities, for the month of January 2017. The most current physician's progress note was dated 01/17/17. The note documented, No new orders received. There was nothing in the progress note to indicate the physician was aware of the elevated blood sugars and the frequency SS insulin was administered. There were no physician's progress notes located in the clinical record or provided by the facility, which addressed the resident's refusal to comply with his physician ordered therapeutic diet. The February 2016, physician's orders [REDACTED]. [MEDICATION NAME] Regular insulin inject per sliding scale: If 51-150 = 0 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, 351-400 = 12 units, 401-450 = 14 units, 451-500 = 16 units subcutaneous (SQ) four times a day related to DM with [MEDICAL CONDITION]. Notify PCP (primary care physician) if FSBS (fingerstick blood sugar) <50MG/DL (below 50 milligram/deciliter) or >500MG/DL (above 500 milligrams/deciliter). Start date 05/03/16. The resident was to have FSBS testing performed four times a day (QID), before meals and at bedtime (AC and HS). On 02/07/16 at 8:45 a.m., an interview was conducted with the resident. He was asked how the food was in the facility. He stated it wasn't very good. He was asked why. He stated it just didn't taste like at home. He was asked if he could get something different if he didn't like what was served. He stated he could, but it tasted the same as what was served. A clear, plastic container was observed in the resident's room. It contained two cans of Crisco shortening. The resident was asked about the shortening. He stated he bought them and also lots of other things so he could cook his own food. He stated he wanted to fry green tomatoes in the shortening. He was asked if he was on a special diet. He stated he was, but he didn't always follow the diet. The clinical record contained no pharmacy consultant recommendations which addressed the frequent use of SS insulin as a means of controlling the resident's elevated blood sugars. On 02/07/17 at 1:45 p.m., an interview was conducted with the director of nursing (DON) and the corporate nurse. The DON was asked about the resident's SS insulin regimen. She was asked if she thought the resident's blood sugars were being managed if he received SS insulin four times a day nearly every day of the month for the past three months. The DON stated the resident was non-compliant with his diet, he wouldn't get out of the bed, and didn't do much for himself. She was asked if the physician was aware of the resident's non-compliance with his diet and if he was aware of the resident's continued elevated blood sugars. She stated the physician was aware of the elevated blood sugars. She was asked where this was documented, since nothing was documented in the nursing progress notes or the physician's progress notes. She made no reply. She was asked if the resident's care plan addressed the resident's non-compliance with his diet. She stated she would need to check. After reviewing the resident's care plan, she stated the resident's non-compliance with his diet had not been care planned. The DON and corporate nurse were asked if the dietician had addressed the resident's non-compliance with his physician ordered diet. The corporate nurse checked the progress notes and stated there was nothing documented about the non-compliance in the dietician's progress notes. She stated the dietician documented last May (May 2016) that the resident did well with his diet. 3. Resident #94 had [DIAGNOSES REDACTED]. A care plan dated 07/18/16, documented .Focus .has diabetes mellitus . Goal .will be free from s/sx of [MEDICAL CONDITION] . Interventions .Dietary consult for nutritional regimen and ongoing monitoring .educate regarding medications and importance of compliance. Have resident verbally state understanding .Humuulin (sic) R sol (sic) as ordered .identify areas .or other difficulties in resident diabetic management .modify problem area .be more manageable .provide and document teaching to the resident .Levimir (sic) Solution as ordered .obtain fsbs ac and at hs Report to PCP (primary care physician) The SS orders dated 07/12/16 were as follows: [MEDICATION NAME] R SS Subcutaneous injection ac and at HS: DX: DM II 151-200=4u (unit); 201-300=10u; 301-350=14u; 351-400=18u; Call MD (medical doctor) for FSBS > (greater than) 400 A MAR indicated [REDACTED]. A pharmacy consult review dated 11/08/16, documented .All medications reviewed .[MEDICATION NAME] R SS continues .Response: Recommend quarterly A1c (glyconated hemoglobin) . A progress note dated 11/08/16, documented .Dr (Name withheld) rounded. No new orders received. A MAR indicated [REDACTED]. A nursing progress note, dated 12/01/16, documented .Meter read HI (sic) Meters read up to 850. Dr (Name withheld) notified, 20u [MEDICATION NAME] R (1 time order) given. Will recheck a 1 hour. A pharmacy consult review, dated 12/06/16, documented .All medications reviewed. [MEDICATION NAME] R SS continues. FSBS 850. MD contacted . A quarterly assessment dated [DATE], documented the resident was cognitively moderately impaired for daily decision making skills. The resident was independent with ADLs (activities of daily living), except required assistance with bathing by one person for stabilization and safety. The resident had an unstable gait and used a wheelchair for mobility. The resident was continent of bowel and bladder. A nursing progress note dated 12/28/16 at 10:55 a.m., documented, .Dr (Name withheld) notified of FSBS gave max dose sliding scale (18u) per Dr (Name withheld), will recheck in one hour and notify physician of FSBS A nursing progress note dated 12/28/16 at 12:01 p.m., documented, .FSBS recheck 437. Dr (name withheld) contacted for further insulin orders . A nursing progress note dated 12/28/16 at 12:51 p.m., documented, .Verbal order received from Dr (name withheld) to give 10 units of [MEDICATION NAME] R. FSBS 400, 10u given per orders, will recheck in one hour . A nursing progress note dated 12/28/16 at 14:04 (2:04 p.m.), documented, .FSBS recheck 270. No further orders received from Dr (name withheld) . A MAR, dated January 2017, documented the resident received SS insulin coverage 88 times out of 124 opportunities related to FSBS glucometer readings. A progress note dated 01/13/17, documented .gave highest sliding scale per (Dr.), will recheck in one hour call for further orders if needed. No numerical FSBS reading was documented. A MAR indicated [REDACTED]. On 02/07/17 at 9:00 a.m., the resident was observed up in his wheelchair in his room. He was asked if he had eaten his morning meal and received his FSBS and insulin. He stated, Yes I ate. They poked my finger and gave me some insulin. He was asked if the facility staff had educated him on his blood sugar and long term sliding scale use. He stated, No. I don't think so. They tell me not to eat sweet stuff. On 02/07/17 at 2:00 p.m., licensed practical nurse (LPN) #2 was asked how often the resident received SS insulin to manage blood sugar levels. She stated, Usually all of the time. Sometimes he refuses, but not often. She was asked if he had been educated on the long term use of SS insulin to manage his blood sugar levels. She stated, I don't know. At 3:00 p.m., the DON was asked if the resident required SS insulin use on a routine basis. She stated, Yes I believe so, I would have to look at his MAR indicated [REDACTED]. She stated, Yes he has been told and we have talked about it in the daily quality assurance (QA) nursing meetings. A review of all progress notes from November 1, 2016 through February 7, 2017, had no documentation to indicate the resident had been educated on use of SS insulin long term use or reflect any changes in the blood sugar management regimen for the resident. On 02/08/17 at 2:00 p.m., the DON was asked if SS insulin use for the long term management of blood sugars had been addressed with the physician. She stated, We are starting to talk about this with the medical director and looking at changing the Levimer dose to a higher dose or to use something else. It has been discussed in the Q-TIP meetings, which is the QA meetings that are nursing oriented.

Based on observation, record review and interview, it was determined the facility failed to ensure they notified the physician of daily, excruciating pain for one (#99) of three sampled residents reviewed for pain management. The resident experienced severe to excruciating pain of the left arm on a daily basis, which was not managed with the current pain management program. This resulted in an harm to the resident. The Resident Census and Conditions of Residents form, dated 01/30/17, documented 35 residents were on a pain management program. Findings: A facility policy titled, Pain Management, documented, .pharmacological therapy .for these types of interventions, contact the resident's physician for the prescribed medication regimen . A facility policy titled, Resident Family or Physician Notification of Change Guideline, documented, Purpose -This is a guideline to know when it may be necessary to notify the resident's . physician .The facility will inform the resident; consult with the physician .of the following events .a need to alter treatment .i.e. a need to discontinue an existing form .or to commence a new form of treatment . 1. Resident #99 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] gel 160 mg (milligram) /5 milliliters (ml) give 650 mg via peg (percutaneous [MEDICAL CONDITION] gastrostomy) tube every four hours as needed for pain. The order was first written on 09/14/16, and changed to [MEDICATION NAME] liquid give 650 mg via peg tube every four hours as needed for pain on 09/15/16. [MEDICATION NAME] tablet 7.5-325 mg give one tablet via peg tube every six hours as needed for pain. The order was written on admission and changed to two tablets for 15 mg on 09/15/16. The GLC (Grace Living Center) Pain Assessment, dated 09/14/16, the day the resident was admitted , did not document the resident had any pain at the time and that the resident was non-verbal. An order administration note, dated 09/17/16, documented, [MEDICATION NAME] tablet 7.5-325 mg .every six hours as needed for pain rating of 6 -10 via numerical scale patient pointed out 8/10 for pain level . An order administration note, dated 09/19/16, documented, [MEDICATION NAME] tablet 7.5-325 mg .every six hours as needed for pain rating of 6 -10 via numerical scale hurting all over . The admission assessment, dated 09/21/16, documented the resident was severely impaired in cognitive skills for daily decision making, had no speech, and required extensive assistance with bed mobility, dressing, and toilet use. The assessment further documented the resident had pain at the time of the assessment at a moderate level, and received as needed pain medication in the last five days. The assessment documented the resident's pain occurred occasionally. A care plan, dated 09/26/16, documented, Focus: (Resident) has acute/chronic pain . Goal (Resident) will not have an interruption in normal activities due to pain Interventions .Administer [MEDICATION NAME] as ordered . Administer [MEDICATION NAME] (specify medication) as per orders. Give 1/2 hour before treatments or care . Administer [MEDICATION NAME] as ordered by the physician . Anticipate the (Resident's) need for pain relief and respond immediately to any complaint of pain . Evaluate the effectiveness of pain interventions . Monitor/document for probable cause of each pain episode. Remove/limit causes where possible . Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphasia; nausea; vomiting; dizziness and falls. Report occurrences to the physician . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Provide (Resident) and family with information about pain and options available for pain management. Discuss and record preferences . The GLC Pain Assessment, dated 09/30/16, documented the resident currently had pain, had pain in the past few months that began about three months ago. The assessment additionally documented the resident had pain every day at horrible, excruciating levels rated at 8-10, based on the facial expression scale on the form. The pain was rated at the greatest level of ten and the least at three. The site of the pain was documented as the upper and lower extremities of her left side. The current pain medication or treatment was documented as [MEDICATION NAME], which provided relief at a level of five (on a scale of 0-10 with ten being no relief). A review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was not administered at all. The resident was admitted to the facility on [DATE], went to the hospital on [DATE], and returned on 09/30/16. The resident received the pain medication eight times between 09/14/16 and 09/27/16. A physician's progress note, dated 10/03/16, did not address the resident's pain she was having on a daily basis. The GLC Pain Assessment, dated 10/14/16, documented the resident currently had pain, had pain in the past few months that began about three months ago. The resident had constant pain at horrible, excruciating levels rated at 8-10, based on the facial expression scale on the form. The pain was rated at the greatest level of ten on a scale of 0 - 10. The left arm was indicated as the location of the pain and movement made the pain worse. The current pain medication or treatment was documented as [MEDICATION NAME] 7.5 milligrams, which provided relief at a level of three (on a scale of 0-10 with ten being no relief). A physician's progress note, dated 10/18/16, did not address the resident's pain she was having on a daily basis. A review of the MAR for October 2016, documented the resident received her [MEDICATION NAME] 43 times. The resident's pain was rated at seven, four times; eight, twelve times; nine, eight times; and eleven times the pain was not rated at all. The [MEDICATION NAME] was administered twice during the month. The resident was out of the facility in the hospital from 10/05/16 through 10/13/16. An order administration note, dated 11/30/16, documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .every six hours as needed for pain two tabs = (equals) 15 mg arm . A review of the MAR for November 2016, documented the resident received her [MEDICATION NAME] 67 times. The resident's pain was rated a ten, twenty times; nine, twelve times; eight, eleven times; and seven, three times. The [MEDICATION NAME] was administered once during the month. A care plan, last updated 12/14/16, documented, .Interventions .Resident is flip flopping in the bed now. She needs monitored and repositioned at least every 2 hrs (hours) .Treat pain as per orders prior to treatment/turning etc. to ensure comfort . An order administration note, dated 12/03/16 at 1:09 a.m., documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet . left arm res (resident) crying . An order administration note, dated 12/03/16 at 11:52 a.m., documented, [MEDICATION NAME] tablet 7.5-325 mg give two tablet .arm hurting . A physician's progress note, dated 12/15/16, did not address the resident's pain. An order administration note, dated 12/17/16 at 11:28 a.m., documented, [MEDICATION NAME] tablet 7.5-325 mg give two tablet .hurting arm . An order administration note, dated 12/17/16 at 7:30 p.m., documented, [MEDICATION NAME] tablet 7.5-325 mg give two tablet .15 mg arm . An order administration note, dated 12/18/16 at 2:53 a.m., documented, [MEDICATION NAME] tablet 7.5-325 mg give two tablet . A quarterly assessment, dated 12/22/16, documented the resident was severely impaired with cognitive skills for daily decision making and had altered level of consciousness. The resident had range of motion deficits to one side of the upper and lower extremities. The assessment further documented the resident received as needed pain medications, with non-verbal indicators or signs of pain occurring daily, such as facial expressions. The GLC Pain Assessment, dated 12/30/16, documented the resident currently had pain, that started greater than three months ago. The pain was rated at a 7 - 8 based on the facial expression of pain scale, which indicated the resident hurt a whole lot. The current pain medication or treatment was documented as [MEDICATION NAME] 7.5 - 325 - 15 mg via peg tube every six hours as needed and [MEDICATION NAME] gel 160 mg/5 ml every four hours as needed. The assessment documented the medication relieved pain at a level of seven (on a scale of 0 - 10 with ten being no relief). A physician's progress note, dated 12/30/16, did not address the resident's continual pain that was not being relieved by medication. A review of the MAR for December 2016, documented the resident received her [MEDICATION NAME] 43 times. The resident's pain was rated a ten, ten times; nine, five times; eight, eighteen times; and seven, two times. The [MEDICATION NAME] was administered once during the month. The resident was out of the facility in the hospital, from 12/22/16 through 12/30/16. An order administration note, dated 01/23/17, documented, [MEDICATION NAME] tablet 7.5 - 325 mg give two tablet .arm hurting . A review of the MAR for January 2017, documented the resident received her [MEDICATION NAME] 46 times. The resident's pain was rated at a ten; nine times; twice at a nine; and twenty-six times; at an eight; the [MEDICATION NAME] was not administered during the month. There was no documentation the facility had notified and consulted with the physician about the resident's current pain management not relieving the pain and the resident continued to experience pain at severe to excruciating levels. On 01/30/17 at 10:44 a.m., certified nurse aide (CNA) #1 was observed repositioning the resident. When the aide moved the resident's left arm, the resident cried out loudly. The CNA stated to the resident she knew she had a lot of pain because of her left arm. She then asked the resident if the pain was in her left arm. The resident nodded her head to indicate yes. The nurse aide was asked about the resident's pain. She stated when they repositioned the resident and moved her left arm she would cry out in a lot in pain. She then stated the resident would cry and scream a lot both when they were working with her and when they were not working with her. A nurse's progress note, dated 01/31/17 at 12:30 p.m., documented, CNA repositioned resident who was lying on her L (left) arm. Arm historically has limited passive range of motion (ROM). Resident grimaced and was crying. Registered nurse (RN) then assisted CNA with repositioning, and supported arm with pillows . Resident is able to communicate her discomfort with facial expression. On 01/31/17 at 4:23 p.m., the resident was observed in bed with facial grimacing. She was asked if she was in pain and she nodded her head to indicate, Yes. She was asked if the pain was in her left arm and she again nodded, Yes. An interview was conducted on 02/01/17 at 2:32 p.m., with RN #1. She was asked to describe the resident. She stated the resident had a stroke, craniotomy, and tried to talk through her tracheotomy. She then stated the resident had quite of bit of pain on the left side, especially the arm. She added the resident had pain when you moved or repositioned her. She was asked to describe the pain. She stated, She cries a lot, so I would give it at least an eight. She then stated they knew how bad the pain was because of her non-verbal cues such as crying and grimacing. She was asked to review the medication administration records for the pain medications. She looked at the records then stated, That is quite a bit being used. She then added the resident's pain was not being managed very well. She was asked if the physician had been notified of the usage and the resident's continual pain after being administered medication. She stated she had not contacted the physician and she was not sure about the other nurses, because she only worked on the weekends. She then stated, I do think the doctor should be made aware of the use. An interview was conducted on 02/01/17 at 4:31 p.m., with the director of nursing (DON). Present during the interview was the corporate RN. The DON was asked what interventions were in place for the resident's pain. She stated [MEDICATION NAME] and [MEDICATION NAME] as needed (PRN). She was then asked to verify the frequency of pain medication used by the resident on the MARS. She verified the frequency of the [MEDICATION NAME] and [MEDICATION NAME] administered to the resident. She was asked if the staff had informed her of the resident's daily pain. She stated she had been told about the grimacing and guarding of her body. She then stated the staff had talked to her about the facial cues and indicators of a lot of pain. She was asked if the physician had been notified of the daily pain and the frequency of medication required. She looked through the chart and stated she did not see any documentation the physician had been notified of the resident's pain and the physician had not addressed the resident's pain in his progress notes. She then stated she thought the resident should be on routine pain medication instead of prn.

Based on record review and interview, it was determined the facility failed to ensure there was sufficient staff to meet the needs of the residents on hall one (station 1) of two halls. The facility identified 61 residents who resided on hall 100 on 01/02/16. Findings: Resident #59 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 10/22/15, documented the resident was cognitively intact. The resident required extensive assistance with transfers, dressing and personal hygiene. A nurse's note, dated 01/02/16 at 5:26 p.m., documented: Focused assessment R/T (related to) C/O (complaints of) pacemaker shocking her. Licensed Practical Nurse (LPN) #5 charge nurse called this nurse to station 1 and stated She wants to go to the hospital, her pacemaker is going off, I'm behind on my blood sugars and I don't have time for this Resident was very upset that pacemaker was shocking her, noticeable increase in anxiety, potassium that resident refused was administered by this nurse. Resident educated that she needed to take her medicine as prescribed by physician to help keep her rhythm normal, and prevent pacemaker from shocking. res (resident) calmed down see VS (vital signs) and weights tab for before and after V/S, resident is now resting at this time with 0 (no) C/O or S/S (signs and/or symptoms) of pain, discomfort, or distress, call light and fluids in reach. (husband) notified. The clinical record contained no documentation an assessment had been completed, the physician had been notified, or the resident had been monitored. On 01/06/16, the facility provided the following information regarding the acuity and census of the residents who resided on hall one hundred on 01/02/16. A. The resident census for hall 100 was 61. B. Seven residents were totally dependent on staff for activities of daily living. C. Five residents received nutrition and medications by percutaneous endoscopic gastrostomy (peg tube). D. Three residents had a [MEDICAL CONDITION]. E. Fifteen residents required fingerstick blood sugars and possible insulin injections prior to the evening meal. F. Ten residents required wound care. Five of the ten had multiple sites which required wound care. The facility staffing records for 01/02/16, were reviewed. The records documented one LPN was on duty on hall 100 and one LPN was on duty on hall 200 for the evening shift. Four certified nurse aides (CNAs) were providing coverage for both hall 100 and the skilled unit for the evening shift. Four certified medication aides were providing coverage for hall 100 and the skilled hall for the evening shift. The combined resident census for both halls was 75. On 01/05/16 at 2:05 p.m., LPN #4 was interviewed about the division of the CNAs for staffing on both halls. She stated two of the CNAs had been assigned to hall 100 and two had been assigned to hall 200 for the evening shift. The LPN added that she understood how it was possible for a nurse to get behind on hall 100 because the hall had residents which had a high acuity of care. The LPN stated she had been told by administration the staffing was determined by the state required ratios. On 01/05/16 at 4:00 p.m., resident # F, who resided on hall 100, was interviewed about the availability of staff. The resident stated there isn't enough staff to help her. She stated one time she had to wait three hours for assistance. At 4:05 p.m., resident #G, who resided on hall 100, was asked about availability of staff. He stated he often had to wait as long as 30 minutes for assistance, because there wasn't enough staff. At 4:10 p.m., resident # H, who resided on hall 100, was interviewed about the availability of staff. He stated there was often not enough staff to provide assistance when he needed it. He added, he had to lay in urine a long time before he could get assistance. At 4:15 p.m., resident #29, who resided on hall 100, was interviewed about the availability of staff. He stated there was definitely not enough staff, especially when he needed a pain pill. He stated there had been times there was only one aide working the hall. Four residents who resided on hall 100, were interviewed about care provided by the staff. They all stated they felt there was not enough staff to meet their needs in a timely manner. One resident stated there had been times there was only one aide on hall 100. They all stated they frequently had to wait extended times for assistance.

Based on record review and interview, it was determined the facility failed to ensure one (#59) of two sampled residents with a pacemaker/defibrillator were fully assessed and monitored after an episode of firing of the defibrillator. This resulted in an actual harm due to the resident was sent to the hospital and admitted to the intensive care unit (ICU) with a [DIAGNOSES REDACTED]. The facility identified no other resident's with a pacemaker/defibrillator who resided in the facility. Findings: Resident #59 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's care plan, dated 07/22/15, documented: Focus Potential for injury r/t (related to) impaired cardiac output Interventions .Sent to (Named hospital) r/t pacemaker firing resulting in irr (irregular) heart beat Date initiated 12/13/15 (Name of resident) HAS A PACEMAKER IMPLANTED IN THE RT (RIGHT) CHEST WALL date initiated 08/19/15 . There was no documentation to indicate the care and treatment of [REDACTED]. A nurse's note, dated 08/20/15 at 11:50 p.m., documented the resident was yelling out for help. The resident stated her defibrillator was going off again and shocked her three times. She complained of chest pain, rated at an 8 (scale of 0-10). The note documented the resident was sent to the emergency room and oxygen was applied at 2 liters/minute. A nurses's note, dated 08/21/15 at 3:46 p.m., documented the resident was admitted to the local hospital with a [DIAGNOSES REDACTED]. A nurse's note, dated 08/28/15 at 6:35 p.m., documented the resident was readmitted to the facility. physician's orders [REDACTED]. The quarterly assessment, dated 10/22/15, documented the resident's cognition was intact, she required extensive assistance with transfers, dressing and personal hygiene. The assessment documented she exhibited rejection of care one to three days during the look back period of the assessment. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The 12/2015 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A nurse's note, dated 12/13/15 at 6:30 a.m., documented, (At) 0530 (5:30 a.m.) called to resident room with C/O (complaints of) pacemaker fired. Heart rate 84 and regular. Spouse notified he wanted to speak with daughter before transferring to hospital. Called back wanted to wait for daughter to get here before decision made. (At) 0600 (6:00 a.m.) again called to resident room pacemaker had fired again. Heart rate now irregular, irregular with rate from 55-75 b/m (beats per minute), physician notified and order obtained to transfer to (local hospital) via EMS (emergency medical services). EMS activated. Spouse notified of new development and that resident on way to (local hospital) . A history and physical (H & P) from the local hospital, dated 12/13/15, documented the chief complaint was chest pain. The pacemaker/defibrillator fired three times last night. The H & P documented the pain was described as pressure located in the central chest area. It documented the pain started last night and the resident had nausea and had experienced diaphoresis ( profuse sweating which is often associated with cardiac compromise). A comprehensive metabolic panel laboratory test was performed and documented the resident's potassium level was 2.1 and was flagged as low. The H & P documented the resident was administered 60 mg of potassium in the emergency department. The calculated potassium deficit was about 742 milliequivalents. The H & P's plan of care documented the resident would receive potassium 40 mEq every four hours for four doses, then receive potassium 10 mEq intravenously for six doses. A nurse's note, dated 12/23/15 at 1:26 p.m., documented the resident was readmitted to the facility and to resume her previous orders. A physician's orders [REDACTED]. The results for the renal panel documented the laboratory test was drawn on 12/30/15 at 6:26 a.m. It documented the date reported was 12/31/15 at 1:10 a.m. with the results of the potassium level out of range at 2.8. The reference range was documented at 3.5 - 5.1. A nurse's note, dated 12/31/15 at 5:11 a.m., documented, Final Lab results received, faxed to (primary care physician), awaiting review. There was no documentation to indicate the physician responded to the faxed lab results sent on 12/31/15. There was no documentation the facility called the physician related to the critically decreased potassium level and the resident was not seen by the physician and provided treatment for [REDACTED]. A nurse's note, dated 01/02/16 at 5:26 p.m., documented, Focused assessment R/T (related to) C/O (complaints of) pace maker shocking her. Licensed Practical Nurse (LPN) #5 charge nurse called this nurse to station 1 and stated She wants to go to the hospital, her pacemaker is going off, I'm behind on my blood sugars and I don't have time for this Resident was very upset that pacemaker was shocking her, noticeable increase in anxiety, potassium that resident refused was administered by this nurse. Resident educated that she needed to take her medicine as prescribed by physician to help keep her rhythm normal, and prevent pacemaker from shocking. res (resident) calmed down see VS (vital signs) and weights tab for before and after V/S, resident is now resting at this time with 0 (no) C/O or S/S (signs/symptoms) of pain, discomfort, or distress, call light and fluids in reach. (husband) notified. There was no documentation to indicate the physician had been notified of the defibrillator shocking the resident. A nurse's note, dated 01/02/16 at 5:46 p.m., documented, Resident is calm at this time and agrees to stay in facility, is not wanting to go to hospital at this time. The next nurse's note, a skilled note dated 01/02/16 at 10:01 p.m., documented the focused assessment was related to skilled status for a urinary tract infection. It documented the resident got very worked up earlier after her daughter left but had since calmed down. There was no documentation to address the previous episode of the defibrillator firing. A nurse's note, dated 01/03/16 at 10:55 a.m., documented a focused assessment was completed related to the skilled status for a urinary tract infection. It documented the resident stayed awake most of the night wanting someone in the room with her and was on the call light or called out for help. When staff went into the room, the resident did not know what she wanted but she wanted the staff member to stay with her. A skilled nurse's note, dated 01/03/16 at 2:00 p.m., documented the resident reported feeling tired with little energy, hopeless, depressed with little interest or pleasure in doing things. She had chest pain (defibrillator) at a level of 6 (scaled of 0 - 10). The note documented a focused assessment related to skilled services status for a urinary tract infection. The resident complained of her defibrillator going off three times and the husband was concerned and wanted her to be sent to the hospital for an evaluation. The note documented the resident continued to refuse her potassium. The physician was notified. The resident was very anxious, and she appeared scared. The resident was sent to the hospital. An H & P from the local hospital, dated 01/03/16, documented the chief complaint for the resident was the defibrillator firing. A laboratory test was drawn and documented the potassium level was 2.2 (the normal range values for potassium was 3.5 to 5.0). The H & P documented a wide complex of [MEDICAL CONDITION](rapid heart rate)/possibly [MEDICAL CONDITION] secondary to [DIAGNOSES REDACTED] and severe symptomatic [DIAGNOSES REDACTED] (low potassium). The H & P plan documented the [MEDICAL CONDITION] resolved in the emergency department. The H & P documented it had been reported the defibrillator went off eight times that day. The 01/2016, MAR, documented the resident was to receive one packet by mouth with meals and at bedtime of Phos-NaK Packet 280 160-250 mg (Potassium and Sodium [MEDICATION NAME]) related to [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. On 01/04/16 at 5:00 p.m., the quality assurance (QA) manager, who was also the acting director of nursing, was asked why resident #59 was not in the building. She stated it was reported to her that the resident's defibrillator kept going off several times and she was admitted to ICU. She was asked when the resident was discharged to the hospital. She looked at the nurses' notes and stated according the nurses' notes it was two days ago (01/02/16). At 5:26 p.m., the QA manager stated the resident was getting shocked by her defibrillator. It had happened a couple of times. She was asked if the doctor was notified of the defibrillator firing on 01/02/16. She stated it documented she was upset and her husband was notified but there is nothing documented to indicate the physician was notified. The QA Manager was asked if there was a transfer sheet to indicate the date of her discharge. She stated she did not see one in the chart. She was asked if she would expect a full nursing assessment of a resident who had complaints of being shocked by a defibrillator. She stated, Yes. She was asked if she would expect the staff to notify the physician. She stated, Yes. She was asked if there was any documentation of follow up assessments regarding the concerns. She stated there should be documentation in the progress notes. At 5:41 p.m., the QA manager provided a skilled note. She stated she was mistaken, the resident was discharged on [DATE]. At 6:08 p.m., the QA manager was asked what the policy and procedure was for the care of a resident with a pacemaker/defibrillator. She stated they did not have a policy for that, they just go by the physician's orders [REDACTED]. She stated, it doesn't say much. At 6:20 p.m., the QA manager stated she had spoken to the resident's physician. She stated the physician informed her all issues concerning the pacemaker/defibrillator should be directed to the cardiologists. The physician orders [REDACTED]. On 01/05/16 at 8:40 a.m., LPN #3 was asked about the resident. She stated she is constantly getting shocked by her defibrillator. She was in ICU right now. She was asked where she would document her findings if the resident was having concerns related to her pacemaker/defibrillator firing. She stated in the progress notes. The LPN stated the resident refused to take her potassium frequently. She stated a nurse, who was a former employee of the facility, informed her to tell everyone to try and get the resident to take the potassium due to the resident's history of low potassium levels. She was asked what protocol she would perform if the resident complained of her defibrillator shocking her. She stated she would listen to her heart and then call the doctor. She further stated the resident had been in ICU three or four times due to her not taking her potassium. (The clinical record documented the resident had only refused four of 161 doses from November 1st 2015 thru January 3rd 2016.) At 1:15 p.m., the corporate registered nurse (RN) was asked when the last time the resident was seen by a cardiologist. She stated it was on 08/20/14, after the pacemaker was replaced in 07/2014. She stated the resident went to the pacemaker clinic on 09/18/14, but did not see a cardiologist. She was to have a follow up appointment in March 2015, but that did not get scheduled. She was asked if the resident has had her pacemaker/defibrillator checked since 09/18/14. She stated, No. At 2:05 p.m., LPN #4 was asked about the incident with resident #59 on 01/02/16. She stated LPN #5 called her down to station I because the resident had been shocked by her defibrillator. LPN #4 added that LPN #5 explained to her she didn't have time to take care of the resident because she was behind on obtaining blood sugars and insulin injections that were due before the evening meal. LPN #4 stated she just sat and talked with the resident for about 30 minutes. The resident was upset. The LPN stated she got the resident to take her potassium and she thought the defibrillator shocked the resident twice. LPN #4 was asked if she performed an assessment on the resident. She stated she listened to her heart and took a set of vital signs. She stated she could have done a better job at charting. The resident was very anxious. She stated she did not auscultate the lung fields due to the resident was screaming. She was asked if the resident had an order for [REDACTED]. The LPN was asked what the protocol was for the care of a resident with a pacemaker/defibrillator. She stated she had not seen the protocol, but usually the doctor will call and set up an appointment. She was asked if this was the first time this had happened to the resident. She stated, this had happened quite a few times. She usually wanted to go to the hospital. She stated, the resident had low potassium levels. She was asked why the resident was not sent to the hospital. She stated if the defibrillator had kept shocking, she would have encouraged her to go. She was asked if she had called the physician. She stated, no she did not. LPN #4 stated she gave report to LPN #5 and went back to her station 2. She was asked if the resident had an order for [REDACTED]. LPN #4 was asked what duties LPN #5 was performing since she was behind. She stated before the supper meal there were about 16 or 17 fingerstick blood sugars to perform along with five residents with percutaneous gastrostomy tubes (PEG) and three residents with a [MEDICAL CONDITION]. That is an awful lot to get done for one nurse.

Based on observation, interview, and record review, it was determined the facility failed to address pain caused by pressure ulcer dressing changes for 1 (#5) of 3 sampled residents with pressure ulcers. The resident repeatedly cried out in pain during the pressure ulcer dressing change, and the facility did not coordinate the dressing change with the administration of the resident's pain medication. This constituted actual harm for resident #5. The facility identified four residents who had pressure ulcers. Findings: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 12/23/10, documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making, and exhibited inattention and disorganized thinking that was continuously present and did not fluctuate. It was also documented the resident was on a scheduled pain medication regimen and had not received any as needed pain medication during the previous 5 days. It was also documented the resident had 1 stage III pressure ulcer. A CAA documentation record, dated 12/30/10, documented, "...Pressure ulcers...Monitor pain as she does not communicate pain. She does take routine [MEDICATION NAME]" The resident's care plan, updated 01/06/11, documented a problem, "...Potential for alteration in comfort r/t pain.." The goal was, "...Pain to be addressed per episode..." Approaches included, "Identify factors that precipitate or aggravate pain..." A physician's telephone order, dated 01/08/11, documented, "[MEDICATION NAME] (a pain medication) 5/500 (5 mg [MEDICATION NAME] and 500 mg [MEDICATION NAME]) (one) po QID...Dx: pain..." Daily wound charting, dated 01/11/11 through 01/14/11, documented the resident had not complained of pain and no pain medication had been given on the 7-3 shift. Daily wound charting, dated 01/15/11 through 01/16/11, documented the resident had not complained of pain. It was not documented if the resident had received pain medication on the 7-3 shift. A pain assessment, dated 01/16/11, documented the resident had no pain, did not know if she had any pain in the past few months, and did not know how often pain occurred. It was documented, "...No signs or symptoms of pain..." Current pain medication or treatment was documented as Tylenol, 10 to 20 milliliters every 4 to 6 hours as needed. Daily wound charting, dated 01/19/11 through 01/21/11, documented the resident had not complained of pain and no pain medication had been given on the 7-3 shift. Daily wound charting, dated 01/22/11 through 01/23/11, contained no documentation related to pain. The form was blank except for the date. Daily wound charting, dated 01/24/11, documented the resident had not complained of pain and no pain medication was given on the 7-3 shift. MARs, dated 01/15/11 through 02/11/11, documented the resident received her physician ordered [MEDICATION NAME] for pain at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. on each day. On 02/11/11 at 11:05 a.m., LPN #1 was observed performing a pressure ulcer dressing change for resident #5. LPN #1 rolled the resident to her left side. The resident cried out, "Easy!" LPN #1 removed the soiled dressing and began to wipe the pressure ulcer with a moistened gauze pad. The resident began crying out. LPN #1 wiped the right and left side of the pressure ulcer, and the resident cried out in pain each time the pressure ulcer was touched. LPN #1 wiped the center of the pressure ulcer, and the resident cried out in pain. She then wiped the right side and the center of the pressure ulcer again, and the resident cried out in pain each time the pressure ulcer was touched. LPN #1 began to apply the dressing to the resident's pressure ulcer. When the dressing was applied to the pressure ulcer, the resident cried out, "Quit, will you quit!" At 11:46 a.m., LPN #1 was asked if the resident always cried out in pain when the pressure ulcer dressing change was being completed. She stated, "Not every time." When asked how often the resident cried out in pain, LPN #1 stated, "Maybe two to three times during the week." LPN #1 was asked if she coordinated the dressing change with the administration of the resident's pain medication. She stated, "We try to. I usually try to do my dressing change after lunch when they've had their meds." LPN #1 stated, "If you're touching it (the pressure ulcer), it's gonna hurt her." At 2:24 p.m., the DON was asked if the facility had a pain management program. She stated, "Yes." When asked what the pain management program consisted of, the DON stated it consisted of residents on routine pain medications. The DON identified 24 residents as being on the pain management program. The DON was asked how many residents had pressure ulcers. She stated, "Four." The DON was asked if she had been informed the resident was experiencing pain during her pressure ulcer dressing change. The DON stated, "No. No one has ever told me." The surveyors notified the DON of the resident's pain during the pressure ulcer dressing change. The DON stated, "Then we are doing the dressing at the wrong time."