Every finding on record at Shirkey Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure 12 of 12 residents who participated in a group meeting knew how to file a grievance in writing, and how to file anonymously. The facility census was 86. Review of facility policy titled Grievance Policy, dated 03/06/17, showed: - Grievances may be filed verbally or in writing and may be filed anonymously; - A verbal grievance can be reported to the Grievance Officer or any member of the facility staff, the staff member will report the grievance to the Grievance Officer; - Grievance forms are available in the front office and nurse's stations. This form can be completed and submitted to the Grievance Officer. An anonymous form will be accepted. 1. During a group meeting on 5/06/25 at 03:10 P.M., 12 of the 12 residents said: - They did not know where a form to file a grievance would be located; - They were not sure how to file the form for a grievance if one was located; - One of the 12 thought Social Services might be the one who handles them. During an interview on 05/07/25 at 10:32 A.M., Registered Nurse (RN) B said: - To file a grievance the residents can contact the ombudsman or can ask to talk to the social worker; - There are no grievance forms or drop box available that he/she knows of; - The residents can go through resident council for a grievance; - He/She has seen a resident ask and the resident was directed to the appropriate resources. During an interview on 05/07/25 at 11:02 AM the Assistant Director of Nursing (ADON) said: - For grievances the residents are sent to the social worker to take the grievance and keep it as anonymous as much as possible; - There is a drop box near the payroll office but he/she didn't think the residents knew how to access it and didn't think it had been opened in awhile. During an interview on 05/07/25 at 11:41 A.M., Licensed Practical Nurse (LPN) A said: - If a resident has a grievance they notify the social worker to get the greivance form; - There is no drop box or greivance forms out for the residents. During an interview on 05/07/25 at 12:00 P.M., LPN C said: - If a resident had a grievance they usually write it on any paper and put it under the Administrator's door; - There is a suggestion box by the front the residents can place it in. During an interview on 05/05/25 at 11:45 A.M., the Administrator said: - Residents with a grievance can see the social worker who will address the complaint with the resident, but is kept confidential; - After hours, the residents can go to their charge nurse with a grievance.

Based on observation, interview and record review, the facility failed to ensure staff maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe. The facility failed to address repairs and cleanliness deficiencies in the 500 Wing Dining Room and failed to fix and repair one resident's faucet (Resident #188) that was unable to be shut off for seven days and when two Resident's sinks were blocked (Resident #28 and #21) and would not drain. The facility census was 86. Review of facility policy, housekeeping room cleaning, dated February 2025, showed: -Housekeeping was 7 days a week. General cleaning is required daily for each occupied unit. Wednesdays are for deep cleaning which was also to be completed when resident discharged or was out to the hospital or on an extended leave of absence. -Wing 4 if it had less than 4 residents would do general cleaning on Wednesdays only and nursing was responsible for others days of the week. -Housekeeping was once a day in each resident's room with spot cleaning and removal of bodily fluid spillage by nursing in between cleanings. 1. Review of Resident #188's Entry tracking Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/30/25, showed he/she entered from short-term general hospital stay on 4/30/25. Observation on 5/5/25 at 9:01 A.M. showed the water at the sink faucet in his/her room was flowing rapidly with a steady stream of water from faucet. During an interview on 5/5/225 at 9:01 A.M., the Resident said: -His/Her water had been running from the sink faucet in his/her room since he/she moved into the facility on [DATE]; -He/She had been told the facility was supposed to be fixing it. Observation on 5/5/25 at 9:17 A.M. showed Maintenance Worker B in resident's room working on faucet. Observation on 5/7/25 at 10:54 A.M. showed water was still running in resident's room. During an interview on 5/7/25 at 10:54 A.M., Resident said that staff came in and said they needed to order a part for the resident's faucet. During an interview on 9/5/8/24 at 9:20 A.M., Maintenance Director said: -He/She did not know exactly what was going on with the faucet running in resident's room; -The water that was running in resident's room was hot water; -The faucet in the resident's room was old and needed to be replaced; -If the handles on the resident's faucet did not get pushed back all the way then the water would not shut off to the faucet. During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said: -Resident's faucet was streaming because the shut off valve was frozen and he/she could not turn off water to fix the problem; -The only way he had to turn water off was turning off the water to the wing; -The only day he/she could turn the water off to the building was on Wednesdays because the staff did showers every other day of the week; -When the faucet would be fixed he/she would have to shut off water to the entire wing and do it on a Wednesday. 2. Review of Resident #28's Admission MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She admitted from a skilled nursing facility on 4/3/25; -Diagnoses included renal failure, dementia, and diabetes. Observation on 5/5/25 at 10:14 A.M. showed the sink in resident's room wasn't draining and water was observed standing in sink. During an interview on 5/5/25 at 10:14 A.M., the Resident said that water in the sink would not drain and it had just started to become plugged up. Observation on 5/6/26 at 8:25 A.M., showed Therapy staff ask the resident what happened to the sink and the Resident said it was stopped up and that staff had tried to unclog it a couple of times. Observation on 5/6/26 at 8:49 A.M. showed two plumbers arrived and entered resident's room to look at sink. A machine was hooked up to the sink and a line was placed down the drain. During an interview on 5/6/25 at 8:49 A.M., the plumber said: -The sink was stopped up in other rooms on the same side of the hall in the facility; -The sink and plumbing was just old in the facility and that is what had caused the issues. During an interview on 5/8/24 at 9:20 A.M., Maintenance Director said: -He/She did not know exactly what was going on with sinks being stopped up in the building; -He/She would called the plumber if he/she had plumbing issues; -When building was built if one sink had problems the one in the room next to it had problems because the plumbing was tied together; -The resident's room was in an older part of the building and the building was built with concrete blocks; -The maintenance staff had been helping him repair issues in the building. During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said: -The drain in resident's room had been slow draining for awhile and it was plugged up again; -The drain had been cleared a few weeks ago by the plumbers and became plugged up again during time resident had COVID and the facility could not have plumbers into service the drain in room while he/she was on isolation; 3. Review of Resident #21's Annual MDS, dated [DATE], showed: -Cognition intact; -He/She had clear speech and was able to make self understood and understand others; -Diagnoses included stroke, renal failure, diabetes, and respiratory failure Observation on 5/5/25 at 1:24 P.M. showed the sink in resident's room was stopped up with water in it. During an interview on 5/5/25 at 1:24 P.M. the resident said: -The facility was aware of the plumbing issue with his/her sink; -His/Her sink had not been draining for a couple of days. During an interview on 5/8/24 at 9:20 A.M., Maintenance Director said: -He/She did not know exactly what was going on with sinks being stopped up in the building; -He/She called the plumber if he/she had plumbing issues; -When building was built if one sink had problems the one in the room next to it had problems because the plumbing was tied together; -The resident's room was in an older part of the building and the building; During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said the drain in resident's room had been slow draining for awhile and it was plugged up again. 4. Observation on 5/05/25 at 9:56 A.M. showed the water fountain in hallway between room [ROOM NUMBER] and 215 had pieces of hair observed in sink and a broken plastic container. Observation on 5/5/25 at 9:56 A.M. showed the hallway had dust accumulated observed along the walls in 200 hall. Observation on 5/5/25 at 11:00 A.M. showed the handrail outside of room [ROOM NUMBER] on the memory care unit was loose and moved when touched. During an interview on 9/5/8/24 at 9:20 A.M., Maintenance Director said: -He/She became aware of maintenance needs by staff telling him/her in hallway; -Staff were supposed to fill out a maintenance log at the nurses station on each hall. During an interview on 5/8/25 at 9:29 A.M., Maintenance staff said: -Hand rails should be securely attached to the wall; -He/She was not aware of a handrail that was loose on memory care unit; -Facility staff was supposed to write up a work ticket located at the nurses station for him/her to be aware of items needing repaired in the facility. During an interview on 5/8/25 at 9:46 A.M., Director of Environmental Services said: -He/She was supervisor over the floor technicians, janitorial staff, and housekeeping staff; -Maintenance was responsible for cleaning the return vents in the building; -The facility was deep cleaned on Wednesdays; -Resident rooms were cleaned every single day; -Hallways were swept every single day; -He/She did not expect the hallway to have dust accumulated. During an interview on 5/8/25 at 11:45 A.M., Administrator said: -He/She did not expect a resident's room faucet to be running for seven days and be unable to shut off; -He/She expected hand rails to be firmly attached to the wall; -He/She did not expect sinks in resident rooms to be stopped up and not draining; -He/She expected resident rooms to be maintained and cleaned daily; 50980 Observation of the 500 Wing Dining Room on 5/7/25 at 8:00 A.M., showed: - Multiple window blinds dirty with dust and spilled stains throughout the room; - Heavy dust on ceiling tiles and light covers from ventilation system, five in total; - 20-30 dead bugs on window sills; - Missing ceiling tile over dishwashing station; - Broken window pane with tape over a large crack; During an interview on 5/7/25 at 9:09 A.M., the Dietary Manager (DM) said /he/she would alert maintenance or housekeeping of the need for repairs or of cleanliness issues in the 500 Hallway Dining Room. She was aware of the cracked window and that is the only issue she knows of in that dining room; During an interview on 5/8/25 at 9:29 A.M., the Maintenance Director said he replaces ceiling tiles when he sees them or when someone tells him. He is not aware of any ceiling tiles that need replacement on the 500 Hall Dining Room. Window repairs, are contracted out to be repaired. He was not aware of any windows in the 500 Hall Dining room that needed replacement; During an interview on 5/8/25 at 10:03 A.M., the Housekeeping Supervisor said: - Housekeeping staff, are responsible for cleaning the 500 hallway dining room. The housekeeping staff clean the floors, but they don't do the window sills or walls unless they have a deep cleaning scheduled. The housekeeping staff are supposed to do deep cleaning weekly on Wednesday. None was done yesterday (Wednesday the 7th) due to low staffing issues. Staffing had been an issue in the housekeeping department. For items that needed to be fixed, such as the window and ceiling tile, a maintenance slip would be submitted to the Administrator who would send it onto the maintenance department to be fix. The window in the dining room had been broken for a long time, and was not sure where maintenance was with fixing that item. She was not aware of any missing ceiling tiles.

Based on the interview and record review, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of nine sampled staff (Licensed Practical Nurse (LPN) B, Certified Nurse Aide (CNA) A, Activity Aide A, Registered Nurse (RN) A, CNA B, Dietary Aide A, Housekeeping Aide A, and Receptionist). The facility also failed to have a criminal record check on file prior to employee's first date working for one of eight sampled staff (Housekeeping Aide A). The facility census was 86. Review of facility policy, dated 11/20/2003, showed: -Policy of the facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property. -Screening A. All applicants for employment in the facility shall, at minimum have the following screening checks conducted: -Appropriate licensing board or registry check; -Criminal background check pursuant to facility policy or state law. 1. Review of LPN B's employee file showed: -Hired on 6/19/24; -No CNA Registry check found. 2. Review of CNA A's employee file showed: -Hired on 1/15/25; -No CNA Registry check found. 3. Review of Activities Aide A employee file showed: -Hired on 12/23/24; -No CNA Registry check found. 4. Review of RN A's employee file showed: -Hired on 4/9/25; -No CNA Registry check found. 5. Review of CNA B's employee file showed: -Hired on 10/28/24; -No CNA Registry check found. 6. Review of Dietary Aide A's employee file showed: -Hired on 11/13/24; -No CNA Registry check found. 7. Review of Housekeeping Aide A's employee file showed: -Hired on 2/26/24; -No background check prior to date of hire; -No CNA Registry check found. 8. Review of Receptionist A's employee file showed: -Hired on 6/12/24; -No CNA Registry check found. During an interview on 5/7/25 at 11:31 A.M., the Assistant Administrator said: -The CNA Registry was checked for just CNA's; -The facility did not check the CNA registry for staff that work in dietary or environmental services; -The receptionist completed the background and registry checks for employees; -Housekeeping Aide A was hired on 2/26/25, and he/she started working on 2/26/25; -Housekeeping Aide A's family care registry check was done on 3/12/25, there was no criminal background check in the employee's. During an interview on 5/7/25 at 11:43 A.M., Receptionist A said: -He/She only checked the Certified Nurse Aide registry on CNA's; -He/She printed off the CNA Registry check form and placed in employee file when he/she completed the checks; -Background checks were completed upon hire; -He/She did not have system in place to check the current employees backgrounds on a periodic basis; -If an employee had been employed for longer than two years he/she recently re-ran their family care registry checks. During an interview on 5/7/25 at 11:47 A.M., the Assistant Administrator said: -He/She did not have a criminal back check for Housekeeping Aide A upon hire; -He/She did not do CNA registry checks for all employees, just the nurse aides. During an interview on 5/8/25 at 11:45 A.M., Administrator said: -He/She expected all employees to have a background check completed and on file prior to working in facility; -He/She did not know that all employees should be searched on the CNA Registry for federal indicators, but now expects all employees to have a CNA Registry check completed upon hire to check for federal indicators; -He/She expected the facility abuse and neglect policy regarding employee screening checks to be followed for criminal background checks and registry checks according to facility policy or state law.

Based on observation, interview, and record review, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected two of the 18 sampled residents, (Resident #4 and Resident #38). The facility census was 86. Review of the facility's policy, Providing Privacy, dated 4/27/14, showed: - It is the policy of this facility to provide privacy to each and every resident, competent or incompetent; - Facility staff must examine and treat residents in a manner that maintains the privacy of their bodies; - Only authorized staff directly involved in treatment should be present when treatments are given; - People not involved in the care of the individual should not be present without the individual's consent while he/she is being examined or treated; - Staff should provide privacy by pulling curtains, shutting blonds, closing doors, and otherwise removing the resident from public view and provide clothing or draping to prevent unnecessary exposure of body parts during the provision of personal cares and services. 1. Review of Resident #4's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/25 showed: - Cognitive skills severely impaired; - Diagnoses included diabetes mellitus, dementia, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and malnutrition. - The resident had seven insulin injections in the last seven days. Review of the resident's care plan, edited 4/22/25 showed: - The resident occasionally had outbursts and verbally makes accusations or denials, or gets visibly upset with situation and person. Occasionally will refuse treatments such as fingersticks for blood sugar. Assess the resident's blood sugar if he/she is having behaviors. - The resident was dependent on staff for blood sugar monitoring and insulin administration. - Resident eats meals in the dining room. Review of the resident's Physician Order Sheet (POS) dated, April 2025, showed: - Start date: 2/18/25 - regular diet with diabetic precautions, thin liquids. - Start date: 3/26/24 - Accuchecks before meals and at bedtime for diabetes mellitus; - Start date: 4/4/25 - Novolog Flexpen (fast acting ) insulin per sliding scale three times daily. For blood sugars 251 - 300 - six units for diabetes mellitus. Blood sugar was 296. Review of the resident's Medication Administration Record (MAR), dated April 2025 showed: - Accuchecks before meals and at bedtime for diabetes mellitus; - Novolog Flexpen insulin per sliding scale three times daily. For blood sugars 251 - 300 - six units for diabetes mellitus. - Accuchecks and insulin was provided to the resident in the Month of April. Observation on 5/7/25 at 11:07 A.M., showed: - The resident sat at the dining room table with two other tablemates and 17 other residents in the dining room in view of the resident; - Certified Medication Technician (CMT) A obtained the resident's blood sugar at the dining room table and administered the insulin in the resident's left upper arm. 2. Review of Resident #38's care plan, revised 6/5/24 showed: - The resident had a diagnosis of diabetes mellitus. Follow the resident's diet order. Remind and encourage meals, snacks appropriate for diabetics. - The resident was dependent on staff for blood sugar monitoring and insulin administration. - Resident eats meals in the dining room. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper and lower extremity impaired on one side; - Diagnoses stroke, diabetes mellitus and hemiparesis (partial paralysis on one side of the body) and hemiplegia (complete paralysis on one side of the body). Review of the resident's POS (Physician Order Sheet), dated May 2025, showed: - Start date: Accuchecks before meals and at bedtime for diabetes mellitus; - Start date: 8/28/18 - Humalog (fast acting) insulin per sliding scale. For blood sugar 251 - 300, give six units for diabetes mellitus. - Start date: 5/14/20 - Humalog insulin 5 units before meals and at bedtime for diabetes mellitus. Review of the resident's MAR, dated May 2025, showed: - Accuchecks before meals and at bedtime for diabetes mellitus; - Humalog insulin per sliding scale. For blood sugar 251 - 300, give six units for diabetes mellitus. - Humalog insulin 5 units before meals and at bedtime for diabetes mellitus. - Resident received Accuchecks and Insulin in the month of May. Observation on 5/7/25 at 11:20 A.M., showed: - The resident sat at the dining room table with a male resident and 17 other residents in the dining room in view of the resident; - CMT A obtained the resident's blood sugar at the dining room table and pulled the resident's blanket back exposing his/her right upper thigh and administered the insulin. During an interview on 5/7/25 at 12:03 P.M., CMT A said: - He/She thought he/she could check blood sugars and administer insulin in the dining room. - He/She did not think there was an issue with privacy. During an interview on 5/8/25 at 9:11 A.M., Licensed Practical Nurse (LPN) A said he/she did not know if they had a policy for obtaining blood sugars and administering insulin in the dining room. During an interview on 5/8/25 at 9:49 A.M., Registered Nurse (RN) B said nursing staff normally take the residents to his/her room to check blood sugars and administer the insulin for privacy. During an interview on 5/8/25 at 11:45 A.M., the Director of Nursing (DON) said staff should not obtain residents blood sugars in the dining room or administer insulin in the dining room because the reisdents have a right to privacy and to be treated with dignity. 47195

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge notice, including providing the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for two residents (Residents #16 and #21) out of eighteen sampled residents. The facility's census was 86. Facility did not provide a policy on transfer notices. 1. Review of Resident #16's Face Sheet showed: -He/She admitted to facility 3/31/25. -Diagnoses included stroke, muscle weakness, depression, and surgical aftercare following surgery to digestive tract. Review of Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, completed for the month of April 2025.,showed: -On 4/5/25 the Resident had an unplanned discharge to short term general hospital, with return anticipated; -On 4/6/25 returned to the facility; -On 4/13/25 the Resident had an unplanned discharge to short term general hospital with return anticipated; -On 4/15/25 returned to the facility. Review of progress notes in electronic medical record, dated 4/5/25-4/14/25, showed: -4/5/25, Resident transferred to the emergency room after complaints of chest pain; -4/6/25, Resident transferred back to the facility; -4/13/25, Resident transferred to hospital due to incision from surgery being red, and inflamed; -4/14/25, Resident was admitted to hospital for cellulitis of abdominal wall; Review of resident documents in electronic medical record, dated 3/31/25-5/7/25, showed no documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital with ombudsman contact information. 2. Review of Resident #21's face sheet showed: -He/She admitted on [DATE]; -Diagnoses included pneumonia, respiratory failure, muscle weakness, peripheral vascular disease, and chronic pain. Review of past MDS, showed: -On 12/14/24, the Resident had an unplanned discharge to hospital with return anticipated; -On 12/24/24, returned to the facility; -On 4/13/25, The Resident had an unplanned discharge to hospital with return anticipated; -On 4/17/25, returned to the facility; During an interview on 5/05/25 at 1:24 P.M., the Resident said he/she had been frequently in and out of the hospital. Review of progress notes in the electronic medical record, dated 12/14/24-4/17/25, showed: -On 12/14/24, he/she was transferred to hospital after a change in condition; -On 4/13/25, he/she was transferred to the hospital for a change in condition; -On 4/17/25, he/she was admitted back to the facility. Review of resident documents in electronic medical record, dated 12/14/25-5/7/25, showed: -There was no documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital with ombudsman contact information. 3. During an interview on 5/06/25 at 1:57 P.M., the Director of Social Services said: -He/She emailed a list of discharges to the ombudsman at the beginning of each month. -He/She did not handle the discharge or transfer paperwork when a resident went to the hospital. During an interview on 5/7/25 at 9:37 A.M., Licensed Practical Nurse C said: -When they send resident's out of facility they send a medication list, continuity of care document, the resident's last laboratory results, bed hold notices; -The resident's bed hold notices were then scanned into the electronic medical record under the other tab in resident documents. During an interview on 5/08/25 at 8:56 A.M. Registered Nurse (RN) B said: -He/She did not have a form or any document that showed ombudsman contact information to send out with resident discharges and/or transfers; -When he/she discharges a resident to the hospital he/she would send two copies, one for the emergency medical responders and one for the hospital. Documents were sent with the resident to include their physician's orders, continuity of care document that included their vitals, medications, and diagnosis, a history and physical, the resident's last laboratory results, code status, care plan, and a bed hold notice. During an interview on 5/8/25 at 9:33 A.M., Licensed Practical Nurse (LPN) A said the facility did not have any discharge forms that they send out with resident or family representatives with the ombudsman contact information on them. During an interview on 5/8/25 at 11:45 A.M., the Director of Nursing said: -He/She did not know of the requirement that information should be provided to the resident regarding the ombudsman's name, mailing address, email address, and telephone number of the office of the state long-term care ombudsman was to be provided to resident in the discharge notice discharge. -Currently the Assistant administrator provided a list of transfers and discharges to the ombudsman at the end of each month. During an interview on 5/8/25 at 11:45 A.M., the Administrator said he/she did not know of requirement for residents or their representatives to be notified of state long-term care ombudsman name, mailing address, email address, and telephone number was to be provided upon transfer or discharge.

Based on interview and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN), the form Centers for Medicare and Medicaid (CMS) - 10055 to two of the three sampled residents (Residents #32 and Resident #139). The SNF ABN provides information to residents/beneficiaries to inform them of their rights that skilled services may not be paid by Medicare and resident or guardian will assume the financial responsibilities. The facility failed to provided the correct Notice of Medicare Noncoverage (NOMNC), which provides information to residents/beneficiaries to inform them of their covered services, and their right to appeal their discharge, for two of the three sampled residents (Resident #32, Resident #190, and Resident 139. The facility additionally failed to provided the correct SNF/ABN form for one of three sampled residents (Resident #190). The facility census was 86. The facility did not have a policy to address SNF Beneficiary Protection Notifications or the Notice of Medicare Non-coverage and right to appeal discharge policy. 1. Review of Resident #32's Admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 2/21/25, showed: - Resident was cognitively intact; - Required assistance with activities of daily living (ADL's); - Diagnoses: Coronary Artery Disease, High Blood Pressure, Obstructive Uropathy. Review of the residents medical records showed: - No advance beneficiary notice in the medical record. - Facility is using outdated NOMNC and should be using form CMS-10123 with expiration date of 11/30/27 listed on bottom; - discharged from Medicare A services on 03/14/25. During an interview on 05/08/25 at 12:28 P.M., the Resident said he/she was unable to recall if the SNF/ABN or NOMNC forms were provided to or signed by the resident. 2. Review of Resident #139's Admission MDS, dated [DATE]., showed: - Resident was cognitively intact; - Required supervision with ADL's; - Diagnoses included: Arthritis, Atrial Fibrillation, Gastro Esophageal Reflux Disease (GERD). Review of the Resident's electronic medical records showed: - discharged from Medicare A services on 12/24/24; - No advance beneficiary notice documentation in the medical record. - Resident had planned to return home but changed his/her mind and stayed until 01/18/25; - Facility is using outdated Notice of Medicare Noncoverage (NOMNC) and should be using form CMS-10123 with expiration of 11/30/27 listed on bottom; - discharged from facility on 01/18/25. 3. Review of Resident #190's Discharge MDS, dated [DATE], showed: - Resident was cognitively intact; - Required substantial assistance with ADL's; - Diagnoses included: Heart failure, High Blood Pressure, GERD. - discharged from facility on 04/03/25. Review of the Resident's electronic medical records showed: - Advance beneficiary notice showed Medicare A services would end on 04/17/25. The resident signed the form on 04/14/25; - Facility used form CMS-10055 (2018) and should have used form CMS-10055 (2024); - Facility is using outdated Notice of Medicare Noncoverage (NOMNC) and should be using form CMS-10123 with expiration of 11/30/27 listed on bottom; During an interview on 05/08/25, at 11:14 A.M., the Assistant Director of Nursing (ADON) said: - He/She is responsible for completing the SNF/ABN and NOMNC forms; - He/She recently took over this responsibility and needed to review previous records; - He/She wasn't sure where to find updated SNF/ABN and NOMNC forms. During an interview on 05/28/25 at 11:45 A.M., the Director of Nursing (DON) said: - The current SNF/ABN forms should be used; - The current NOMNC forms should be used.

Based on observation, interview and record review, the facility failed follow their policy regarding expired medications, and insulin when the facility staff did not date opened insulin pens or dispose expired insulin pens, which affected six of the 18 sampled residents, (Resident #7, #10, #12, #23, #61 and #70). The facility census was 86. Review of the facility's policy titled, Expired Meds and Supplies, dated 3/27/19 showed: - On the first of every month when change over is complete, the nurses and Certified Medication Technicians (CMTs) will audit the med carts, treatment carts, refrigerators, cabinets and supply rooms; - Any medication or supply found to be expired or that will expire that month will be destroyed. Review of the facility's policy titled, Insulin Pens,, dated 11/1/16, showed: - Every vial or insulin pen must be dated upon opening; - If the expiration date on the pen falls before the 42, 28, 14 days after opening, please discard. 1. Observation and interview on 5/7/25 at 8:44 A.M., of the 2A medication cart showed: - Resident #61's Lantus (long acting) insulin pen was opened and did not have a date when it was opened; - Resident #23's Lispro (fast acting) insulin pen was opened and did not have a date when it was opened; - Resident #23's Lantus insulin pen was opened and did not have a date when it was opened; - Resident #12's Humalog (fast acting) insulin pen was opened on 4/6/25 and expired on 5/4/25 and was still being used; - CMT F said the insulin pens should be dated when opened, and should not use insulin pens that are expired or not dated. Whoever is working would check the medication cart for expired medications. During an interview on 5/8/25 at 9:11 A.M., Licensed Practical Nurse (LPN) A said: - The insulin pens should be dated when opened; - The nurses or CMTs should not use insulin pens that are expired or not dated when opened. During an interview on 5/8/25 at 9:49 A.M., Registered Nurse (RN) B said: - The insulin pens should be dated when opened; - The insulin pens should not be used after the expiration date; - The CMTs on days should be checking the insulin pens when they use them and/or the nurses who are on the cart should be checking the insulin pens. 52043 During an interview on 05/06/25 at 11:03 A.M., CMT C said all stock meds and insulin should be dated when opened by nursing staff; During an interview on 05/06/25 at 02:08 P.M., CMT D said when opening insulin we label with date opened; Observation of medication cart and interview with CMT B on 05/07/25 at 10:11 A.M., showed: - Resident #7's Lantus pen open and not dated, sitting in top drawer of medication cart; - Resident #70's two Tresiba pens open and not dated, sitting in top drawer of medication cart; - Resident #10's Lispro pen open and not dated, sitting in top drawer of medication cart; - Certified Medication Technician (CMT) B stated that is night shift's medication cart and all insulin pens should be dated when opened; Review of Medication Administration Record for Resident's #7, #70, and #10 on 05/08/25 showed all three were administered insulin on night shift on 05/05/25 through 05/07/25. During an interview on 05/08/25 at 11:45 A.M., the Director of Nursing (DON) said: - Staff should date insulin pens when opening; - Staff should not use expired insulin pens.

Based on observation, interview and record review, the facility failed to record food temperatures in the temperature log after cooking food items and failed to ensure staff served food to the residents that was palatable and at an appetizing temperature when hot food was served at unappetizing temperatures for five (Residents #5, #14, #21, #40, and #42) out of 18 sampled residents. The facility census was 86. Review of facility policy, Food Temperatures, undated, showed: - All hot food items must be served at a temperature of at least 140F; - Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. A recording form is also needed to document temperatures. To take hot food temperatures insert the thermometer and record the temperature and then remove the thermometer from the food item. Repeat these guidelines until all hot food temperatures have been taken; - Temperatures should be taken periodically to ensure hot foods stay above 140F and cold foods stay below 40F during the portioning, transporting and serving process until received by the resident; 1. Review of Resident #42's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/21/25, showed: - Resident is cognitively intact; - Diagnosis included: neurological disorder and diabetes; During an interview on 5/6/25 at 8:37 A.M., the Resident said the food is edible but it's not hot at all and it's not enjoyable to eat when it's cold; 2. Review of Resident #5's Annual MDS, dated [DATE], showed: - Resident was cognitively intact; - Resident is independent for eating and requires no assistance; - Diagnosis included: heart rhythm disorder, heart failure, and high blood pressure; During an interview on 5/5/25 at 1:59 P.M., the Resident said: - The food is cold when he/she gets a room tray. Many times the meal tray is delivered uncovered. The vegetables are either overcooked or under cooked. He/she was able to eat the florets today but the stem was hard and couldn't chew them. He/she does not enjoy meals when they are not cooked correctly or served hot. 3. Review of Resident #40's Quarterly MDS, dated [DATE], showed: - Resident had moderately impaired cognition; - Resident is independent for eating and requires no assistance; - Diagnosis included: heart disease, dementia, and Parkinson's disease; During an interview on 5/5/25 at 11:13 A.M., the Resident said: - He/she eats in the dining room and the facility makes them wait 30 minutes or longer before staff delivers meal trays and it happens for all meals. The food is cold when he/she gets it and the breakfast meal is the worst for being cold. He/she does not like it when the food is cold and they won't eat it at all. It makes him/her feel mad and disgusted. 4. Review of Resident #14's Quarterly MDS, dated [DATE], showed: - Resident had moderately impaired cognition; - Resident is independent for eating and requires no staff assistance; - Diagnosis included: stroke, heart failure, high blood pressure, and diabetes; During an interview on 5/5/25 at 2:33 P.M., the Resident said the food does not taste good and it's normally cold when it's served which makes him/her upset; 5. Review of Resident #21's Annual MDS, dated [DATE], showed: - Resident is cognitively intact; - Resident had clear speech and was able to make self understood and understands others; - Diagnosis included: stroke, renal failure, diabetes, and respiratory failure; During an interview on 5/525 at 1:19 P.M., the Resident said the food could be much better because it does not come out hot and today it was cold again which he/she doesn't like. During an interview on 5/5/25 at 1:20 P.M., a family member said: - The resident is not eating well and is concerned about how much the resident is eating because they hardly eat anything at meals. The resident always wants food from outside the facility brought in and for family member to feed him/her. Observation on 5/7/25 at 10:35 A.M. showed: - Hot food items mashed potatoes, mixed vegetables and chicken nuggets temperature checked by Dietary Aide B and then placed on the steam line and covered in foil and/or with steel container tops. The temperatures were not recorded in the temperature log before placing on the steam line; During an interview on 5/7/25 at 11:00 A.M., the Dietary Manager (DM) said food items are temperature checked to make sure they are done cooking, but the only temperatures recorded in the log are the ones that are taken from the steam line right before meal service starts; Observation on 5/7/25 at 11:20 A.M., showed temperature checks done by Dietary Aide B on all steam line items, all were above 140F; Continuous observation on 5/7/25, showed: - 11:35 A.M. test tray for 200 hallway loaded onto food cart last and departed kitchen; - 11:37 A.M. cart sitting in 200 hallway and cart heating coil unplugged; - 11:44 A.M. first food tray is removed from cart and delivered to a room [ROOM NUMBER]; - 12:10 P.M. last food tray delivered to residents on 200 hallway and test tray turned over for temperature checks; During a temperature check on hallway 200 test tray on 5/7/25 at 12:10 P.M., showed: - Chicken nuggets were recorded at 111F which is below requirement; - Mixed Vegetable were recorded at 106F which is below requirement; - Mashed potatoes and gravy were recorded at 117F which is below requirement; During an interview on 5/7/25 at 12:25 P.M., the (DM) said the cart would normally be plugged in while handing out trays but the switch has been broken for about a week and parts are on order. During an interview on 5/8/25 at 11:45 A.M., the Administrator said he would expect hot foods to be served to residents in their room in accordance with state and federal regulations. During an interview on 5/14/25 at 9:20 A.M., the Dietician said: - Temperatures should be taken after cooking according to state and federal guidelines for temperature requirements. These temperatures should be recorded in the temperature log. Temperatures should be taken on all food items on the steam line prior to serving; - Food should be served that is palatable to residents and normally at 140F but at the minimum food served in the dining room or in resident rooms should be no lower than 120F.

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food safety when staff failed to annotate receipt dates on incoming deliveries of food, failed to dispose of expired food items, failed to store food items at least 6 inches off the ground, failed to properly label and seal opened food items, and failed to maintain cleanliness in the storerooms and 500 Wing dinging room. This affected all residents by putting them at risk for food borne illness. The facility census was 86. Review of facility policy Food Storage, dated 2005, showed: - All storage areas should have adequate humidity controls to prevent condensation and moisture; - Food items will be stored on shelves, food is stored a minimum of six inches above the floor on clean racks or other clean surfaces; - All containers must be legible and accurately labeled; - Food should be dated as it is placed on the shelves, old stock is always used first; - Leftover food is store in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated, leftover food is used within three days or discarded; - All refrigerator units are kept clean and in good working condition at all times; - All foods should be covered, labeled, and dated. Review of facility policy Use of Leftovers, dated 2005, showed: - Leftovers should be covered, labeled, and dated. Do not serve leftovers that have not been properly stored, throw it out if in doubt; - Any food that was served for a meal and not served is a leftover; - Leftovers must be used within 72 hours or discard. A facility policy covering the use by times of various food items used in the facility was requested but not provided. Observation of the Kitchen Storeroom at 9:00 A.M., showed: - Box of Cream of Wheat opened, not resealed with no dates written on the box. The box had a expiration date of ,d+[DATE] (expired); - No received dates annotated on any of the canned foods stored on the shelves; - Food cases opened did not have dates written on boxes of when they were received or opened. Observation of the Paper Storeroom at 9:10 A.M., showed: - Cleaning gear (Vacuum Cleaner) stored next to cases of canned foods; - Insulation debris and wood pieces on the ground in the paper storeroom; - Floor has dirt under the storage racks; - (5) boxes of liquid shortening stored on the ground with one holding the door open. Observation of the Walk-in Refrigerator at 9:14 A.M., showed: - Package of provolone cheese opened ,d+[DATE] not discarded; - Side wall of refrigerator has condensation on wall and inside junction box with rust on walls and heavy rust on junction box; - Onion skins on the floor and under the storage racks; - Repackaged green onions dated ,d+[DATE]; - Beef base paste opened ,d+[DATE]; - Pickles in plastic container opened ,d+[DATE]; Observation of the stand-up Freezer at 9:18 A.M., showed a bag of green vegetables, resealed, unlabeled and undated. During an interview on [DATE] at 9:30 A.M., the Dietary Manager (DM) said: - We use the First-In First-Out (FIFO) method for stock rotation and do not write down receipt dates on products that come into the facility kitchen. The staff knows to place new food items in the back of the shelves so older items are picked from the front; - All dates annotated on food items are open dates not when it will be expired, Normally three days for items that are leftovers or have been cooked for meals but it varies. It is everyone's responsibility to check for expired food items and we currently have 15 kitchen staff. The staff learn about expiration dates through our internal training. Observation in Main Dining Room on [DATE] at 1:45 P.M., showed: - Juice labeled CB with a date of [DATE] stored in a plastic jug in the refrigerator expired, not discarded; - Prune juice in 48oz bottle opened [DATE] stored in the refrigerator not discarded; - Apple juice box in the refrigerator, open and not sealed, not dated, and not discarded. Observation in 500 Wing Dining Room on [DATE] at 8:00 A.M., showed: - Wall at drink station had liquid and food stains embedded; - Microwave had caked on burnt food covering the entire inside of the cooking area; - Back splash of sink was dirty near the dishwasher area; - Floor area around hand washing station was very dirty; - Refrigerator #1: Had food debris and spilled liquids on the interior surfaces; - Refrigerator #2: Sign on front: Label and date refrigerated items, juices, food, etc - Refrigerator #2: Applesauce leftover ,d+[DATE] (expired) not discarded; - Refrigerator #2: Had heavy spills and debris inside panels and on top of racks; - Refrigerator #2: (1) bowl with foil, not labeled or dated and not discarded. During an interview on [DATE] at 8:25 A.M., CNA G said: - The responsibility for cleaning this area is on dietary and maintenance and the CNAs will sometimes clean something if they have time but will notify staff responsible to clean those areas but it's not always done. For the microwave meals staff will heat the item up in the microwave for them and serve. The current state of cleanliness of the microwave is not satisfactory to CNA G and she would tell dietary about it. During an interview on [DATE] at 8:30 A.M., CNA H said the date on a food item is the date it was made or stored. It is good for three days from the initial date. So an item that has a date of ,d+[DATE] on it would be discarded on ,d+[DATE]. During an interview on [DATE] at 3:00 P.M., the DM said: - The dishwasher and dietary staff are responsible for cleaning the equipment and food prep areas in the main dining room and the 500 Wing Dining Room. This falls mainly on the dishwashers. The DM is responsible for inspecting those areas for cleanliness such as label and dating and general cleanliness of the area. - There is currently no written policy on how long to keep foods. Leftovers are kept for three days. Condiments are kept for two weeks but it varies. Cereal for 30 days but not sure. For raw frozen foods she looks for freezer burn especially if the item has been there for a while. She also monitors for dates for when boxes are opened. - Every Monday there is a freezer walk through for inspection; - Juices have a three day window for using no matter what the container; - She goes by the expiration date on the container for milk; - There is no cleaning schedule published for staff members to sign off that they have completed their assignments; - She would expect the microwave to be clean and this is the responsibility of a dietary staff member; - She would expect the janitorial staff or housekeeping to keep the dining room clean and devoid of heavy dirt areas; - She would expect the inside of refrigerators to be wiped down and spills cleaned up; - A plastic container of pickles opened on ,d+[DATE] should be disposed of within two to three weeks but she is not sure; - Cleaning gear which is currently stored next to the spice rack will be moved due to it being unsanitary. During an interview on [DATE] at 9:15 A.M., the Dietician said: - She would expect dietary staff to monitor and clean kitchen equipment and drink stations in the dining rooms. This would include the ice coolers, microwave, and sink areas; - She would expect the floors of the walk-in refrigerator to be free of food debris and packages; - She would not expect food items to be stored on the floor or holding doors open; - Frozen vegetables repackaged should be sealed and the date of opening annotated; - Incoming food items should have a date of receipt placed on them. All items should be labeled with a sharpie or a label maker; - A plastic pickle container opened and resealed with a date of ,d+[DATE] should be good for 7 to 14 days but she would have to check with the guidelines. These should be posted on the refrigerator at the facility; - Different foods can have different use by dates based on the food item. During an interview on [DATE] at 11:45 A.M., the Administrator said: - He would not expect incoming food items to have dates written on them, new stock is put in the back and items are pulled from the front. When boxes and items are opened yes they should have dates; - Leftovers can be held two to three days depending on the food item; - He is not sure on all food items and would have to refer to the DM for clarification; - The food storage policy should cover all the different categories of food items and how long they can be kept when opened; - He would expect the inside of refrigerators to be free of debris and dried liquid spills; - He would not expect dirty cleaning equipment to be stored near food items.

Based on observation, interview, and record review the facility failed to ensure staff followed infection control practices regarding urinary catheters (a flexible tube inserted through the urethra or suprapubically, through a small incision in the abdomen, into the bladder to drain urine) and a enteral feeding tube (a tube that is inserted into the digestive tract to deliver nutrition) care for two Residents (Residents #16 and #66) when proper Enhanced Barrier Precautions (EBP) were not utilized by staff when emptying catheter drainage bag for Resident #66 and when providing medication administration by use of enteral tube for Resident #16. This affected two of the 18 sampled residents. The facility census was 86. Review of the facility policy Foley Catheters, dated 5/28/19, showed drain spouts are to be cleaned with an alcohol wipe before placing it back into its container. Review of the facility policy EBP, dated 11/14/24, showed: - EBP are to be used to decrease the transmission of resident to resident spread of the Centers for Disease Control (CDC) target Multi-Drug Resistant Organisms (MDRO's) for the duration of their stay when contact precautions do not apply and to protect those with indwelling medical equipment such as, indwelling urinary catheters, accessed IV's, tracheotomies, central lines, ventilators, dialysis shunts and feeding tubes, these precautions are also used for chronic open wounds and surgical sites that are unhealed; - EBP includes the use of gloves and gowns for all high risk/contact activities; - EBP is the use of gloves and gowns with dressing, bathing or showering, transfers in residents rooms or in the shower room, all hygiene you are performing of resident peri/cath care, toothbrushing, hairbrushing, changing linens, toileting, device care (cleaning and emptying), wound care, therapy sessions, and lab draws; - Carts will be placed inside room for gowns or place in a dedicated drawer if resident does not want cart. Review of the facility policy, Enteral Feeding Procedure, dated 6/30/14, showed: - Tubing should be changed every time the enteral feed bottle is changed; - The bottle should be dated and initialed at each change; - The 60 cc syringe should be changed as well when the enteral feed bottle is changed; - The graduate is replaced on the last day of the month and as needed. 1. Review of Resident #66's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 4/8/25., showed: - Resident was cognitively intact; - Required substantial nursing assistance with toileting hygiene; - Had an indwelling catheter; - Diagnoses: obstructive uropathy, borderline intellectual functioning, arthritis. Review of comprehensive care plan, dated 01/20/25, showed: - Required Enhanced Barrier Precautions due to suprapubic catheter; - Required assistance with some activities of daily living (ADL's); - Needed assistance with site care, catheter care and emptying of the drainage bag. Observation on 05/06/25 at 08:27 A.M., showed: - CNA C entered room to empty Resident #66's catheter drainage bag; - Washed hands and applied gloves but did not apply gown; - Emptied urine into graduate, wet a wash rag, and wiped the end of the drain spout. During an interview on 05/06/25 at 08:12 A.M., Resident #66 said: - Sometimes nursing staff don't wear gowns and gloves when providing catheter care; - He/She wasn't sure it was a big problem but thought staff should wear them. During an interview on 05/06/25 at 08:30 A.M., Certified Nursing Assistant (CNA) C said: - He/She had been there two months and recieved about a week of training; - When performing catheter care for residents, staff should wear gowns and gloves, then said, I forgot didn't I; - There should be a red barrel for EBP trash, but he/she thinks that's just for isolation people; - Staff should clean the catheter spigot with a wash rag then take the dirty rag to laundry/hazmat. During an interview on 05/05/25 at 02:27 P.M., LPN E said: - There are EBP gowns and gloves at nurses station and in the rooms in a box with drawers; - Staff can use the gown for the day then just throw in regular trash can; - The catheter spigot should be cleaned with alcohol; - For enteral feedings, staff should apply gowns and gloves and possibly a mask. During an interview on 05/06/25 at 10:50 A.M., Certified Medication Technician (CMT) E said: - When cleaning catheters staff would wash hands then put on gloves and gown; - Have alcohol wipes, graduate, and towel to put graduate on; - Clean spigot with alcohol wipe, drain, and clean spigot again; - Empty graduate into the toilet and cover with a bag. During an interview on 05/06/25 at 02:08 P.M., CMT D said: - He/She would wash hands and apply gowns and gloves; - Then place a towel under the graduate, empty it, then use alcohol wipe to clean the drain spout. During an interview on 05/07/25 at 08:01 A.M., Registered Nurse (RN) B said he/she always uses EBP gowns and gloves, and throw away in trash or remove in trash. Observation and interview with CNA E on 05/07/25 at 12:16 P.M., showed: - CNA E knocked and entered room, sanitized hands, and applied gown and gloves; - Placed graduate on paper towel on floor; - Drained catheter leg bag into graduate, closed drain, and wiped drain spout with alcohol wipe; - Put towel and wipe into trash, measured then emptied graduate into toilet; - Returned graduate to cover on toilet and removed gown and gloves then washed hands; - Stated staff should use gown and gloves and the drain should be wiped with an alcohol wipe. During an interview on 05/08/25 at 09:20 A.M., the Director of Nursing (DON) said: - Resident #16 had just been moved to the memory care and the nurse told me he/she forgot to use the gown. Staff should use EBP with these cares; - CNA C who didn't use a gown with Resident #66 should have used EBP with his/her cares. During an interview on 05/08/25 at 09:34 A.M., the Infection Preventionist said: - Staff should use EBP with Resident #16's cares; - Staff should use EBP with Resident #66's cares. 47195 2. Review of Resident #16's Admission MDS, dated [DATE], showed: - Cognition moderately impaired; - He/She had a feeding tube; - He/She received 51% or more of total calories through parenteral or tube feeding; - He/She received 51% 501 cc/day or more of his/her fluid intake via tube feeding; - He/She was independent with eating; - Diagnosis included: surgical aftercare following surgery on digestive system, dysphagia, absence of part of digestive tract, and malnutrition. Review of care plan, revised 4/14/25, showed: - Resident required enteral feeding tube for nurtrition; - He/She used a EnFit 20 g-tube (type of gastrostomy or jejunostomy tube designed for delivering enteral nutrition directly into the stomach or intestines). - Administer medications through the g- tube. Evaluate/record/report effectiveness and any adverse side effects. - Administer enteral feeding at three times a day via bolus. Currently taking Isosource 1.5; Review of physician's orders, dated 5/7/25, showed: - Diet-mechanical soft thin liquids for pleasure feedings as needed; - Started 4/3/25, Geri-Lanta (alum-mag hydroxide -simeth) OTC) suspension; 200-200-20 mg/5mL; amt: 30 cc via peg tube; oral, special instructions: for indigestion, every 6 hours PRN - Started 4/21/25, Isosource 1.5 gastric tube. 1 can three times a day with 100 cubic centimeters (cc) water flushes before and after use. Verify placement after use, check residual prior to administration (TID) 8:00 A.M., 2:00 P.M., and 10:00 P.M.; Observation and interview on 05/05/25 at 01:14 P.M., showed: - Licensed Practical Nurse (LPN) C entered the room to administer enteral medications for the Resident #16; - There were no gloves, gowns, or masks available in the room at this time; - LPN C went back and forth from where? getting supplies and stated resident had just recently moved onto the unit; - LPN C returned with new 60 cc syringe for flushing of medications/water, a graduate (A measuring container for liquids), and labeled the graduate 5/5/25; - LPN C washed hands again and applied gloves, but did not use gown as none were available in room; - Opened syringe, checked tube for placement with air and stethoscope and drew back checking for residual tube feeding; - Poured in medications with water as ordered and the nutritional supplement in to the enteral feeding tube, flushed tube and clamped off; completed without wearing isolation gown; - LPN C stated resident had an EBP box in front of other room but staff didn't bring it over here. He/She totally forgot it, but stated staff do use them for the resident; Observation on 5/7/25 at 1:12 P.M.-1:29 P.M. showed Registered Nurse (RN) B providing Resident #16 his/her eternal feed as per his/her feeding tube by using a 60cc/ml syringe and gravity. RN B obtained the eternal syringe that was sitting in the resident's room on his/her sink. The syringe was removed from an undated and opened plastic bag that sat inside a graduate dated 5/5/25. The syringe and plastic bag the syringe was removed from, were both undated. During an interview on 5/7/25 at 1:29, RN B said: - Night shift was responsible for changing out the eternal feeding syringes; - The syringe bag was normally dated but the syringe bag that he/she had pulled the syringe out of today to use for Resident #16's eternal feed did not have a date on it; - He/She did not know when the syringe had been opened; - He/She did not know how often the graduates were replaced; - He/She planned to go and obtain a new syringe and ensure it was dated. Observation on 5/8/25 at 8:13 A.M. showed the resident's eternal feed syringe was sitting in a graduate on the sink inside an opened syringe plastic bag. The plastic bag was dated 5/7/25, and the graduate was labeled and dated 5/7/25. During an interview on 5/8/25 at 9:33 A.M., Licensed Practical Nurse (LPN) A said - The syringe for eternal feeds should be dated; - Eternal feeding syringes would be replaced nightly. During an interview on 05/08/25 at 09:34 A.M., the Infection Preventionist said staff should use EBP with Resident #16's cares; During an interview on 5/8/25 at 11:45 A.M., the Director of Nursing said: - Eternal feed syringes should be changed daily; - The charge nurse was responsible for changing the syringes; - He/She expected staff to date the graduate and put the syringe in the graduate to store it; - He/She did not expect staff to date the syringe but only the graduate.

Based on observations, interviews, and facility policy review, the facility failed to keep the scoops out of food storage bins and ensure stored food was dated. This had the potential to affect 86 of 86 residents who resided in the facility and consumed food prepared from the facility's kitchen. Review of the facility's undated policy titled Resident Food Storage, revealed 1 .Food or beverages brought into the facility for resident consumption will be labeled and dated for monitoring food safety. Food or beverages in the original container marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage During an initial tour of the kitchen on 04/02/24 at 8:55 AM, with the Dietary Manager (DM), the following observations were made: Dry Storage and kitchen: a. One 5-pound bag, containing yellow cake mix, was observed open and undated. b. A large clear container labeled, containing thickener, were observed with scoops lying in the thickener. The thickener was also undated. Interview on 4/03/24 at 8:55 AM, DM stated scoops should not be kept in the containers. DM stated they expect scoops to be placed in a plastic bag and placed on top of the container. During a follow-up tour of the kitchen on 04/03/24 at 11:48 AM, with the DM, the following observations were made: Freezer and kitchen: a. Two loafs of Rye bread covered in ice crystals, was observed undated. b. 1 large bag of frozen chicken breast, was observed undated. During an interview on 04/03/24 at 8:55 AM, the DM stated they expect staff to place opened bagged items into an empty clear container and label and date or place in a clear bag and date. During an interview on 04/03/24 at 11:48 AM, the DM stated their expectation is for items to be closed when they were done being used. DM stated the two loaves of bread were left over and should have been dated. DM stated the chicken package must have been the last one in the box and someone took it out because normally keep items in the box and date the box. DM stated all dietary staff were responsible for ensuring items were dated and their expectation was that it would be done.

Based on interview and record review, the facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the 11/28/23 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked, unable to attend. Review of the 02/20/24 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked as, unable to attend. During an interview on 04/05/24 at 11:53 AM, the QAPI Nurse was asked if the Medical Director or their designee attended the quarterly meetings. The QAPI Nurse stated, He does attend the meetings, but not the last ones. The QAPI Nurse was asked if she was aware that the Medical Director or their designee are to attend the meetings, as required in the regulation. She stated, Yes.

Based on observations, record review, staff and family interviews, and facility policy review, the facility failed to (1) assess resident (R) 23's falls, monitor the effectiveness of the interventions, or modify the interventions to prevent further falls and/or injuries for one of three residents reviewed for falls (R23, R46, and R57); (2) provide a fire blanket and fire extinguisher in the three designated resident smoking areas to reduce the risk of harm for the three residents who smoke (R26, R30, and R42); and (3) to conduct a smoking assessment for one of three residents (R)26, to determine independent versus supervised smoking needs. 1. Review of the facility's 2006 policy titled, Unusual Occurrences, provided by the Administrator, revealed the following: All incidents will require that an incident report be filled out by the charge nurse. Incidents are falls, bruises, skin tears and anything that the charge nurse would consider an unusual occurrence. Once the incident report is complete . the coordinator will log all incidents to the unusual occurrence tracking log. From the tracking log, the unit coordinator will report at the monthly quality assurance meeting as to whether there has been any trending of these occurrences and what measures were put in place for prevention of further occurrences. Review of R23's Census, located in the electronic medical record (EMR) under the Resident tab, revealed R23 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; other intervertebral disc degeneration, lumbar region; other abnormalities of gait and mobility; unspecified lack of coordination; difficulty in walking; muscle weakness; cognitive communication deficit; unsteadiness on feet; syncope and collapse; and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/12/24, located under the RAI tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R23 was cognitively intact. Review of the facility's Incident Reports for R23 revealed fourteen falls in a six month time period. Falls were reported to have occurred on 09/06/23, 10/9/23, 10/22/23, 11/8/23, 11/15/23, 11/19/23, 11/19/23 (second fall same day), 01/20/24, 01/25/24, 01/27/24, 02/3/24, 02/7/24, 02/10/24, and 02/11/24. R23 was identified to have been ill December 2023 and initiated hospice care on 12/08/23. Each fall noted as found on floor. There was no documentation of fall assessments or root causes analysis after the falls. During an interview with the Unit Manager (LPN1) on 04/04/24 at 9:52 AM, regarding R23's fourteen falls. LPN1 was asked about a timeline of interventions, what was put in place when for R23. LPN1 stated, you'll have to look in the care plan book, at the nurses' station, I don't know. Review of R23's most recent care plan, located at the nurses' station, updated 03/21/24, revealed R23 was at risk for falling d/t (due to) taking an antidepressant for DX (diagnosis): depression and anxiety. She has been on this medication since her admission to this facility and is stable on this med (medication). and having a seizure d/o (disorder) . due to a decline in mobility and functional status. The interventions were listed as: Maintain a safe environment. Limit clutter and keep frequently used items within reach. Keep bed in lowest position with brakes locked. Reinforce safety precautions as (R23) does not always remember. Remind her to use call light and how to use it. She is not to attempt to get up without assistance. Remand resident not to ambulate/transfer without assistance. (R23's) ability to bear weight is limited, she is to transfer via Hoyer lift and two helpers. (R23) has been prescribed antiplatelet therapy, may take longer to stop bleeding if an injury. On 04/03/24 at 11:43 AM, R23 was observed in her room seated in a Geri-chair visiting a family member (FM2). R23 and FM2 were interviewed regarding the numerous falls sustained by R23. FM2 stated, the fall in November was the big one where (R23) hurt her back, then they put her in this (Geri chair) or in the bed. When asked about interventions post falls, FM2 stated, the bed was changed, but it's not always down low when we visit and she's in the bed, but the mats are usually on the sides of the bed now. During the family visit, R23 was transferred into bed which remained in the high position after family left. This was observed on 04/03/24 at 1:27 PM. On 04/04/24 at 11:19 AM, a telephone interview was conducted with R23's family member (FM3). FM3 stated, she has had multiple falls, I am concerned about the falls and making sure (R23) always has her call light, that is her only lifeline. FM3 stated, I requested a bed alarm and was told no. Observation of R23 on 04/02/24 at 9:44AM, revealed the resident in her room, in bed which was raised. A staff member walked into the room to provide personal care. Observation of R23 on 04/04/24 at 11:57 AM, revealed R23 in bed. The bed was not in a low position. During an interview with the Director of Nurses (DON), on 04/05/24 at 1:10 PM the DON was asked if a root cause analysis and/or evaluation of R23's fourteen falls had been completed. The DON stated, She had that many? No, we don't do that. When asked if R23 was reviewed in the facility's weekly clinical meeting, the DON looked at three pages of typed notes from a meeting and said, not since January. When asked what interventions had been put in place and when, the DON stated, I cannot tell you when interventions were put in place, I don't know. When asked if the DON could locate when interventions were implemented to prevent further falls and/or injuries for R23, the DON stated, no, it's not in the medical record. 2. Review of the facility's undated Resident Smoking Policy, provided by the Administrator, revealed Residents of [NAME] Nursing and Rehabilitation Center are allowed to smoke under to levels of supervision: 1) If the resident has been assessed by the nursing dept. to be physically and cognitively able to smoke without supervision, then we ask that the resident inform their unit if going outside. Residents may continue to smoke unsupervised so long as their condition continues to allow. If there is an injury to the smoker, i.e. they burn themselves or become inattentive, then they will be placed on supervised smoking schedule. 2) If the resident has been assessed not to be safe due to physical or cognitive issues, then the resident will have to comply with the supervised smoking times. All smokers will use the designated smoking areas regardless of whether you are supervised or not. There is never to be any smoking within the facility. Violation of this policy can result in facility issuing a 30 day notice of discharge. Review of the posted smoking times, at the 200 hall nurses' station, revealed the times to be 9:00 AM, 1:00 PM, 3:00 PM, 6:00 PM, and 9:00 PM. Review of R 26's Face Sheet, located in the EMR under the Resident tab revealed R26 was admitted on [DATE] with diagnoses that included cervical disc disorder with myelopathy, metabolic encephalopathy, muscle weakness, unspecified lack of coordination, and cognitive communication deficit. Review of the quarterly MDS, located under the RAI tab with an ARD of 01/02/24, revealed a Brief Interview for BIMS score of 14 out of 15 indicating R26 is cognitively intact. Review of R26's care plan, located under the RAI tab in the EMR, revealed R26 may smoke as desired unless condition changes and requires supervision. Smoking materials are kept by nursing staff. (R26) is to turn in all smoking materials after smoking. Offer smoking apron for protection from burns. He often declines to use it. Edited 03/30/23. The last date, written at the bottom of the care plan page was 10/16/23, and read Cont. (continue) with POC (plan of care) x90d (times ninety days). Observation of one of the designated smoking areas, on the 200 hall, on 04/02/24 at 10:32 AM, revealed R26 in his electric wheelchair, with a smoking apron on, and Registered Nurse (RN) 1 supervising. A self-extinguishing ashtray was visible. There was not a smoking blanket or fire extinguisher available in the designated smoking area in case of a fire emergency. RN1 and the Infection Preventionist (IP), smoking at the time, both stated there had never been a smoking blanket or a fire extinguisher at any of the smoking areas. When asked about resident smoking assessments, the IP stated, the Director of Nurses (DON) completes the smoking assessments. Observations were conducted of the three designated smoking areas, 200 hall, the front of the building, and the 500 hall on 04/02/24 at 10:45 AM, 04/03/24 at 12:30 PM, and 04/04/24 at 9:30 AM. All areas had self-extinguishing ashtrays. No area had a fire blanket or a fire extinguisher available for an emergency. On 04/04/24 at 9:45 AM, R26 drove, in his electric wheelchair, to the 200 hall nurses' station and requested a cigarette and a cigar from the Licensed Practical Nurse (LPN) 4. LPN4 was observed to hand R26 the cigarette, cigar, and lighter and R26 drove to the 200 hall smoking area. R26 was outside smoking for approximately five minutes before LPN4 left the nurses' station to supervise R26. LPN4 was asked if R26 was an independent smoker, she stated, no, he has to be supervised. On 04/05/24 at 9:52 AM, the Unit Manager (LPN1) was asked for R26's smoking assessment for review. LPN1 stated, if there is one, it's in the care plan book at the nurses' station, I don't do them. Review of the care plan book, located at the nurses' station, nor the EMR contained a smoking assessment for R26 when reviewed on 04/04/24 at 10:33 AM. In an interview with the DON on 04/05/24 at 1:15 PM, she stated we don't do smoking assessments, should we? When asked where information was documented to show the facility assessed R26 for his smoking abilities, the DON stated, it's in the care plan, (R26) was independent until he burned a hole in his blanket, then he was supervised. When asked when did R26 burn a hole in his blanket, the DON said, I don't know. The DON was informed of the observation of LPN4 providing R23 a cigarette, cigar, and lighter as she stayed at the desk on the computer, the DON said, she should not have given him the cigarette, cigar, or lighter until she was ready to supervise him. On 04/05/24 at 1:45 PM, the MDS Coordinator (LPN3), in charge of care plans, was asked for documentation that R26 had been assessed for smoking. LPN3 showed the care plan that read resident is a smoker. The facility had no documentation to present that R26's smoking abilities had been assessed.

Based on observations, interviews, record review and facility policy review, the facility failed to: have a system in place to ensure respiratory equipment to include oxygen tubing was dated/labeled when changed out, failed to ensure documentation of cleansing of C-pap masks(Continuous positive airway pressure- a form of positive airway pressure that is continuously applied to the upper respiratory tract of a person), C-pap tubing, and water chamber were being cleaned and changed as per physician orders on Sundays, failed to ensure a C-pap machine was kept off the floor, and failed to have clean oxygen filters, maintain oxygen in the nose, and apply oxygen continuously for two of two residents (Resident (R) 51 and R48) reviewed for respiratory therapy out of a total sample of 21 residents. This failure placed the residents at risk for respiratory illnesses, and further increased the risk of contamination of the respiratory equipment. Review of the facility's untitled policy, dated 02/28/2019and provided by the Director of Nursing (DON), indicated, All oxygen concentrator filters need to be cleaned every week on Sunday night. Even concentrators that are not being used. Oxygen tubing must be changed weekly and dated. Oxygen tubing and nebulizer tubing must be stored in a plastic bag, and CPAP's hose, mask, and H20 (water) chamber must be cleaned weekly 3 parts water and 1 part vinegar. 1.During an observation of R51 made on 04/02/24 at 2:35 PM, upon entrance into R51's room R51 was observed to be lying in bed with oxygen on via nasal cannula. The oxygen tubing was observed to have no date/label as to when the oxygen tubing had been changed out. Further observation revealed R51's C-pap machine was located on the floor on the left side of the resident's bed by the head of the bed. At this time, R51's C-pap machine mask, hose, and H20 chamber were observed to be sitting on a ledge of a window. The C-pap tubing was observed to be hanging down off the window ledge. There was no evidence of when the C-pap mask, H20 chamber or tubing had been cleaned, or changed out. During an interview made on 04/02/24 at 3:30 PM, R51 stated that she was on oxygen for shortness of breath. When asked if staff were changing out the oxygen tubing or cleaning her C-pap mask and H20 chamber regularly, R51 stated, I don't know. During a second observation of R51 made on 04/03/24 at 9:41 AM, Certified Nursing Assistant (CNA) 7 was observed pushing R51 in her wheelchair from the 500-unit dining room with the oxygen concentrator behind it. At this time, observation of the oxygen tubing on the oxygen concentrator was still not dated/labeled as to when it was changed out. During an observation of R51 made on 04/03/24 at 12:17 PM, CNA1 was observed pushing R51 in her wheelchair from the 500-unit dining room with the oxygen concentrator behind it. At this time, observation of the oxygen tubing on the oxygen concentrator was still not dated/labeled as to when it was changed out. During an observation and interview made on 04/03/24 at 12:22 PM, R51 was observed to be sitting in her wheelchair in her room. At this time R51 was wearing her oxygen via nasal cannula. During the interview, when asked if staff were cleaning her C-pap mask with warm water and vinegar, R51 stated, Well, no. Not really. When asked if staff were coming to change the oxygen tubing either from the oxygen concentrator, or changing the C-pap hose and H20 water chamber regularly, R51 stated, Well, no. At this time, R51's C-pap machine was again observed sitting on the floor on the left side of the resident's head of the bed. The C-pap machine mask, hose, and H20 chamber were observed again to be sitting on a ledge of the window. The C-pap tubing was observed to be hanging down off the window ledge. There was no evidence of when the C-pap mask, H20 chamber or tubing had been cleaned, or changed out. During an interview on 04/03/24 at 12:30 PM regarding R51's oxygen tubing and C-pap machine, CNA7 and CNA1 stated, If they need to be changed then we will just do that on a as needed basis. CNA7 stated, We change out the water and oxygen tubing. When asked how often, CNA7 stated, Just whenever. CNA 7 further was asked if there would be any documentation of when the oxygen tubing is changed out, she stated, We are supposed to put a piece of tape on the oxygen tubing with the date and our initials when we change it out. That is the same with the humidifiers. We are supposed to put the date and our initials when we change those out, but with [name of R51] she has her own humidifier bottle, so we just add distilled water to when needed. Regarding R51's C-pap machine mask, tubing, and H20 water chamber, CNA7 stated, The night shift is supposed to change out the water and clean the C-pap masks. Review of an undated Face Sheet located in R51's electronic medical record (EMR) under the Resident tab indicated diagnoses to include Acute and chronic respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), acute respiratory distress syndrome, congestive heart failure, and obstructive sleep apnea. Review of a Significant Change Minimum Data Set [MDS] located in R51's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 01/02/24 revealed R51 was receiving oxygen therapy and had a Brief Interview for Mental Status [BIMS] score of 14/15 indicated no cognitive impairment. Review of Physician Orders, dated 12/27/23, located in R51's EMR under the Orders tab indicated, Admit to [name of hospice] d/t (due to) Respiratory failure. Review of Physician Orders, dated 01/01/24, located in R51's EMR under the Orders tab indicated, Cleanse C-pap mask, tubing and H20 chamber weekly on Sunday with 3 cups of warm water and 1 cup of white vinegar, let air dry and be ready for use by HS (evening) once a day on Sunday 7am-7pm. Review of Physician Orders, dated 04/03/24, located in R51's EMR under the Orders tab indicated, Change all oxygen and nebulizer tubing the last Sunday of each month on day shift. (CMT's, nurse to monitor to assure it was completed) once a day on last Sunday of the month at 5pm. During an interview on 04/03/24 at 12:37 PM, Licensed Practical Nurse (LPN)3 was asked who changes out the oxygen tubing and who cleans the residents C-pap masks, changes out the tubing and ensures the H20 water chamber is clean, LPN3 stated, The med tech would change out the tubing. It used to be weekly, but now I think its monthly just as needed. Regarding the humidifiers, The med tech or me can change those out when we see it needs to be changed. We are supposed to be documenting when they are changed out on the MARS [Medication Administration Record]. LPN3 stated, With the C-pap, she just has distilled water in her room, so we just replace that when we see its low. LPN3 then stated, Regarding the cleaning of the C-pap mask, that is supposed to be done weekly by the night shift. That would be documented in the ADL [Activities of Daily Living] book. The CNAs are supposed to clean the C-paps, sanitize, and wipe down after each use. That would be the night shift. Review of the ADL (Activities of Daily Living) Flowsheets dated 01/02/24-01/31/24 indicated no documentation of cleansing R51's C-pap mask, tubing & H20 chamber was being documented as completed on Sundays as ordered. Review of the ADL Flowsheet dated 02/01/24-02/29/24 indicated three inconsistencies on Sunday 02/04/24, Sunday 02/18/24, and on Sunday 02/25/24 in which there was no documentation of cleansing R51's C-pap mask, tubing & H20 chamber as ordered to be done on Sundays. Review of the ADL Flowsheet dated 03/01/24-03/31/24 indicated inconsistencies on Sunday 03/03/24, Sunday 03/10/24, Sunday 03/17/24, Sunday 03/24/24 and on Sunday 03/31/24 in which there was no documentation of cleansing R51's C-pap mask, tubing, & H20 chamber as ordered to be done on Sundays. During an observation made on 04/03/24 of R51 at 12:49 PM with LPN3, R51 was observed to be lying in her bed with the oxygen on. When observing the oxygen tubing connected to the oxygen concentrator not being dated/labeled, LPN3 confirmed and stated, No, I do not see a date or initials as to when the oxygen tubing was changed out. At this time, R51's C-pap machine was again observed to be on the floor on the left side of the resident's bed. R51's C-pap mask and tubing were again observed to be still sitting on the window seal ledge. During interview, LPN3 stated, I will have to get a table and put her C-pap machine on it because I see its on the floor and it should not be. LPN3 stated, The C-pap mask should be cleaned every Sunday but I'm not seeing a date as to when it was cleaned last. I will need to get some new oxygen tubing as well because I don't know the last time this was change out. During an interview made on 04/3/24 at 1:00 PM, regarding resident's oxygen tubing, and C-pap machines, Certified Medication Aide (CMA)1 stated, We are supposed to change out the oxygen tubing once a week. We run the C-pap masks through water, and I believe it is the med techs and the nurses that do that, but I'm not sure. CMA1 stated that she had not cleaned R51's C-pap mask or changed out the oxygen tubing that she could recall. During an interview made on 04/03/24 at 1:16 PM, regarding oxygen tubing, respiratory equipment, and C-pap machines, the DON stated, The oxygen tubing is changed out monthly and its usually the last day of the month. The C-pap mask, and tubing should be in a plastic bag. That would be my expectation. The DON further stated, I'm thinking anybody can change out the humidifiers anytime they are empty, and with the oxygen tubing, it should be changed out by the night shift aides. The nurse would ensure its done and should be signing off on that. The DON further stated, It would be my expectation the C-pap masks are being cleaned as ordered as well. When the documentation of the inconsistencies was shown to the DON regarding R51's C-pap mask not being cleaned and 02 not being dated/labeled, the DON stated, I was not aware that it wasn't being done. Unfortunately, if it wasn't documented, then it didn't happen. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed R48 was admitted to the facility on [DATE] with diagnoses which included dementia, stroke, and heart failure. Review of an 07/30/22 Physician Order located in the Orders tab of the EMR revealed, Oxygen titrate to maintain sats above 90%. Diagnosis is hypoxia. Review of the quarterly MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/02/24 revealed, R48 had a BIMS score of three out of 15 which indicated she was severely impaired in cognition and used oxygen daily. During an observation on 04/02/24 at 10:32 AM, R48 was observed sitting in her high-back wheelchair, in her room. The nasal cannula was not positioned in both nares and was only observed in one naris. The oxygen concentrator filter was covered with white lint and there was no humidifier bottle attached. During an observation 04/02/24 at 11:46 AM, R48 was observed with the oxygen nasal cannula was observed on her face, but not in her nares. During an observation on 04/02/24 at 12:03 PM, Certified Medication Technician (CMT) 4 was asked why her nasal cannula was not in her nares. CMT 4 was then observed to reposition R48's nasal cannula into her nares. CMT 4 was asked who was responsible for ensuring the filter was clean and there was a humidifier bottle. CMT 4 confirmed that the filter was dirty and stated, We all are responsible for ensuring that it is clean, and tubing is changed. During an observation on 04/03/24 at 9:25 AM, R48 was observed sitting in her wheelchair at the dining room table. R48 was not wearing her oxygen and the concentrator was observed in her room. Certified Nurse Aide (CNA) 3 was asked why she wasn't wearing her oxygen. CNA 3 confirmed she wasn't wearing her oxygen but then stated, I don't know why she isn't wearing [the oxygen].

Based on interview and record review, the facility failed to provide showers to two residents who preferred showers (Residents (R)8, and R73) of five residents reviewed in a total sample of 21 residents. This failure placed the residents at risk of a diminished quality of life. Findings include: 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R8 was admitted to the facility 03/01/10 with diagnoses that included Parkinson's disease (a progressive neurological disorder), dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/06/24 revealed R8 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. In addition, the assessment revealed she required substantial assistance with showering. Review of an 01/22/19 ADL [activities of daily living] Care Plan, revised on 11/16/23 which was located in the Care Plan tab of the EMR, revealed R8 is at risk for decline in ADL abilities related to progressive dementia and general weakness. At this time, she is independent with her ADLs, only needing help if having illness or when she requests. A 01/22/19 intervention revealed, Bathe per choice of whirlpool, shower, or bed bath twice weekly. R8 requires extensive assist of 1 for bathing. During an interview on 04/02/24 at 12:15 PM, R8 was asked if she was provided showers per her schedule. R8 stated, I am to get two showers [her choice of bathing] per week . I haven't had a shower since last Tuesday [lapse of seven days]. R8 was asked if she was aware of any reason as to why she had not received her showers. R8 stated, I haven't heard a word as to why, but I think it's due to being short staffed. Review of the Shower Sheet located in a binder at the nurses' station, revealed the following dates that there was no documentation of R8 having received a shower. January 2, 2024. January 9, 2024. February 16, 2024. March 26, 2024. March 29, 2024. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed, R73 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination) and mental illness. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 03/19/24 revealed R73 had a BIMS score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. In addition, R73 required substantial assistance with showering. Review of the 01/19/23 ADL Care Plan, located in the Care Plan tab of the EMR revealed, Self-Care Deficit: R73 showers herself with supervision for safety and assistance to safely transfer to the shower chair . During an interview on 04/02/24 at 10:06 AM, R73 was asked if she received her showers per her preference. R73 stated, I never refuse a shower as it is important to me. My showers are twice a week, they are short-staffed, and they can't always give me one. R73 was asked if they were able to provide a shower later in the day or the next day. R73 stated, No, I just have to wait until next week. I wish it didn't happen. Review of the Shower Sheet located in a binder at the nurses' station, revealed the following dates that there was no documentation of R73 having received a shower. January 4, 2024. January 15, 2024. February 1, 2024 March 25, 2024. April 1, 2024. During an interview on 04/02/24 at 2:25 PM, Licensed Practical Nurse (LPN)5 was asked about the missing documentation in the shower book. LPN 5 stated, It was probably due to a staffing issue. If we have two CNAs [Certified Nurse Aides], it cannot be done. If we have three CNAs, I will assign an aide to showers. I do try and help out with showers, but it's not always possible.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure resident Care Plans were updated/revised for two residents (Residents (R) 84, R6) of 21 sampled residents. The facility failed to update the Care Plan for R84 related to her behaviors and oxygen usage for R6. This failure created an increased risk for the residents to care and services that may not be appropriate for their current clinical condition. Review of the facility policy titled, Updating Care Plans, dated 04/05/18 revealed, . Care Plans need to be continually updated as the resident's needs change. The Care Plan needs to reflect the resident's current status at any given moment . 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/27/24, revealed R84 had a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated she was severely impaired in cognition, had physical and verbal behaviors, rejected care for one to three days during the observation period. In addition, it was documented that R84's behaviors had worsened since admission. Review of the 03/05/24 Behavior Care Plan located in the Care Plan tab of the EMR revealed, R84 has episodes of inappropriate behavior which interfere with her care and the care of other residents. She can be combative and strike out. Approaches, dated 03/05/24 include the following: .R84 has a scheduled anti-psychotic medication for management her [sic] behavior and anxiety. She also has a prn [as needed] for management of breakthrough behavior which presents as a safety issue . R84 verbalizes delusions about family and events. Provide reassurance and distract as much as possible with activities or conversations. R84's anxiety sometimes presents with verbal and physical behavior. Try to remove her from the situation, allow her to calm [sic]. Limit stimulation if she appears upset. When she refuses or resists care, reapproach at a later time. Wandering: R84 is up wandering and pacing throughout the unit. She tries doors to find her care/family, etc. She also wanders into other resident rooms. Staff to [sic] monitor her where abouts [sic] and redirect as needed to keep her safe. Take her to group activities or common areas and encourage her participation. During an observation on 04/02/24 at 1:19 PM, R84 was observed sitting on the floor in the common area. Certified Medication Technician (CMT) 4, upon observing the surveyor having entered the secured dementia unit, stated She is care planned to be sitting on the floor. CMT 4 tried to assist R84 to stand up however, R84 was able to stand independently without assistance. During an observation on 04/04/25 at 9:28 AM, R84 was observed to ambulate independently in the common area, then lean over and sit on the floor, then stand up again and continue to ambulate, then repeat this behavior. Review of the Behavior Care Plan did not show the behavior of sitting on the floor as a problem nor was there an approach which included how staff were to address this behavior with R84 safely. During an interview on 04/04/24 at 12:21 PM, Licensed Practical Nurse (LPN) 4 was asked when the behavior of sitting on the floor start. LPN 4 stated, It's been that way all along. During an interview on 04/04/24 at 12:23 PM the Unit Manager (UM) 1 was asked about the behavior of sitting on the floor. UM 1 stated, Her family at home stated she was a floor sitter. It was reported to MDS about the behavior so it could be care planned. UM 1 was told that that information was not in the Care Plan. UM 1 reviewed the comprehensive Care Plan and the Care Plan book located at the nurses' station and stated, There is nothing in her Care Plan about the behavior. 2. Review of R6's Face Sheet, located in the resident's electronic medical records (EMR) section titled Face Sheet, revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure and chronic atrial fibrillation. Review of R6's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/24, located in the resident's EMR under the MDS tab indicated the facility assessed R6 to have a Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating R6 had intact cognition. Review of R6's Care Plan, located on Unit five in the Care Plan book, revised 03/28/24 revealed the resident did not have a oxygen care plan to address their continuous oxygen order. Review of R6's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R6 the following orders: -O2[oxygen] Titrate via nasal cannula to maintain O2 sats>PRN [as needed] with 2 Liters and O2 sats with start date of 03/20/24. Observation and interview on 04/02/24 at 10:00 AM, R6 was observed sitting in wheelchair with oxygen on face. R6 stated they had been using oxygen since their last hospital visit last month in March 2024. An interview on 04/05/24 at 1:55 PM, with the Assistant Director of Nursing (ADON) revealed they were the MDS Coordinator and ADON and they were responsible for initiating and updating care plan as they are completing any quarterly, annual, or significant change MDS's. ADON revealed they updated R6's care plan when they updated their last significant change MDS, and they just missed the oxygen. ADON stated it was important to include oxygen on the care plan so that staff would be aware of and know how to care for R6.

Based on observations, interviews, record reviews, and review of the facility assessment, the facility failed to ensure sufficient nurse staffing to meet the needs of the residents resulting in residents not receiving showers for two (Residents (R) 73, R8) of five sampled residents, activities to meet residents' needs in the secured dementia unit. These failures placed residents at risk of a diminished quality of life and potential unmet care needs. 1. This tag is cross-referenced to F676; ADL [maintain activities of daily living] as not diminish or decline. Based on interview and record review, including shower schedules, the facility failed to consistently provide showers for R73, and R8. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 02/06/24 revealed R8 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 12:15 PM, R8 stated, I am to get two showers [her choice of bathing] per week .I haven't had a shower since last Tuesday [lapse of seven days]. R8 was asked if she was aware of any reason as to why she had not received her showers. R8 stated, I haven't heard a word as to why, but I think it's due to being short staffed. Review of the quarterly MDS located in the MDS with an ARD of 02/06/24 revealed R65 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 1:36 PM, R65 stated, Yes, I don't think there is enough staff. It is mostly on the afternoon shift. When I put my call light on, sometimes they don't come at all (to answer the call light). Review of the quarterly MDS located in the MDS tab of the EMR with and ARD of 03/19/24 revealed R73 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 10:06 AM, R73 stated, I never refuse a shower as it is important to me. My showers are twice a week, they are short staffed, and they can't always give me one. 2. This tag is cross-referenced to F679: Activities. Based on observation, interview, and record review, the facility failed to provide a program of meaningful activities for residents who reside in the secured dementia unit. During observations on 04/02/24 and 04/04/24, in the secured dementia unit, there were nine residents in total who resided on the unit. During these observations, residents were not observed in an activity but instead were laying in the beds. One resident, R84, was observed wandering around the unit, sitting on the floor and then getting up and walking again. During the survey from 04/02/24 to 04/04/24The secured dementia unit showed that only one staff member was available to assist the residents with ADL [activities of daily living] needs, pass medications, intervene if there were behaviors and provide activities for the nine residents. During an interview on 04/04/24 at 9:08 AM, Certified Nurse Aide (CNA) 2 [who was also a CMA-Certified Medication Aide) was asked why there were no residents in the common area. She stated, I have no idea why. CNA2 was asked if she was the only person to care for the nine residents on the unit. She stated, Yes. CNA 2 confirmed that she provided the nine residents with ADL care, their medications, handled behaviors, and provided activities. CNA 2 further stated that we just moved to this unit, on the 200 hall from the 400 hall this week, so we are just getting used to it here. During an interview on 04/04/24 at 12:21 PM, Licensed Practical Nurse (LPN) 3 stated, I used to be on the secured dementia unit prior to coming to the 200 hall, so I am familiar with the residents on the dementia unit. LPN3 further stated, The dementia unit used to be on the 400 hall, we had a nurse and a CNA/CMA available on the unit and we were able to do activities but now I have to be at the desk on the 200 hall and be available to the dementia unit. During an interview on 04/04/24 at 1:10 PM, the Activities Director (AD) stated, I know they (the dementia unit residents) are laying in their beds. The Administrator told me that the census is low so the aides have to the activities. We moved to the 200 hall to consolidate staffing. The Administrator stated they couldn't put anyone back their so the CNAs had to do activities. The AD was asked if she felt the facility was short-staffed. She stated, Yes, I do. The AD further stated that on 400 hall, we used to have a patio, and during the summer we would take the residents outside, have popsicles and reminisce but with the new unit on the 200 hall, we don't have a way for them to go outside. During an interview on 04/05/24 at 8:50 AM, the Infection Preventionist (IP) stated that she was also responsible for staffing. The IP stated that she was on a 30 hour per week employee, and it was difficult to both jobs. The IP was asked if she attended the weekly QAA (Quality Assessment and Assurance) meetings. She stated, No, they hold the meetings when I am not here. The IP stated that she has to make a list for the to discuss regarding infection control and staffing. Review of the 02/28/24 Facility Assessment, (based on information from 2023) provided by the Administrator, revealed the average daily census on the 400 hall was 13.6 residents. Staffing the unit included the following breakdown: DAY SHIFT: Unit Manager: 0.5 (part-time) Licensed Nurse; 1.0 (full-time) CMT: 1.0 (full-time) CNA: 1.0 (full-time) NIGHT SHIFT: CMT: 1.0 (full-time) CNA; 1.0 (full-time) During an interview on 04/05/24 at approximately 12:00 PM, the Administrator stated, If we don't have money for a staff position, we just won't have a position.

Based on interview and record review, the facility failed to complete an Abnormal Involuntary Movement Scale [AIMS-a test that rates involuntary muscle movements (tardive dyskinesia) on residents who are administered antipsychotic medications] assessment for two residents (Resident (R) 65 and R84) and failed to re-evaluate the need for an antipsychotic medication for one resident (R4) of five residents reviewed for unnecessary medications in a total sample of 21. These failures placed residents at risk for unrecognized side effects. 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R65 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, and pulmonary disease. Review of a 10/24/23 Psychotropic Medication Change Progress Note, located in the Progress Notes tab of the EMR and recorded as a late entry on 11/07/23, revealed NEW ORDER: Seroquel [an antipsychotic medication] 12.5 mg at bedtime for increased behaviors, hallucinations, and paranoia. Seroquel can have the side effect of tardive dyskinesia which can be permanent. Review of an 11/03/23 Physician Order located in the Orders tab of the EMR revealed on 11/03/23, the Seroquel was discontinued. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/07/23 revealed R65 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact and had hallucinations (a perception of something not present). Review of a 12/05/23 Physician Order located in the Orders tab of the EMR revealed, Rexulti [an antipsychotic medication] 0.5 mg daily for depression/behaviors. Rexulti can cause tardive dyskinesia. Review of the Observations tab and the Resident Documents tab of the EMR revealed no documentation that an AIMS assessment was completed at the time R65 was started on the antipsychotic medications. During an interview on 04/05/24 at 11:29 AM, the Director of Nursing (DON) was asked if the AIMS assessment was completed and what the expectation was regarding staff doing the assessment. The DON stated, The Unit Managers were responsible, and they are to be done upon admission and every six months afterwards. The DON was unable to confirm or deny the AIMS assessments were completed for R65. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 02/27/24 revealed R84 had a BIMS score of four out of 15 which indicated she was severely impaired in cognition, had physical and verbal behaviors, rejected care, and wandered daily. In addition, the MDS showed that she was administered an antipsychotic medication. Review of the 03/13/24 Psychotropic Medication Review located in the Resident Documents tab of the EMR revealed the following: Olanzapine 5 mg BID (02/28/24). Risperidone 0.5 mg BID (02/19/24). Review of the Observations tab and the Resident Documents tab in the EMR did not show an AIMS assessment was completed, at the time of admission and when the Olanzapine was started. Olanzapine and Risperidone can cause tardive dyskinesia. During an interview on 04/04/24 at 12:31 PM, Unit Manager (UM)1 was asked if AIMS was completed upon admission for the Risperidone and when the Olanzapine was started. UM1 stated, No, it wasn't done. I don't know why as she came in with them. 3. The facility failed to complete AIMS assessments, every three months, for R4 as directed in the care plan for psychotropic drug use. Review of R4's Continuity of Care Document, located in the electronic medical record (EMR) under the Resident tab, revealed R4 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified dementia with behavioral disturbance; bipolar disorder; and anxiety disorder. Review of the annual MDS assessment with an ARD of 01/02/24 revealed a BIMS score of 99 indicating an inability to participate in the assessment. Review of the physician's orders, located in the EMR under the Resident tab revealed R4 received the following medications: a. fluoxetine (Prozac) solution 5ml (milliliters) one time a day at 8:00 AM for depression /appetite, ordered 06/16/21. Fluoxetine (an antidepressant may cause tardive dyskinesia, a movement disorder). b. Seroquel 25 mg, one tablet twice a day for bipolar disorder, increased to twice a day on 09/22/23. Seroquel is an antipsychotic and may cause tardive dyskinesia. Review of R4's Psychotropic Drug Use care plan, initiated 02/05/21 and last updated on 04/04/24, revealed R4 takes Seroquel for bipolar disorder . Prozac for depression. Included in the care plan approaches was AIMS (abnormal involuntary movement scale) every three months for antipsychotic use; monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms; and monitor for therapeutic and side effects of anti-psychotic medications. On 04/02/24 at 10:01 AM R4 was observed, , in her room seated in her geri-chair. The resident was awake and observed to exhibit tongue thrusting. R4 engaged in a very brief conversation/introduction and stated, thanks for stopping, upon exiting her room. On 04/02/24 at 11:44 AM, R4 was observed seated at a table in the assisted dining room. R4 was observed to exhibit tongue thrusting while feeding herself a pureed meal with thickened liquids. The resident responded with hello when spoken to. Review of a facility report titled Antipsychotic Medication Evaluation (AME), dated 09/26/23, located in the EMR under the documents tab, specific to Seroquel, revealed recent change to BID (twice a day), wait one month then reassess. There were no evaluations found in the EMR to address the specified reassessment. Review of a Nurses Progress Note, dated 02/18/24, located in the EMR under the Resident tab revealed Daughter here in facility. Complaints of resident saying unusual things. Resident was observed with hallucinations early this shift. Pointing across room and stated do you see those little boys over there? Reassured resident no little boys in room at this time. Daughter left and called facility. Would like resident to be checked for UTI (urinary tract infection). Placed resident on UTI protocol. Will speak to NP tomorrow. Daughter advised that resident usually sticks tongue out when UTI is present. In an interview with the Unit Manager (LPN1) on 04/05/24 at 9:52 AM, she stated, ask the DON (Director of Nurses) for AIMS assessments. When asked about R4's tongue thrusting, LPN1 stated, she is? When asked about the 02/18/24 progress note, written by LPN1, she stated she didn't have a UTI, I don't remember writing about sticking her tongue out. LPN1 stated, she doesn't have a UTI now. During an interview, on 04/05/24 at 1:01 PM, with the Director of Nurses (DON), the DON was asked about the follow up to the AME dated 09/26/23. The DON stated, I would hope the charge nurse would identify it. When asked if R4 had been reviewed in the facility's weekly Clinical Meeting, the DON stated, every resident on an antipsychotic would be reviewed. When asked what was discussed in regard to R4, the DON stated, I don't have any notes on her. The DON was asked to locate any AME evaluations, AIMS evaluations, or documentation that R4's psychotropic medication use was being evaluated on a routine basis, the DON stated there's nothing in her record, we don't have anything.

During an observation, interview, and review of facility policy, the facility failed to prepare, store, and label medications according to standard nursing practice for one of four Certified Medication Aide (Certified Medication Aide (CMA3) observed during medication pass. This failure placed prescription-based medications readily accessible to residents, increased health complications, and the possibility of giving the wrong medication to the wrong resident. Review of an untitled facility policy, dated 04/29/14, revealed, Medication is never to be left unattended. If you must leave your cart, then all medications are to be locked inside. During a medication pass observation on 04/05/24 at 7:40 AM, Medication cart 5 [NAME] was parked outside a room. CMA3 was not stationed at the cart but was in a resident's room. The cart showed that there were three individual plastic cups on top of the cart which were observed to contain powder mixed in liquid, which had gelled at the bottom of the cup. Inside each cup was a plastic spoon. The individual cups were not labeled. CMA 3 returned to the cart and was asked what was in the cups sitting on her medication cart. CMA3 stated, These are medications for the morning med pass. CMA3 was asked if she premixed medications often. CMA3 stated, Yes, I can't lie. CMA 3 further stated, I am supposed to lock them up and not prepare the meds until I administer them. CMA 3 was asked what was in the medication cups. She stated, Lactulose (a liquid medication for constipation), liquid protein and Miralax (a medication for constipation.) CMA3 returned the 5 [NAME] medication cart to the nurses' station and placed the medications into the bottom drawer and locked the cart. CMT3 then obtained the 5 East medication cart and proceeded down the hall. On top of the medication cart revealed five individual plastic cups of medications, unlabeled. CMA3 was asked what was in the cups. She stated, Miralax. CMA3was asked when the medications were premixed. She stated, I mixed them up about an hour ago. CMA3 was asked if the medications were labeled. She stated, No. CMA 3 was asked how she knew which medication was to be used for each resident. She stated, I just know. During an interview on 04/05/24 at 9:46 AM, the Director of Nursing (DON) was asked what her expectation was regarding labeling, storing, and preparing medications. The DON stated, My expectation is that meds are not prepared in advance and not left out unattended on the carts.

Based on employee record review and interviews, the facility failed to have documentation of completion of a minimum of 12 hours of required in-service training to include Dementia care and Abuse, Neglect, and Exploitation for five of five Certified Nursing Assistants (CNAs) (CNA 1, 2, 4, 6, and 7). By not ensuring employees are meeting the required trainings and in-services, residents may be at risk and unable to get their needs met. Review of the facility's Facility Assessment updated February 28, 2024, indicated, Staff Education: Orientation, Annual: Required annual education/training (minimum of 12 hours annually for Nursing Assistants) . During an interview on 04/04/24 at 9:52 AM, CNA1 was asked about trainings and in-services on dementia care and abuse and neglect. CNA1 stated, We have annual in-services, and we cover abuse and neglect. When specifically asked about dementia care, the CNA stated, Prior to coming here, I got trainings, but not really here. No, I don't believe so. During an interview on 04/04/24 at 9:55 AM, CNA7 was asked about annual trainings on abuse, neglect and dementia care. CNA7 stated, Once a month we get trainings, and also on abuse and neglect. When specifically asked about dementia care, the CNA stated, No, not really. We learn on the go. Review of the Employee Personnel files for CNA1, date of hire 08/30/21, indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the Employee Personnel file for CNA2, date of hire 09/04/07,indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the Employee Personnel file for CNA4, date of hire 12/15/10, indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the employee Personnel file for CNA6, date of hire 02/18/20 indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. Review of the employee Personnel file for CNA7, date of hire 05/16/18, indicated annual trainings that were conducted throughout 2023 to include abuse/neglect and dementia care, however there was no evidence of the required 12 hours completed. During an interview on 04/04/24 at 10:27 AM with the Infection Preventionist (IP) (person who conducts the annual trainings) stated, do most of the in-services with the assistance of the Director of Nursing (DON). We cover abuse/neglect and dementia care. The IP then stated, I don't keep track of the actual hours though. We do not keep track of employee hours completed. I only make sure I train them on the required trainings for the year. The IP then stated, We have trainings and meetings that can be 30 minutes or up to 1-hour 1/2, just depends. Once a year, we do trainings and that usually takes a couple of hours to go through all our policies, etc. We do orientation, then skills drills annually. During an interview on 04/04/24 at 11:50 AM, with the DON she stated, At least once a month we are doing trainings, or addressing something. When specifically asked how do you ensure the staff are meeting the required 12 hours of trainings and in-services, the DON stated, Well, other than the fact that they sign in when we do our trainings, I don't have a way to track how many hours they are completing. I've never been questioned about the number of hours before. I haven't kept track of their hours, and I don't have a specific policy. During orientation, there is a checklist that we go by. During a second interview on 04/05/24 at 8:15 AM, the IP stated, I do general orientation and we sign all paperwork, do background checks, etc. With dementia care, we talk about dementia care, and give various scenarios. I know they are supposed to have the 12 hours of in-services. I've never been asked to document the number of hours they are completing. I'm aware they have to have at least 12 hours of trainings on things like Abuse, neglect, and dementia care, I just haven't been documenting that.

Based on observation, record review and interview, the facility failed to notify the resident's physician and to have new interventions in place for a resident with significant unplanned weight loss to prevent the resident from further weight loss for one sampled resident (Resident #56) out of 19 sampled residents. The facility census was 95 residents. The facility did not provide a policy for weight loss. 1. Review of Resident #56's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/18/22 showed: -Brief Interview for Mental Status (BIMS) of 7 (indicates moderate cognitive impairment) -Total dependence on staff for all Activities of Daily Living (ADLs) -Weight of 116 pounds (lbs) -No physician prescribed weight loss. -Weight loss of 5% or more -No difficulty swallowing or chewing -No meal percentages noted. Review of the resident's face sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Intracerebral hemorrhage (bleeding in the brain tissues, with resulting brain damage) affecting the right side -[CONDITION(S)] (irregular, rapid heart rate that can lead to blood clots) -Dysphagia (difficulty swallowing) -Muscle weakness and -Lack of coordination. Review of the resident's care plan updated on 1/27/22 showed: -He/she requires assistance with all Activities of Daily Living(ADLs such as bathing, transfers, toileting, personal hygiene, nutrition) due to bilateral [CONDITION(S)]: (limited feeling and movement due to nerve damage on one side of the body) right side, dominant side, is worse than the left. -He/she requires a mechanically altered diet due to [CONDITION(S)] ([CONDITION(S)]: also known as a stroke, where blood flow to the brain is impaired, causing damage to the brain). -He/she will maintain nutritional status by: use of mechanical soft diet, eats in the dining room, fair-good appetite, offer of snacks, offer substitutes, and monitor weight, inability to feed him/herself and requires extensive assistance to total dependence on staff. -No care plan for weight loss or fluctuations in weight. -No approaches to combat weight loss. Review of electronic health recorded weights showed: -11/11/21 Weight: 137 lbs -12/09/21 Weight: 125 lbs -01/02/22 Weight: 122.6 lbs -01/09/22 Weight: 122.6 lbs -01/16/22 Weight: 116.8 lbs -01/23/22 Weight: 118.4 lbs -02/13/22 Weight: 112.2 lbs -02/20/22 Weight: 108 lbs -02/27/22 Weight: 108.8 lbs -03/06/22 Weight: 110 lbs -03/13/22 Weight: 109.4 lbs -03/20/22 Weight: 109.2 lbs -03/27/22 Weight: 109.4 lbs -04/03/22 Weight: 109.4 lbs -04/10/22 Weight: 110.4 lbs -04/16/22 Weight: 110.4 lbs -04/17/22 Weight: 109.4 lbs -November to December 2021 showed a 12 lbs weight loss or 8.76% in 30 days. -December 2021 to January 2022 showed a 9 lbs weight loss or 7.20% in 30 days. -January to February 2022 showed a 10 lbs weight loss or 8.47% in 30 days. -With a total of 31 lb weight loss or 20.15% 6 months. Review of electronic health record dietary notes showed: -Registered Dietician note on: - 12/30/2021 Nutrition referral for resident having weight loss in 30 days. Current body weight : 125 lbs, 30 day weight 137 lbs, showing 12 lb weight loss. -He/she has meal set up, cut up of food and feeding of mechanical soft, thin liquids and as needed puree foods. -Oral intake 50%, which may not always meet his/her nutrition needs. -Nutrition prescription: Carnation Instant Breakfast (CIB) 240 cubic centimeters (cc) three times a day in between meals. -Dietary Manager note on: -01/27/22 Quarterly review. - Resident remains on a mechanical soft diet with as needed puree. -He/she eats meals in his/her room. -He/she is fed by staff most times. -He/she uses a handled cup with a straw. -His/her appetite is poor. -he/she receives CIB twice a day as a supplement. -His/her weight is stable at this time at 123 lbs. -Registered Dietician note on: -02/22/2022 Nutrition progress note review. -He/she has increased functional decline, having had COVID 19, weakness, and per nursing is mostly non-verbal. -His/her appetite remains poor, and per staff, he/she pockets food and only has taken in a few bites of food at a meal. -He/she uses straws for thin liquids and has no swallowing difficulty. -His/her diet remains appropriate for pocketing/chewing: mechanical soft and as needed puree -His/her diet is appropriate, but at high risk due to poor intake and showing significant weight loss, - His/her current body weight is 112 lbs and 30 day weight 123 lbs, 90 day weight 137 lbs. -The staff has initiated CIB two times daily for calories and protein. -No recommendations. Continue to monitor -Registered Dietician note on: -03/11/22 Nutrition referral note. -His/her current body weight is 110 lbs, 30 day weight was 112 lbs, and 3 month weight 125 lbs. -He/she has some decline noted, decreased cognition, and anxiety. -He/she has a contracture, limited mobility, and nursing offers meals with set up and assist as needed. -Fluids are encouraged. -He/she does have CIB 2 times a day for nutrition, which remains appropriate. -Continue with plan of care and monitor as needed. Review of the resident's medical record showed staff did not notify his/her physician of the resident's weight loss in November 2021, December 2021, January 2022 or February 2022. Review of the resident's April 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Carnation Instant Breakfast (CIB) in milk or juice between meals twice a day for weight loss. Order date of 2/8/22 - Diet of mechanical soft (chopped meats and vegetables), as needed puree (baby food consistency) with thin fluids (regular fluids) and resident is to use handle/straw cups for all meals/liquids. Review of April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -CIB administered twice daily at 8:00 A.M. and 5:00 P.M. -CIB initialed as given April 1 through 18, 2022. During interview and observation on 4/14/22 at 9:17 A.M., Certified Nurse Aide (CNA) G said: -The resident's care plans tell specific care needs. -CNA G assisted the resident with his/her meal intake, and provided encouragement to eat. During an interview on 4/14/22 at 3:56 P.M. Licensed Practical Nurse (LPN) B said: -The CNA's are responsible for obtaining weights for residents on their assigned unit. -The CNA's report any weight changes to him/her. -He/she fills out a dietary report with any weight changes, and charts the weight in the computer . -Dietary makes a plan for any resident with weight loss. -He/she does not call the physician for weight loss. -He/she is unsure if dietary notifies the physician of weight loss. During an interview on 4/19/22 at 9:24 A.M. the Dietary Manager said: -Nursing reports residents' weights to him/her. -Residents' weight changes are discussed at the weekly weight committee meeting. -He/she does not call the physician about weight loss. -He/she believes nursing notifies the physician of weight loss. During an interview on 4/19/22 at 11:51 A.M. the Director of Nursing (DON) said: -Residents' weights are obtained monthly. -Any resident with a 5% or 10% weight loss is considered a significant loss. -Any significant loss: - the resident is placed on weekly weight until stable. -The physician is notified by nursing, and supplements are requested at that time. -The clinical team discusses weights weekly, usually on Thursdays. -The Dietician reviews and makes recommendations. -If a resident is a weight loss and they have been on CIB twice a day and still not maintaining then the team discusses other interventions like stimulants, or double portions. -Weight loss and interventions should be care planned for each individual and documented in progress notes -He/she is aware that the resident has had a weight loss. -He/she is unsure why other interventions are not in place. -He/she would expected the physician to be notified.

Based on interview and record review the facility failed to notify one of 24 sampled residents (Resident # 5) physician of increased pain. Staff failed to identify and implement interventions for ongoing pain control and denied the resident the right to have additional pain medication; did not consult with the competent resident first before declining cares and treatment, which the chronic and increased pain led to a weight loss of 7.8% in three months. The facility census was 175. 1. Review of the facility's Resident Right policy given to resident's and family's on admission showed: - The policy and procedure of Shirkey Nursing and Rehabilitation Center is to comply with the patient self determination act; - The facility will educate family's and patients on the right to formulate a Durable Power of Attorney and the right for an individual to direct his/her own care; - The resident has the right to access services outside the facility; - Invoke the health care agent if the resident does not have decision making capability; - The facility will review the resident's condition and existing choices and continue to modify as appropriate; 2. Review of Resident # 5's Problem list dated 6/12/13, showed: - Problems included left leg pain. Review of admission Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 7/15/13, showed: - [DIAGNOSES REDACTED]. - Received as needed pain medications; - Staff did not provide non medication interventions; - Did not indicate if a staff pain assessment should be completed; - The resident did have vocal complaints of pain in the last five days (that hurts, ouch, stop); - Indicators of pain or possible pain observed daily; - Knew the names and faces of staff; - Knew he/she lives in a nursing home and the location of his/her room; - Did not have a weight loss. Review of the Care Area assessment dated [DATE], showed: - Pain triggered for care assessment. Review of the care plan contribution sheet dated 7/25/13 through 10/24/13, showed: - Did not show family participation. Review of 60 day scheduled MDS, dated [DATE], showed: - Received as needed pain medications; - Staff did not provide non medication interventions; - Did not indicate if a staff pain assessment should be completed; - The resident did have vocal complaints of pain in the last five days (that hurts, ouch, stop); - Indicators of pain or possible pain observed daily; - Knew the names and faces of staff; - Knew he/she lives in a nursing home and the location of his/her room; - Did not have a weight loss. Review of the hospital physician noted dated 10/2/13, showed: - Resident received a [MEDICAL CONDITION] after being discussed and confirmed with her family prior to surgery; - Complained of severe pain in his/her left leg and arm. Review of the physician telephone orders showed: - On 10/7/13, [MEDICATION NAME] (used for moderate to severe chronic pain, providing long [MEDICATION NAME] pain relief from persistent pain) 25 micrograms (mcg) topically every 72 hours for pain; - On 10/21/13, discontinue [MEDICATION NAME] every 72 hours, refused by family. Review of significant change MDS, dated [DATE], showed: - Received as needed pain medications; - Staff did not provide non medication interventions; - Did not indicate if a staff pain assessment should be completed; - The resident did have vocal complaints of pain in the last five days (that hurts, ouch, stop); - Indicators of pain or possible pain observed daily. Review of the nurses notes dated 10/18/14, showed: - Resident crying out in pain, saying I hurt; - [MEDICATION NAME] (short acting pain medication used for moderate to severe pain) given; - Did not indicate if the resident's pain relief. Review of the care plan dated 10/22/14, showed: - Problem; complaints of pain related to open areas on buttocks; - Did not identify left lower extremity pain; - Goal; will verbalize relief from pain; - Interventions; assess effects of pain on the resident such as disturbances in sleep, activity, self care, appetite and psychosocial; - Evaluate effectiveness of pain management interventions and adjust if ineffective; - Monitor and record any complaints of pain, location, frequency, intensity, affects on function, alleviating factors and aggravating factors; - Problem; Nutritional status, received a mechanical soft diet; - Goal; adequate intake without significant weight change; - Interventions; thickened liquids, family brings meals at times, monitor weights; offer substitutes with dislikes and assist with meals. Review of the nurses notes showed: - On 12/2/13, resident did not want to go to bed; - Resident's Family Member (FM) C requested the resident be put in bed; - Staff put the resident to bed and the resident continued to be upset; - FM C requested staff to give the resident anxiety medication; - Staff already gave anxiety medication; - FM C upset and requested anxiety medication should only be given at family request; - On 12/9/13, FM C refused to let staff to turn the resident in bed; - Demanded the resident be left on right side; - Staff tried to explain the need for repositioning. Review of the quarterly MDS, dated [DATE], showed: - Received as needed pain medications; - Staff did not provide non medication interventions; - Did not indicate if a staff pain assessment should be completed; - The resident did have vocal complaints of pain in the last five days (that hurts, ouch, stop); - Indicators of pain or possible pain observed daily; - Knew he/she lives in a nursing home and the location of his/her room; - Did not have a weight loss. Review of the nurses notes showed: - On 1/18/14, FM C refused to allow staff to turn resident in bed at 12:00 A.M., 2:00 A.M., 4:00 A.M., 6:00 A.M.; - On 2/18/14, rated pain at an eight on a scale of zero to 10; - Very agitated and yelling out in pain; - The resident stated he/she needed the big pain pill; - On 2/22/14, [MEDICATION NAME] given for pain at family request; - Resident yelling out in pain; - On 3/3/14, resident found on the floor lying on left side; - Resident reported he/she tried to reposition self in chair and fell out onto the floor; - Resident complained of left sided neck pain with a red area noted on the left cheek bone; - Physician ordered for the resident to be sent to the emergency room for possible neck injury; - FM C refused to allow the resident to go to the emergency room ; - FM C instructed staff to put the resident in bed daily at one P.M., even if the resident refused. Review of the skin condition record showed: - On 3/14/14 left lower amputation, beefy red and necrosis (rotten flesh); - On 3/19/14 left lower amputation, beefy red and necrosis with pain. Review of the Resident Data Collection sheet dated 3/25/14, showed: - Severe daily pain in left lower extremity. Review of the Skilled Nurses Notes dated 3/25/14, showed: - Pain in left lower extremity and did not indicate the intensity of the pain. Review of the Skilled Nurses Notes showed: - On 3/26/14, pain in left lower extremity with a pain rating of 10 on a scale of zero to 10; - On 3/27/14, pain in left lower extremity with a pain rating of 10 on a scale of zero to 10; - Received new order to give [MEDICATION NAME] two tabs every hours as needed for pain; - FM C refused to allow the resident to have two [MEDICATION NAME]; - Staff attempted to educate the family that one [MEDICATION NAME] had little to no affect on the resident's pain and the resident refused lunch related to being in so much pain; - FM C continued to refuse pain medication and the resident continued to be in pain; - Left lower extremity surgical wound appeared to have bone protruding from the skin; - Wound showed white area that appeared to be bone; - Resident very protective of the area and cried out to stop during the dressing change; - FM C at the bedside; - On 3/28/14 pain in left lower extremity and did not indicate the intensity of the pain; - On 3/29/14, pain in left lower extremity and did not indicate the intensity of the pain; - Decreased appetite; Review of the Skilled Nurses Notes dated 3/30/14 through 4/7/14, showed: - Pain in left lower extremity and did not indicate the intensity of the pain. Review of the skin condition record showed: - On 3/28/14 left lower amputation, beefy red and necrosis with bone showing and pain. Review of the admission MDS, dated [DATE], after the resident returned from the wound clinic showed: - Received as needed pain medications; - Staff did not provide non medication interventions; - Did not indicate if a staff pain assessment should be completed; - The resident did have vocal complaints of pain in the last five days (that hurts, ouch, stop); - Indicators of pain or possible pain observed daily; - Knew the names and faces of staff; - Disorganized thinking, easily distracted and difficulty following what said; - Did not have a weight loss. Review of the skin condition record showed: - On 4/3/14 left lower amputation, beefy red and necrosis with pain. Review of the RxList website showed: - [MEDICATION NAME] dosage should be adjusted to the severity of the pain and response to the patient; - If the pain is constant the medication should be given on schedule around the clock; - The usual adult dose is one to two tablets every six hours. Review of the Physician order [REDACTED]. - [MEDICATION NAME] 5-325 milligrams (mg) one tablet, every four hours as needed for pain; - [MEDICATION NAME] (anxiety medication) 0.5 mg three times a day as needed for anxiety; - Tylenol 325 mg, every four hours as needed for pain; - [MEDICATION NAME] (non narcotic pain reliever) 50 mg, every four hours as needed for pain. Review of the resident's weights showed: - The resident did have a weight loss of 7.8% in the last three months. Review of the resident's as needed (prn) nursing flow sheets , dated January 2014, showed: - [MEDICATION NAME], a medication used to treat moderate to severe pain,50 milligrams (mg), orally every four hours prn pain; - [MEDICATION NAME], a medication used to treat anxiety, .5 mg orally up to three times a day as needed for anxiety/agitation; - Tylenol 325 mg orally as needed for pain or fever. Review of the resident's prn medication notes, for January 2014 showed: - 1/3/14 10:02 A.M., staff gave the resident [MEDICATION NAME] 50 mg orally for hip pain, staff did not chart the result of the medication; - 1/4/14 at 11:10 A.M. , staff gave the resident [MEDICATION NAME] 50 mg orally for back pain, at 2:00 P.M. staff charted no change in pain; - 1/5/14 at 4:30 P.M., staff gave the resident [MEDICATION NAME] 50 mg orally for back pain, at 6:00 P.M. staff charted no change in pain; - 1/6/14 at 12:50 A.M., staff gave the resident [MEDICATION NAME] 50 mg orally for arm pain, at 2:00 P.M. staff charted no change in pain; - 1/8/14 at 5:50 P.M., staff gave the resident [MEDICATION NAME] 50 mg orally for back pain, at 7:00 P.M. staff charted the resident asleep after pain medication; - 1/9/14 at 12:15 P.M., staff gave the resident [MEDICATION NAME] 50 mg orally for back and side pain, at 2:00 P.M. staff charted no change in pain; - 1/10/14 at 9:40 A.M., staff gave the resident [MEDICATION NAME] 50 mg orally for pain, at 11:00 A.M. staff charted no change in pain; - 1/10/14 at 4:30 P.M., staff gave the resident .5 mg [MEDICATION NAME], a medication for anxiety) orally for anxiety, at 6:00 P.M. staff charted no change in anxiety; - 1/11/14 at 4:40 P.M., staff gave the resident .5 mg of [MEDICATION NAME] for anxiety, at 5:30 P.M., at 5:30 P.M. staff charted no change in anxiety; - 1/11/14 at 7:40 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at midnight staff charted the resident was resting; - 1/12/14 at 1:10 P.M. staff gave the resident 325 mg Tylenol for headache, staff did not chart the results of the medication; - 1/13/14 at 8:15 A.M. staff gave the resident Tylenol 325 mg orally for headache, at 11:00 A.M. staff charted no change in pain; - 11/13/14 at 5:30 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for headache, at 7:00 P.M. staff charted no change in pain; - 11/13/14 at 9:30 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 11:00 P.M. staff charted the pain medication was effective; - 1/14/14 at 5:40 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, staff did not chart the results of the pain medication; - 1/15/14 at 9:40 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 11:00 A.M. staff charted no change in pain; - 1/17/14 at 2:00 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for headache, at 3:00 A.M. staff charted the pain medication was effective; - 1/18/14 at 8:00 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 10:30 P.M. staff charted the medication was effective; - 1/19/14 at 4:00 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 5:00 P.M. staff charted the resident was asleep; - 1/21/14 at 6:40 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for neck pain, staff did not chart the results of the pain medication; - 1/24/14 at 1:20 P.M. staff gave the resident [MEDICATION NAME] 50 mg for general pain, at 3:00 P.M. staff charted no change in pain; - 1/24/14 at 6:20 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for neck pain, staff did not chart the results of the pain medication; - 1/25/14 at 11:50 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for neck pain, staff charted no change in pain; - 1/25/14 at 6:20 P.M. staff gave the resident Tylenol 325 mg orally for headache, staff did not chart the results of the medication; - 1/27/14 at 2:50 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for back pain, at 4:00 P.M. staff charted pain better; - 1/28/14 at 8:50 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for back pain, at 10:30 A.M. staff charted pain better; - 1/28/14 at 4:10 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for back pain, at 6:00 P.M. staff charted no change in pain; - 1/29/14 at 8:35 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for neck pain, at 10:00 A.M. staff charted no change in pain; - 1/29/14 at 5:00 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for buttocks pain, at 6:00 P.M. staff charted no change in pain; - 1/30/14 at 8:50 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for headache, at 10:00 A.M. staff charted no change in pain; - 1/31/14 at 8:30 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for neck pain, at 11:45 P.M. staff charted neck pain better. Review of the resident's as needed (prn) medications nursing flow sheets, dated March 2014, showed: - [MEDICATION NAME] 50 mg, orally every four hours prn pain; - [MEDICATION NAME] .5 mg orally up to three times a day as needed for anxiety/agitation; - Tylenol 325 mg orally as needed for pain or fever. Review of the resident's nursing prn flow sheet , dated March 2014, showed: - [MEDICATION NAME], a narcotic/Tylenol combination used to treat moderate to severe acute pain, 5-325 mg one orally every four hours for pain; - On 3/25/14 the physician changed the order to [MEDICATION NAME] 5-325 mg one orally every six hours as needed and [MEDICATION NAME] 5-325 mg two orally every six hours as needed for pain; - On 3/25/14, the physician ordered [MEDICATION NAME], a medication used to treat muscle spasms, 10 mg orally. Review of the resident's prn medication sheet, for March 2014, showed: - 3/3/14 at 12:00 P.M. staff gave the resident [MEDICATION NAME] 10 mg for muscle spasms, at 1:00 P.M. staff started no relief of muscle spasms; - 3/3/14 at 5:00 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for neck pain, at 6:00 P.M. staff charted no pain relief; - 3/9/14 at 2:00 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for muscle pain, at 3:00 staff charted no change in pain; - 3/9/14 at 6:00 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for no reason given, at 8:00 A.M. staff charted no relief; - 3/9/14 at 2:05 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 4:00 P.M. staff charted pain medication effective; - 3/12/14 at 12:45 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 8:00 P.M. staff charted pain medication effective; - 3/13/14 at 3:30 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 7:00 A.M. staff charted the pain medication "little help"; - 3/13/14 at 9:30 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 11:30 staff charted pain medication effective; - 3/17/14 at 8:50 A.M. staff gave the resident [MEDICATION NAME] .5 mg orally for anxiety, at 10:00 A.M. staff charted no change in anxiety; - 3/21/14 at 8:40 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 10:00 A.M. staff charted no change in pain; - 3/26/14 at 8:50 A.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 10:00 A.M. staff charted no change in pain; - 3/31/14 at 9:20 P.M. staff gave the resident [MEDICATION NAME] 50 mg orally for leg pain, at 12:00 A.M. staff charted the pain medication was effective. Review of the resident's pain management sheet, used to assess [MEDICATION NAME] only, for March 2014, showed: - 3/5/14 no time noted, the resident rated his/her leg pain an 8 (out of 10 scale 10 being the worst), staff gave the resident [MEDICATION NAME] 50 mg orally, no time noted, the resident rated his/her leg pain at 5 and staff charted effective; - 3/5/14 no time noted, the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, no time given, the resident rated his/her pain a 6 and staff charted effective; - 3/7/14 at 6:35 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, staff did not chart a follow-up pain assessment; - 3/9/14 at 2:05 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, the resident later rated his/her pain 5 and staff charted the pain relief effective at 4:00 P.M.; - 3/11/14 at 3:25 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, the resident tater rated his/her pain still an 8 but staff charted some relief; - 3/12/14 at 12:45 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, the resident later rated his/her pain a 5 and staff said some help; - 3/13/14 at 9:30 A.M., the resident rated his/her pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, the resident later rater his/her pain a 6 and staff charted effective pain relief; - 3/15/14 at 8:45 A.M., the resident rated his/her pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, at 11:50 A.M. the resident rated his/her pain a 6 and staff charted "some help"; - 3/15/14 at 1:45 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, at 6:00 P.M. the resident rated his/her pain a 6 and staff charted "some help"; - 3/16/14 at 2:10 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, the resident later rated his/her pain at 6; - 3/20/14 at 8:20 P.M., the resident rated his/her leg pain an 8, staff gave the resident [MEDICATION NAME] 50 mg orally, later the resident rated his/her pain at 6. Review of the resident's pain management pain flow sheet for [MEDICATION NAME] 5/325, dated March 2014, showed: - 3/8/14 no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5; - 3/10/14 no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5; - 3/12/14 no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5; - 3/14/14 at 10:30 A.M., the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5; - 3/14/14 at 5:25 P.M., the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5; - 3/17/14 at 10:45 A.M., the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 7; - 3/18/14 at no time given., the resident rated his/her pain (no site given) a 9, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 7; - 3/19/14 at no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 6; - 3/19/14 at no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 6; - 3/20/14 at no time given, the resident rated his/her pain (no site given) a 9, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 7; - 3/21/14 at no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 6; - 3/26/14 at 8:45 A.M., the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 6; - 3/27/14 at no time given, the resident rated his/her pain (no site given) an 8, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 7, staff charted little pain relief; - 3/27/14 at no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 8, staff charted very little pain relief; - 3/28/14 at no time given, the resident rated his/her pain (no site given) a 10, staff gave the resident [MEDICATION NAME] 5/325, staff did not chart pain follow-up; - 3/28/14 at no time given, the resident rated his/her pain (no site given) an 8, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 8, staff charted no relief; - 3/31/14 at no time given, the resident rated his/her pain (no site given) an 8, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain an 8, staff charted the resident complained of pain; - 3/31/14 at no time given, the resident rated his/her pain (no site given) an 8, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5, staff charted the resident was yelling and grimacing; - 3/31/14 at no time given, the resident rated his/her pain (no site given) a 9, staff gave the resident [MEDICATION NAME] 5/325, later the resident rated his/her pain a 5, staff charted the resident complained and grimaced; Review of the resident's pain management sheet, for April 2014, showed: - 4/1/14 at 10:45 A.M., the resident rated his/her pain a 10 and was yelling and crying, no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain 7 while yelling and crying; - 4/1/14 at 8:30 P.M., the resident rated his/her pain a 10 and refused cares, no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain 4; - 4/3/14 at 10:30 A.M., the resident rated his/her pain an 8 and said "I hurt", no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain 5; - 4/4/14 at 8:20 P.M., the resident rated his/her pain an 8 and said "I hurt", no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain 5; - 4/4/14 at no time given ,the resident rated his/her pain a 10 and yelled, no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain an 8; - 4/5/14 at no time given ,the resident rated his/her pain a 10 and grimaced, no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain a 5; - 4/5/14 at no time given ,the resident rated his/her pain a 10 and yelled, no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain a 7; - 4/6/14 at no time given ,the resident rated his/her pain a 10 , no source of pain mentioned, staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain a 5; - 4/7/14 at no time given ,the resident rated his/her leg pain an 8-9 , staff gave the resident [MEDICATION NAME] 5/325 orally, later the resident rated his/her pain a 5. Record review of the medical record showed: - The resident went to the hospital on [DATE], to receive a second amputation of the left lower extremity related the condition of the wound. During an interview on 4/9/14, at 9:00 A.M., Unit Manager, Licensed Practical Nurse (LPN) G said: - The resident did have constant pain and the family finally allowed staff to give [MEDICATION NAME] at the family's discretion; - The resident did have [MEDICATION NAME] ordered at one time but the family refused staff to give it to him/her, so it was discontinued; - She did not meet with the care plan team or the physician since the resident returned from the hospital but she did attempt to educate the family on the importance of pain control. During an interview on 4/9/14, at 9:40 A.M., Certified Nurse Aide (CNA) D said: - The resident did have excruciating pain anytime staff moved him/her; - Once or twice a day the resident would yell and cry out in pain when staff moved the resident; - Staff repositioned the resident on a minimum of six times daily on the day shift and eight times a day on bath days, two times a week; - Sometimes the resident requested pain medication and he/she would notify the nurse. During an interview on 4/9/14, at 9:50 A.M., Certified Medication Technician Aide (CMT) C said: - The resident complained of pain in left shoulder and leg at least two or three times daily; - Usually each time he/she came in contact with the resident to give medications; - Family would allow him/her to give the resident Tramodal but the nurse gave [MEDICATION NAME] and they did not want the resident to always have it; - The [MEDICATION NAME] only helped with the shoulder pain, bringing it down to a pain level of four; - She appeared to be in constant pain from the unrelieved leg pain. During an interview on 4/9/14, at 10:00 A.M., CNA K said: - The resident complained of pain in left leg; - Complained of pain and yelled out he/she hurt anytime staff adjusted the resident's position; - Would not eat meals at times related to pain and made the statement he/she did not want to be in constant pain. During an interview on 4/9/14, at 11:20 A.M., Unit Manager, LPN G said: - The [MEDICATION NAME] would cover the resident's shoulder pain but never covered the resident's leg pain; - The resident always had pain, even after receiving [MEDICATION NAME]; - He/she attempted to discuss [MEDICATION NAME] as a option for pain control but the family refused; - They frequently refused pain medication before dressing changes; - She did not call the doctor with the ongoing pain issues because Family member C refused the pain medication anyway; - Family member B could decline the pain medication because he/she was the Durable Power of Attorney (DPOA); - Family Members C and D would be in the resident's room and the resident would say over and over again that it hurts and they would not allow staff to give the pain medication; - The resident's pain issues started before the resident's leg amputation. During an interview on 4/9/14, at 11:45 A.M., LPN F said: - He/she cared for the resident since admission; - Either FM C or D are at the resident's bedside around the clock; - Family member D was more relaxed around the resident; - Family member C hindered care's such as pain management, dressing changes, and repositioning in bed; - He/she felt very concerned about the resident's pain and recently the resident bone stuck at least three inches out of the wound; - He/she continues education with the family on pain management and got the [MEDICATION NAME] increased to two tabs every four hours but the family only allowed staff to give one tablet; - Sometimes the resident cried out in pain and the family would only allow staff to give staff to give [MEDICATION NAME]; - The resident did have constant pain and it became worse with movement; - The resident said daily it hurt and asked staff why it hurt so bad; - The pain increased from the beginning of his/her stay from around a 3 on a pain scale of 0 to 10 to a 10 before he/she went to the hospital for a second amputation on 4/8/14; - Cried out and moaned in pain daily the last four to six weeks; - The resident begged and pleaded for him/her not to do the dressing change because the family members did not always allow pain medication prior to the dressing change; - He/she changed the resident's dressing anyway because the family had the authority to decline the pain medications as the DPOA; - He/she didn't call the physician about the pain because the family refused the pain medication; - He/she did discuss the pain issue with the Director of Nurses (DON); - The pain affected the resident's mood, and activities, did not want to get out of bed and the resident's appetite. During an interview, on 4/9/14 at 4:00 P.M. the DON said: - She did not know the family did not allow the resident to always have pain medicine; - She knew last week the family only allowed the resident to have one pain pill; - If the resident needed something stronger than [MEDICATION NAME] the nursing staff talked with the family to see if they could give the resident something stronger; - The resident was very capable of telling staff his/her wants and needs; - Staff should have held a pain meeting to discuss the issues related to the resident's pain and the doctor should have been included in the discussion; - Staff should have reported the resident's pain to her and she would have taken care of it. During an interview on 4/9/14, at 4:30 P.M., Administrator said: - He received several calls after hours about the family's refusal of things but none of the calls concerned pain issues; - He told staff to follow the family's request related to their authority as Durable Power of Attorney; - He did have a family meeting several months ago to discuss these issues with the family; - He would expect the nurse to call the physician if the resident did not have pain relief and the family refused pain medication; - If the family continued to refuse pain medication, the doctor should be involved and if that did not work then he would discuss discharge and reporting the family to the state; - Pain should have been discussed in the weekly wound meeting. During an interview, on 4/10/14 at 11:00 A.M. the DON said: - Certified Medicine Technicians (CMT) charted on the as needed (prn) flow sheets only; - CMT's were not trained to assess pain using a pain scale; - CMTs cannot give schedule II narcotics, such as [MEDICATION NAME]; - Licensed staff gave schedule II narcotics; - Licensed staff charted resident pain according to a facility pain scale. During an interview on 4/10/14, at 11:00 A.M., the Speech Therapist said: - She did therapy with the resident during a certification period at the end of last year; - The resident did complain of pain but did not appear to be in pain; - She did see the resident nine times since 3/26/14, and the resident did not have a good attention span, [MEDICATION NAME] less than ten minutes with cueing; - She did not perform any physical therapy with the resident but felt the resident did not have the ability of communicate his/her pain appropriately; - She did not feel the resident had pain and her assessments are more accurate related to the resident's lack of ability to communicate pain appropriately; - She heard the family refuse to allow staff to give pain medications; - They said it would snow the resident; -The family made the d