Every finding on record at Stillwater Creek Skilled Nursing and Therapy

Based on record review and interview, the facility failed to notify the physician of a resident leaving AMA for 1 (#4) of 1 sampled resident reviewed for leaving the facility AMA. The administrator identified 62 residents resided in the facility. Findings: Resident #4 had diagnoses which included alcohol abuse, other psychoactive abuse with intoxication, chronic heart failure, anxiety, depression, and anemia. A late entry progress note, dated 11/25/24, showed Resident #4 left the facility under the care of their friend and all medications were in the resident's possession. There was no documentation Resident #4's physician was notified the resident left AMA. On 03/04/25 at 4:14 p.m., the administrator was asked if Resident #4's physician was notified the resident left AMA, or if there was any documentation the physician was notified. The administrator stated there was no documentation. On 03/04/25 at 4:20 p.m., corporate nurse consultant #1 was asked if the facility had a policy or procedure for a resident leaving AMA. They stated, No.

Based on record review and interview the facility failed to notify the physician when fingerstick blood sugar results were greater than 501 for one (#57) of one sampled resident reviewed for change in condition. The Administrator identified 66 residents resided in the facility. Findings: A Resident's Family or Physician Notification of Change Guideline policy dated 12/01/09, read in part .The facility will .consult with the resident's physician .of the following events .A need to alter treatment significantly. (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . Resident #57 had diagnoses which included, heart failure and type two diabetes mellitus. A physician order, dated 01/10/24, documented to administer Humalog Insulin subcutaneously before meals and at bedtime per sliding scale. Resident #57's January and February 2024 MAR documented the resident was to be administered the following insulin on a sliding scale: .Humalog Injection inject per sliding scale: If 0-60 = 0 units, Give glucose recheck in 15 mins if still below 60 call MD; 61-149 = 0 units; 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units; 451-500 = 14 units; 501-999 = 16 units Call MD, subcutaneously before meals and at bedtime . The clinical health record did not contain documentation the physician had been notified of the fingerstick blood sugar results on the following days; a. On 01/27/24 FSBS was 528, b. On 01/28/24 FSBS was 501 at 11 am, and 545 at 9 pm, c. On 02/1/24 at 4 p.m. FSBS was 556, d. On 02/5/24 at 4:00 p.m., FSBS was 501, and e. On 02/10/24 at 11:00 a.m., FSBS was 544. On 03/14/24 01:46 p.m., LPN #2 was asked where would the documentation be if the physician had been notified regarding an elevated fingerstick blood sugar. They stated it should generate a progress note. On 03/14/24 02:27 p.m. the Corp Nurse Consult #1 was shown the January MAR and asked if there was any documentation the physician had been notified regarding the results greater than 501 on the following days: 01/27/24 FSBS was 528, and on 01/28/24 FSBS was 501 at 11 am, and 545 at 9 pm. The corporate nurse stated there was no documentation the physician had been notified. On 03/14/24 02:28 p.m., the Corp. Nurse Consult #1 was shown the February 2024 MAR and asked if there was any documentation the physician had been notified regarding the results greater than 501 on the following days: On 2/1/24 at 4 p.m. FSBS was 556, on 2/5/24 at 4:00 p.m., FSBS was 501, and on 2/10/24 at 11:00 a.m., FSBS was 544. They stated they did not see any nursing documentation the physician had been notified.

Based on record review and interview, the facility failed to ensure: a. behavior and side effect monitoring was conducted for the use of psychotropic medications for one (#127), and b. PRN antianxiety medications were limited to 14 days for one (#9) of five sampled residents reviewed for unnecessary medications. Corporate Nurse Consultant #1 identified 11 residents had orders for routine psychotropic medications and six residents had orders for PRN antianxiety medications. Findings: A Medications Requiring Behavior and Effect Monitoring policy, dated 10/25/21, read in part, .Antipsychotics .required monitoring .Targeted Behaviors, Side Effects .quetiapine . 1. Res #127 had diagnoses which included dementia with other behavioral disturbance. A physician's order, dated 03/04/24, documented quetiapine fumarate (antipsychotic medication) 100 mg. Give one tablet by mouth at bedtime. End date 03/06/24. A physician's order, dated 03/06/24, documented quetiapine fumarate 150 mg. Give 0.5 tablet by mouth bedtime for three days. End date 03/09/24. A physician's order, dated 03/10/24, documented quetiapine fumarate 50 mg. Give one tablet by mouth bedtime for three days. End date 03/13/24. There was no documentation behaviors and side effect were monitored 03/04/24 through 03/12/23. On 03/14/24 at 11:24 a.m., the administrator was asked to provide behavior and side effect monitoring for 03/04/24 through 03/12/24 for the use of quetiapine fumarate. On 03/14/24 at 12:25 p.m., the administrtaor stated there was no documentation behaviors and side effects were monitored. They stated they should have been monitored. They stated it was overlooked. 46387 2. Res #9 had diagnoses which included anxiety disorder. A physician order, dated 04/13/23, documented to administer Ativan oral tablet 0.5 mg every 12 hours as needed for anxiety. A monthly medication review, dated 05/01/23, documented the pharmacist's request to add a stop date to the as needed Ativan order per regulations. There was no documented stop date to the order until 08/05/23. A MAR for May 2023 documented Res #9 received the as needed Ativan 33 times. A MAR for June 2023 documented Res #9 received the as needed Ativan 25 times. A MAR for July 2023 documented Res #9 received the as needed Ativan 29 times. A MAR for August 2023 documented Res #9 received the as needed Ativan four times. The order was discontinued on 08/05/23. On 03/14/24 at 3:00 p.m. Corporate consult RN #1 stated a 14 day stop date was not added to the order.

Based on record review and interview the facility failed to obtain laboratory studies as ordered for one (#5) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility. Findings: Res #5 had diagnoses which included hypokalemia. A lab result, dated 06/20/23, documented Res #5 had a low potassium level. A handwritten note on the result documented the nurse practitioner was notified, and a new order was received to administer potassium 10 meq and repeat CMP on 6/26/23. A nurse progress note, dated 6/23/2023 at 12:33 p.m., documented a focused assessment related to labs. CBC, CMP and lipid panel sent to nurse practitioner for review. New orders to give KCL 20 meq now and repeat CMP on Monday 06/26/23. On 03/12/24 at 4:08 p.m., the missing labs were requested from the ADON. On 03/15/24 at 9:14 a.m., the administrator stated it was their understanding that the facility was unable to locate documentation for the repeat lab on 6/26/23.

Based on observation, record review, and interview, the facility failed to prevent development of new pressure ulcers for one (#15) of one sampled residents reviewed for pressure ulcers. Corporate consult RN #1 identified six residents resided in the facility with pressure ulcers. Findings: Res #15 had diagnoses which included quadriplegia, pressure induced deep tissue damage of left heel, and pressure ulcer of sacral region stage IV. A physician order, dated 02/12/24, documented heel lift boots in place every shift for wound prevention. A care plan, reviewed 02/13/24, documented Res #15 was to have heel lift boots in place every shift, and staff were to float heels with pillows while in bed. A weekly skin evaluation, dated 03/11/24 at 11:08 a.m., documented Res #15 had no new skin issues. On 03/12/24 at 9:15 a.m., Res #15 was observed in bed on their back. Both feet were observed without any pressure relieving devices in place. The resident's bare feet were observed pressed into the footboard of the bed. The right great toe, second toe, and third toe were observed curling under from pressure/contact with the footboards. No offload or pressure reducing devices were observed in the resident's room. On 03/12/24 at 12:15 p.m., Res #15 was observed during medication administration. The resident's bare feet continued to be pressed against the footboard without any offload/pressure reduction devices in place. A nurse progress note, dated 03/12/24 at 5:10 p.m., documented a post-wound assessment of the sacral wound. The note documented the left heel deep tissue injury was stable. The note did not document any new discoloration or pressure injuries. On 03/13/24 at 9:53 a.m., wound nurse #1 was observed providing ordered wound care for Res #15. The resident was observed to have a new purple area to right great toe. The nurse was made aware and stated they would have to contact the provider. A nurse progress note, dated 03/13/24 at 10:22 a.m., documented a new purple discoloration was noted to left great toe. The note documented the resident also had a new purple area to the right heel. On 03/13/24 at 11:33 a.m., CNA #3 stated the resident was supposed to wear offload boots daily. They stated if they were not in place they were to notify the nurse. They stated they could not recall if they were in place yesterday. On 03/13/24 at 11:37 a.m., LPN #1 stated the nurses and aides were responsible for ensuring the pressure reduction devices were in place. They stated they had noticed yesterday the boots were not in place and had not located them in the room. They stated they meant to go get them and place them on the resident but did not. They stated they did not notify anyone the offload boots were not in place.

Based on observation, record review, and interview, the facility failed to obtain orders for continuous oxygen and failed to ensure oxygen tubing was changed and dated per physician orders for two (#1 and #9) of two sampled residents reviewed for oxygen administration. Corporate consult RN #1 identified 13 residents received oxygen in the facility. Findings: 1. Res #1 had diagnoses which included COPD. A physician order, dated 11/17/22, documented to administer oxygen at 2 liters per minute as needed to maintain oxygen saturation above 89%. A physician order, dated 11/17/22, documented to change oxygen tubing and humidifier bottle monthly on the 15th on night shift. The order documented to date tubing. A quarterly MDS, dated [DATE], documented Res #1 was cognitively intact. On 03/11/24 at 12:22 p.m., Res #1 was observed in bed with oxygen being administered via nasal cannula from a concentrator. The tubing was observed without a date indicating when it was last changed. The humidification bottle on the concentrator was observed without a date indicating when it was last changed. The oxygen was observed to be set at 2 liters per minute. The resident stated they required oxygen most of the time to ensure their levels remained up. They stated they felt they needed the oxygen continuously. They stated they were unsure the last time the tubing and humidification bottle was changed. On 03/12/24 at 11:41 a.m., Res #1 was observed in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 4 liters per minutes. On 03/12/24 at 3:16 p.m., LPN #1 was asked to accompany the surveyor to Res #1's room. The LPN stated the oxygen concentrator was set at 4 liters per minutes. The LPN reviewed the resident's orders and stated there was not an order for continuous oxygen. They stated the as needed order was for 2 liters per minute. 2. Res #9 had diagnoses which included COPD. A physician order, dated 09/06/23, documented to administer oxygen via nasal cannula at 2 liters per minute as needed. A physician order, dated 11/15/23, documented to change oxygen tubing and humidifier bottle monthly on the 15th on night shift. The order dated to date the tubing. A significant change MDS, dated [DATE], documented Res #1 was cognitively intact. On 03/11/24 at 12:56 p.m., Res #1 was observed seated in bed. The resident was observed with oxygen being delivered via nasal cannula from a concentrator. The concentrator was observed set at 3 liters per minute. A portable oxygen tank on the resident's wheelchair was observed set at 3.5 liters per minute. The tubing attached to the concentrator was not dated. The humidifier bottle on the concentrator was not dated. The tubing attached to the portable bottle on the wheelchair was not dated. The resident stated they required oxygen all the time. They stated their oxygen tubing had never been changed. They removed the tubing from their nose and pointed out the cannula was discolored. The cannula was observed with a slight yellow tinge to the tubing. A physician order, dated 03/13/24, documented to administer oxygen at 3 liters per minute continuously. On 03/13/24 at 1:18 p.m., Res #9 was observed transferring self from wheelchair to bed. The resident's portable oxygen was observed set at 2 liters per minute. The bedside concentrator was observed set at 2 liters per minute. On 03/14/24 at 10:35 a.m., LPN #1 stated the order for continuous oxygen was obtained after they had noted the resident only had orders for as needed oxygen. The LPN stated the resident had recently been requiring the oxygen all the time. The LPN stated the oxygen was ordered at 3 liters per minute.

Based on record review and interview, the facility failed to ensure there was ongoing assessment of a resident on dialysis for one (#54) of one sampled resident reviewed for dialysis services. The administrator identified two residents received dialysis services. Findings: A Guidelines for Dialysis After Care policy and procedure, dated 07/11/12, read in part, .Inspection of the AVF .access and entire access extremity including hands or feet .Presence/absence or thrill and/or bruits .Signs and Symptoms of infection .Bruising and/or bleeding .Peripheral Pulses .Erosion of Skin or Sores over access site .Post dialysis dressing removal includes .Dressing should be removed 4 hours after dialysis treatment . Res #54 had diagnoses which included ESRD. Physician orders, dated 02/02/24, documented, dialysis Tuesday, Thursday, and Friday; check AVF for thrill and bruit every shift. If absent notify the physician; monitor AVF for s/s of trauma and/or infection every shift; and remove AVF dressing four hours after dialysis treatment. The February and March 2024 dialysis communication forms and skilled nurses' notes were reviewed. There was no documentation 20 out of 58 opportunities the AVF was checked for thrill and bruit, monitored for s/s of trauma, and/or infection every shift. There was no documentation seven out of 13 opportunities the AVF dressing was removed four hours after dialysis treatment. On 03/12/24 at 12:46 p.m., the ADON was asked where it was documented when a resident on dialysis had physician orders for ongoing assessment. They stated it would be documented on the TAR. They stated they would check the TARs for Res #54. On 03/12/24 at 12:58 p.m., the ADON stated they used the dialysis communication form consistently to document everything. They were made aware the form did not document the resident being checked for thrill and bruit each shift, monitored for s/s of trauma and/or infection each shift, or the dressing changed after dialysis. On 03/12/24 at 1:04 p.m., the ADON stated the daily skilled nurses' notes documented they monitored for dialysis management. They were asked what it indicated when the dialysis management box was checked. They stated it meant they assessed the resident. On 03/12/24 at 1:17 p.m., corporate nurse consultant #1 stated they had daily skilled nurses notes documenting dialysis management. They stated they followed policy for monitoring, but not for following physician orders to monitor each shift.

Based on observation, record review and interview, the facility failed to ensure medications were administered according to physician orders for one (#12) of five sampled residents reviewed for unnecessary mediations. The administrator identified 66 residents resided in the facility. Findings: Res #12 had diagnoses which included diabetes, coronary artery disease, and hypertension. A physician order, dated 09/14/23, documented to administer insulin glargine subcutaneous solution 20 units subcutaneously two times a day for diabetes at 6:00 a.m. and 9:00 p.m. A physician order, dated 09/14/23, documented to administer insulin aspart subcutaneous solution per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12; 451 - 999 = 12 For FSBS greater than 450, give 12 units and notify MD for further instructions before meals and at bedtime related to diabetes. A physician order, dated 11/23/23, documented to administer Victoza subcutaneous solution 1.2 mg one time per day at 6:00 a.m. for diabetes. A physician order, dated 12/09/23, documented to administer amlodipine besylate oral tablet 10 mg one time per day for hypertension. The order documented to hold the medication if the systolic blood pressure was below 110, the diastolic blood pressure was below 60, or the pulse was below 60. A physician order, dated 12/09/23, documented to administer losartan potassium oral tablet 50 mg one time per day for hypertension. The order documented to hold the medication if the systolic blood pressure was below 110, or the diastolic blood pressure was below 60. A physician order, dated 12/09/23, documented to administer carvedilol oral tablet 6.25 mg two times per day for hypertension. The order documented to hold the medication if systolic blood pressure was below 110, diastolic blood pressure below 60, or pulse below 60. A quarterly MDS, dated [DATE], doucmented the resident was cognitively intact. A MAR for January 2024 documented Res #12's blood pressure was 128/57 on 01/04/24, 125/57 on 01/08/24, 163/50 on 01/10/24, and 139/49 on 01/20/24. The MAR documented Res #12 received their amlodipine on 01/08/24, 01/10/24, and 01/20/24. The MAR documented Res #12 received their losartan on 01/20/24. The MAR documented Res #12 received the carvedilol on 01/04/24, 01/10/24, and 01/20/24. An insulin administration record for January 2024, documented Res #12's Victoza was administered greater than one hour after the prescribed administration time on 01/24/24 and 01/28/24. The administration record documented the insulin glargine was administered greater than one hour after the prescribed time for the 6:00 a.m. dose on 01/10/24, and 01/28/24. The administration record documented the 4:00 p.m. dose of insulin aspart was administered greater than one hour after prescribed time on 01/04/24. The record documented the 6:00 a.m. dose was administered greater than one hour after the prescribed time on 01/05/24. The insulin aspart 01/05/24 4:00 p.m. dose was blank. A MAR for February 2024 documented Res #12's blood pressure was 139/49 on 02/10/24. The MAR documented Res #12 received the carvedilol on 02/10/24. An insulin administration record for February 2024, documented Res #12 Victoza was administered greater than one hour after the prescribed administration time on 02/01/24, 02/07/24, and 02/17/24. The administration record documented the insulin glargine was administered greater than one hour after the prescribed time for the 6:00 a.m. dose on 02/07/24, and 02/17/24, and the 9:00 p.m. dose was administered greater than one hour after the prescribed administration time on 02/13/24. An insulin administration record for March 2024, documented Res #12's Victoza was administered greater than one hour after the prescribed administration time on 03/03/24, 03/09/24, and 03/10/24. The administration record documented the insulin glargine was administered greater than one hour after the 6:00 a.m. prescribed time on 03/03/24 and 03/09/23. The administration record documented the 9:00 p.m. dose of insulin glargine on 03/10/24 was not administered. On 03/11/24 at 11:45 a.m., Res #12 was observed in their room in the bed. The resident stated they often received their medications late. On 03/14/24 at 9:59 a.m. CMA #2 stated the blood pressure medications should have been held on the above dates because the blood pressure was out of parameters. On 03/14/24 at 10:09 a.m. LPN #1 stated insulin can be administered an hour before to an hour after the prescribed time. They were shown the above dates and stated the insulin was administered late. They stated the blanks on the MAR meant the medication was not given.

Based on record review and interview the facility failed to monitor for side effects related to the use of Warfarin for one (#62) of one sampled resident reviewed anticoagulant use. The Administrator identified 66 residents resided in the facility. Findings: Resident #62 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction. September, October, November, December and January MAR's documented Resident #62 had been administered Warfarin as ordered by the physician. The clinical health record did not document Resident #62 had been monitored for side effects related to the use of Warfarin from 09/08/23 through 01/22/24. Resident #62's TAR, dated 01/22/24, read in part .Monitor: Nose/gum bleeding, coughing or bloodtinged sputum, hematuria, black/tarry stools, vomiting of blood or coffee ground-like material, abnormal or excessive bruising, low b/p, Change in cognition, cyanosis, every shift for anti-coagulation therapy Warfarin . On 03/12/24 at 02:21 p.m. the Corp. Nurse Consultant #1 was asked if Resident #62 had been monitored for side effects in the months of September, October, November, and December 2023. They stated there were no orders to monitor for side effects until January 2024.

Based on record review and interview, the facility failed to ensure a medication regimen review was responded to timely for one (#9) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility. Findings: Res #9 had diagnoses which included bipolar disorder, insomnia, and depression. A physician order, dated 09/07/23, documented to administer Zoloft oral tablet 50 mg one time per day for depression. A physician order, dated 09/07/23, documented to administer Abilify oral tablet 2 mg one time per day for bipolar disorder. A physician order, dated 10/18/23, documented to administer Trazodone HCL oral tablet 300 mg at bedtime for bipolar disorder. A monthly medication review, dated 12/18/23, documented the pharmacist request to attempt a gradual dose reduction of the residents Zoloft, Abilify, or trazodone. The medication review was not documented as responded to until 02/12/24 in which the physician declined the GDR. On 03/14/24 at 2:51 PM, Corporate consult RN #1 stated if there is not a response within 30 days to a monthly medication review the facility must go to the medical director.

Based on record review and interview the facility failed to update a care plan with smoking interventions for one #57) of one sampled resident reviewed for smoking. The Administrator identified 66 residents resided in the facility and the list of smoking residents documented eleven residents smoked. Findings: A Smoking Policy and Procedure revised 02/24/20, read in part .To offer the resident the ability to smoke free of danger to self and others .The resident may choose to utilize an electronic cigarette .physicians should be notified to appropriately update care plan and set goals for residents regarding smoking habits . Resident #57 had diagnoses which included, heart failure and type two diabetes mellitus. Resident #57's care plan did not have any interventions or safety measures implemented for smoking. On 03/11/24 at 12:59 p.m., Resident #57 was asked if they smoked. They stated that they were and was able to smoke when they wanted. On 03/12/24 12:44 p.m., the Administrator was asked if Resident #57 was a smoker. They stated the resident had signed a smoking contract, had started smoking cigarettes and had used electronic cigarettes vaped when they admitted . On 03/14/24 11:55 a.m., the corporate nurse was shown the care plan and asked if there were any interventions for smoking. They stated No. They were asked if the care plan should identify the resident as a smoker. They stated if the resident is a smoker it should be care planned. On 03/12/24 12:45 p.m. the corporate nurse was shown the smoking assessment ,dated 02/02/24, and stated the assessment documented the resident was a smoker and it should have been care planned.

Based on record review and interview, the facility failed to complete a significant change assessment for a resident with declines in ADLs for one (#48) of two sampled residents reviewed for ADLs. The administrator identified 66 residents resided in the facility. Findings: An annual MDS, dated [DATE], documented Res #48 had no functional impairments in range of motion. The MDS documented Res #48 required setup/cleanup assistance with upper body dressing. The MDS documented Res #48 required supervision with walking 10 feet. The MDS documented Res #48 required partial/moderate assistance with lower body dressing and applying and removing footwear. A quarterly MDS, dated [DATE], documented Res #48 had declined in range of motion and had impairments of upper and lower extremities on both sides. The MDS documented Res #48 had declined in their ability to perform toileting hygiene, and showering/bathing self and required partial/moderate assistance. The MDS documented Res #48 was newly dependent with upper and lower body dressing, and applying/removing footwear. The MDS documented Res #48 was newly dependent with walking 10 feet. On 03/13/24 at 2:03 p.m., corporate MDS coordinator #1 stated the significant change had been missed and should have been completed.

Based on record review and interview, the facility failed to ensure the OHCA was notified after a resident received a significant mental health diagnoses for two (#17 and #37) of three residents reviewed for PASRR. The Resident Census and Conditions of Residents report, documented 72 residents who reside in the facility. Findings: 1. Res #17 was admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and anxiety disorder. On 02/28/19, a new diagnosis of psychotic disorder with delusions due to known physiological condition was documented in the resident's diagnoses in the medical record. On 01/27/23 at 10:15 a.m., the DON and corporate nurse consultant #1 stated the OHCA should have been called after the new diagnoses was added on 02/28/19. 2. Res #37 admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and anxiety disorder. On 12/03/21, a new diagnosis of delusional disorder was documented in the resident's record. On 01/27/23 at 10:16 a.m., the DON and corporate nurse consultant #1 stated the OHCA should have been called after the new diagnoses was added on 12/03/21.

Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for two (#6 and #11) of 23 residents whose care plans were reviewed. The facility failed to develop a care plan: a. related to wandering behaviors for Res #11 and b. related to ADL care including refusals to bathe for Res #6. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility. Findings: 1. Res #6 was admitted to the facility on [DATE] and had diagnoses which included dementia, Parkinson's disease, and seizures. The admission MDS, dated [DATE], documented the resident's cognition was severely impaired, required assistance with ADLs, had not bathed in the last seven days, and had no rejection of care behaviors. On 01/23/23 at 3:53 p.m., Res #6 was observed in her room in bed. The resident was asked if they were getting their baths as scheduled. The resident stated they had not had a bath in five weeks. The resident's bathing record documented the resident was scheduled for a bath on Tuesday, Thursday, and Saturday on the evening shift. The bathing record for the last 30 days documented the resident refused eight showers, received seven showers, and missed two showers out of 14 opportunities. The resident's current care plan was reviewed and did not contain a care plan for ADL care, bathing, or rejection of care behaviors. On 01/25/23 at 4:41 p.m., CNA #2 stated the resident did refuse showers often. On 01/27/23 at 12:22 p.m., the corporate MDS nurse stated the resident should have had a care plan for ADL care and for rejection of care. 46909 2. Resident #11 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, bipolar disorder, and unspecified anxiety disorder. A quarterly assessment, dated 12/03/22, documented the resident was cognitively impaired; had behavioral disturbances; and required assistance with activities of daily living; and had no impairment in the upper and lower extremities. On 01/23/24 at 1:00 p.m., Res #11 was observed wandering throughout the facility. On 01/24/23 at 10:00 a.m., Res #11 was observed wandering throughout the facility. A record review of the resident's care plan was completed and there was no care plan for wandering. On 01/26/23 at 5:00 p.m., an interview was conducted with the DON. She stated that the care plan did not include wandering, but should have. .

Based on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for six (#2, 17, 21, 23, 30, and #124) of six residents reviewed for ADL care. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included COPD, dementia, and depressive disorder. A care plan, last revised 11/11/22, documented bathing Tuesday, Thursday, Saturday on the 3-11 shift. Res #2 required one to two staff participation with bathing. Provide Res #2 with a sponge bath when a full bath or shower cannot be tolerated. Res #2 will often refuse showers. A five day assessment, dated 01/03/23, documented the resident was intact with cognition and required extensive assistance with bathing. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. The resident should have received 13 baths during the 30 day time frame. There were two documented baths, six refused baths, and five scheduled baths that were not documented for the resident. On 01/23/23 at 2:38 p.m., Res #2 stated the facility did not have enough staff with only one aide on the hall and they were run ragged. She stated she had to wait an hour for some one to get her water. She stated she did not get any baths last week. Resident #2 stated she was dependant on staff for her care. On 01/24/23 a skin monitoring shower review sheet, documented the resident refused a bath. This form was signed by the charge nurse that she was aware the resident refused a bath on 01/24/23. There were no other shower sheets that documented the resident had a shower or refused a bath. On 01/25/23 at 3:56 p.m., Res #2 stated she had refused bathing because she had one staff member she liked to bath her. Res #2 stated she did not think the staff had asked six times to bath her in the past 30 days. Res #2 stated she really did not like bed baths and preferred a staff member to take her to the shower. On 01/25/23 at 4:11 p.m., CNA #4 stated the facility did not have enough staff to get everything done. CNA #4 stated the facility needed two CNAs per hall. CNA #4 stated if someone called in no one else usually took their place. CNA #4 stated the baths were not getting done because there was not enough staff. CNA #4 stated they did try to get to the call lights as quick as they could, 10 to 15 minutes was the standard time. The CNA stated it was a struggle when we had to use the lift because another staff had to help. CNA #4 stated Res #2 will refuse a bath most of the time, but the staff can usually talk her into taking a bed bath most of the time. On 01/25/23 at 4:24 p.m., CNA #2 stated when a resident refused a bath the staff should give the resident another option or wait a little while and go back and ask again. CNA #2 stated if they still refuse a bath they are to tell the charge nurse and the nurse will go talk to the resident to see if the resident will take a bath. She stated resident #2 refused baths very frequently. She was pretty hit or miss on taking a bath. CNA #2 stated if the resident's sister did not want a bath then Res #2 would say no also. CNA #2 stated the staff member the resident wanted to bath her probably could get the resident to bathe, she worked evening and weekend shifts. 2. Res #21 had diagnoses which included respiratory failure with hypercapnia, neuropathy, and chronic pain. A quarterly assessment, dated 01/11/23, documented the resident was intact with cognition and required total assistance with bathing. The assessment documented the resident had rejected care during the look back period. A care plan, last reviewed 01/17/23, documented if the resident refused care, staff should re-attempt care at a different time if possible with a different staff member. Res #21 required total assistance for bathing when the resident wanted to bathe. Baths were scheduled Monday, Wednesday, and Friday on the 3-11 shift. The EHR bathing documentation for the last 30 days had the resident scheduled for bathing on Monday, Wednesday, Friday on the 3-11 shift and PRN. Two baths were documented as refused and one day was documented the resident was not available. From 12/27/22 to 01/24/23 the resident was scheduled for 12 baths. The resident had no documented baths during these dates. On 01/24/23 at 11:00 a.m., Res #21 stated they did not get baths as scheduled. Baths were few and far between. Res #21 stated she would rather get up and go to the shower than get a bed bath. On 01/25/23 at 4:17 p.m., CNA #4 stated when CNA #2 worked, she would make sure Res #21 was bathed. On 01/25/23 at 4:35 p.m., CNA #2 stated Res #21 would let her bathe the resident. Res #21 was very modest and had a lot of pain. CNA #2 stated when the resident had her pain medication she was more up for taking a bath and was a two person assist with her bathing. CNA #2 stated the staff also should complete a shower sheet besides documenting in the EHR. She stated the shower sheets where then turned in to the charge nurse. On 01/25/23 at 4:55 p.m., LPN #1 stated the CNA should fill out a skin monitoring shower review. If a resident refused a bath the CNA should document refused and then let the charge nurse know. LPN #1 stated the form then goes in the skin wound book until the corporate nurse took them out. 3. Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. An annual assessment, dated 12/21/22, documented the resident was intact with cognition and required extensive assistance with bathing. A care plan, last reviewed 12/27/22, documented the nurse was to ensure the resident was taking showers as scheduled. If the resident refused for the CNA, the nurse was to attempt. The EHR bathing documentation for the last 30 days had the resident scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. Res #30 had 13 scheduled baths and none were documented as given. The bathing record documented four unscheduled baths as refused. On 01/27/23 at 2:15 p.m., LPN #1 stated she was not able to find any bathing shower sheets for Res #30. On 01/27/23 at 2:20 p.m., the DON stated she was not aware of all the resident refusals regarding bathing. 46909 4. Res #17 had diagnoses which included cervical spina bifida with hydrocephalus, recurrent depressive disorder, psychotic disorder with delusions, and anxiety disorder. A quarterly assessment, dated 11/08/22, documented the resident was cognitively intact and required moderate to extensive assistance with ADLs. The resident's bathing record, from 12/21/22 to 01/20/23, documented the resident had a bath/shower two times. On 01/24/23 at 7:46 a.m., Res #17 stated she had gone two weeks without a bath and/or shower. The resident stated it took too long for the aides to answer the call lights. On 01/25/23 at 5:33 p.m., LPN #1 stated the resident would only allow certain females to give her a bath. On 01/25.23 at 4:11 p.m., CNA #4 stated she worked day shift and most of the time there was not enough staff to finish everything. She stated there needed to be two aides on each hall but at this time there was only one on each hall and an aide that floats between halls. 29358 5. Res #124's admission MDS assessment, dated 12/08/22, documented the resident was cognitively intact, required the assistance of two people with bathing, and had no rejection of care behaviors, The resident's bathing record documented the scheduled times for bathing were Tuesdays, Thursdays, and Saturdays. The record documented for the last 30 days, the resident had 14 opportunities for bathing. The record documented the resident received three showers, refused eight times, and missed three showers. On 01/23/23 at 5:27 p.m., the resident was asked if she received her baths as scheduled. The resident stated sometimes they skip her. She stated she has not had a bath in two weeks. The resident's hair was observed to be greasy and separated. On 01/25/23 at 4:15 p.m., the resident was asked if she ever refused to take her baths. The resident stated the only time she had refused was when they came to take her to the shower at 8:30 in the evening. She stated she did not want to go to bed with her hair wet. She stated most of the time no one had ever asked her if she wanted a bath. The resident's hair still observed greasy as earlier in the week. On 01/25/23 at 4:30 p.m., LPN #2 stated she just learned this week that the resident had been refusing baths. She stated she was not sure why she was refusing. On 01/27/23 at 2:16 p.m., LPN #1 stated CNAs the process was for the CNA's to fill out a bath sheet for a resident on their bath when they had a shower or when they refused. The LPN could not find any bath sheets for Res #124. On 01/25/23 at 4:41 p.m., CMA #2 stated the resident was easy going with showers and usually would not refuse, but she had not worked her hall recently. On 01/27/23 at 2:19 p.m., the DON stated she was not aware of refusals of bathing and residents not getting bathed as scheduled. 6. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they were hurting and their nose itched. The resident was asked if they could use their call light. They looked over at it and shook their head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what they needed. The resident stated they were hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under their right hand. The CNA at that time put the call light disc under the resident's hand. The CNA then left the room without repositioning the resident and without verbalizing her intent. Immediately after the CNA left the resident's room LPN #3 and LPN #4 entered the room with a tray which contained wound supplies. LPN #4 turned off the call light. The two nurses had a discussion between themselves, picked up the tray from the bedside table, then left the room. On 01/24/23 at 10:41 a.m., LPN #3 and LPN #4 came in the room with the wound supplies. The nurses were observed conducting incontinent care and wound care. On 01/27/23 at 3:02 p.m., the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light.

Based on record review, observation, and interview, the facility failed to obtain blood pressures for one (#30) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. A physician order, dated 05/29/20, documented prazosin 5 mg at bedtime related to hypertensive heart disease with heart failure. Hold if systolic BP <110. A physician order, dated 05/25/21, documented metoprolol ER 50 mg one time a day related to hypertensive heart disease with heart failure. Hold if systolic BP is <110, diastolic BP <60, or pulse <60. A physician order, dated 06/03/21, documented isosorbide 10 mg two times a day related to angina pectoris. Hold for systolic BP <110, diastolic BP <60, or pulse <60. A physician order, dated 11/24/21, documented ranolazine ER 500 mg two times a day related to angina pectoris. Hold if systolic BP < 110 or diastolic BP < 60. An annual assessment, dated 12/21/22, documented the resident was intact with cognition and was independent with most activities of daily living. A care plan, last reviewed 12/27/22, documented to obtain blood pressure readings before giving medications and PRN. The care plan documented to take blood pressure readings under the same conditions each time. The January 2023 MAR documented metoprolol with three days where BP and heart rate were not documented and medication was held. The January 2023 MAR documented for prazosin there was four days the BP was not documented, of those four days, three days the medication was held and one day the medication was administered. The MAR documented there were two other times there were BP's of 127/52 and 116/44 and the medication was held. The order only addressed the systolic blood pressure. The January 2023 MAR documented for isosorbide there were nine times the resident's BP and heart rate were not documented. Seven times the medication was held, one time the medication was refused, and one time the medication was given. The January 2023 MAR documented for ranolazine there were nine times the resident's BP was not documented, was held eight times, and refused one time. On 01/23/23 at 1:52 p.m., Res #30 was observed in his bed. He reported he got dizzy when he got up. On 01/27/23 at 10:17 a.m., the IP stated the BP should be documented on the MAR. She stated if the medication was held there should be documentation of why it was held. On 01/27/23 at 11:48 a.m., the DON stated the resident went out to the hospital quite frequently for chest pains. The DON stated the BP should be documented on the MAR. On 01/27/23 at 12:33 p.m., the DON stated the CMA should let the nurse know when holding a medication. The DON stated the facility did not have a policy on notifying the physician when a medication was held.

Based on record review, observation, and interview, the facility failed to maintain a safe, clean, comfortable, homelike environment regarding wheelchair maintenance and air temperatures. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: 1. On 01/23/23 at 4:02 p.m., Res #13 stated she stayed cold all the time and had to wear multiple layers of clothing to stay warm. Res #13 was observed to have on two coats, two sock hats, the hood from one of her jackets, and a pair of gloves. The temperature was taken in the resident's bathroom and it was 68.2 degrees F. The temperature at the resident bed was 68.0 degrees F. There was a white blanket observed folded up on the window ledge but a draft was still felt coming through the window. On 01/24/23 at 11:44 a.m., Res #13's room temperature at the bed was 59.5 degrees and in the bathroom it was 63.1 degrees. On 01/25/23 at 10:40 a.m., the temperature in Res #13's room was 66.7 degrees at the bed and the bathroom was 65.7 degrees. On 01/25/23 at 10:45 a.m., room [ROOM NUMBER] was 67.8 degrees. In the middle of Hall 100 by the thermostat it was 69.9 degrees. The thermostat was set on 74 and the temperature on the thermostat read 74 degrees. On 01/25/23 at 10:49 a.m., the temperature in room [ROOM NUMBER] was 70.8 degrees. Res #49 stated he got cold at night. The resident had a jacket on and several blankets on his bed. On 01/25/23 at 11:05 a.m., the maintenance man stated he did the air and water temperatures every week randomly. A review of the air temperature logs reveled resident room temperatures were not documented on the log. On 01/25/23 at 4:29 p.m., CNA #2 stated Hall 200 is the warmer hall and Hall 400 was the colder hall. She said the shower rooms in the facility were really cold. She stated Hall 400 had a heater in the shower room and the other hall shower rooms did not. CNA #2 stated the residents have to load up with blankets then they have a hard time getting in and out of bed. On 01/25/23 at 5:59 p.m., the maintenance man obtained the temperature in room [ROOM NUMBER], it was 61.7 degrees. He stated the temperature in the room was chilly. He said there were vents in the shower rooms on all the halls. On 01/25/23 at 6:08 p.m., the maintenance man checked the temperature in Hall 100 shower room. He stated at the window the temperature was 62 degrees. He stated the temperature in the upper corners of the shower room were 66 degrees. On 01/27/23 at 8:37 a.m., the maintenance man stated some rooms were colder around the windows and there was a draft around some of the windows, so it was colder in some of the rooms. 29358 2. Res #6 was admitted to the facility on [DATE] and had diagnoses which included dementia, Parkinson's disease, and seizures. The admission MDS, dated [DATE], documented the resident's cognition was severely impaired, required assistance with ADLs, and used a W/C for a mobility device. On 01/23/23 at 3:55 p.m., Res #6 was observed in her room in bed. The resident's W/C was near the bed. The W/C was missing the entire arm pad on the left side and the right side pad cover had multiple cracks and tears in the material and was rough to the touch. The resident stated it was the facility's W/C and it had been given to her to use upon admittance to the facility. On 01/23/23 at 3:59 p.m., the DON answered the resident's call light. At that time she was asked about the W/C arms missing and in disrepair. She stated the W/C should have been put on the maintenance log to be fixed. 3. Res #124 was admitted to the facility on [DATE] and had diagnoses which included a hip fracture. The admission MDS assessment, dated 12/08/22, documented the resident's cognition was intact and the resident required assistance with ADLs. On 01/23/23 at 5:23 p.m., Res #124 was observed sitting in their W/C. The W/C arm pad on the left was torn and had foam hanging out over the side of the arm pad. The right side pad had multiple cracks and tears and was rough to the touch. The resident stated the chair belonged to the facility and it was like that when they gave it to her to use. On 01/27/23 at 2:19 p.m., the DON stated she had noticed the resident's W/C yesterday and had it sent to maintenance to be repaired. 4. Res #42's admission MDS assessment, dated 11/01/22, documented the resident was cognitively intact and required assistance with ADLs. On 01/24/23 at 12:09 p.m., the resident's rm 411 had a temperature of 66.5 degrees F. The resident stated his room was always cold and even colder at night. The resident was observed in bed covered with blankets. 5. Res #63's quarterly MDS assessment, dated 12/01/22, documented the resident's cognition was moderately impaired and required assistance with ADLs. The assessment documented the resident's diagnoses included CVA and hemiparesis. On 01/25/23 at 11:15 a.m., the resident's rm 407 had a temperature of 63.7. The resident had a T-shirt on and stated he was not cold. On 01/25/23 at 11:17 a.m., CMA #2, came in the room while the temperature was being measured. The CMA was asked if the residents had complained of their rooms being too cold. The CMA stated residents had complained about their rooms being cold. The CMA stated they were supposed to log the concern in the computer system for maintenance to address. On 01/25/23 at 11:18 a.m., an observation was made of the Hall 400 thermostat with a reading of 74 degrees. 6. Res #40's quarterly MDS assessment, dated 10/11/22, docuented the resident's cognition was intact and was independent with set-up help only. On 01/25/23 at 11:21 a.m., the resident's rm 406 had a temperature of 68.3 degrees F. The resident was lying in bed with a coat on which was zipped up and a large thick blanket over her. The resident stated she was the resident council president. She stated residents had complained about cold rooms. She stated she had to dress warm and use blankets to keep warm while in her room. 7. Res #16's quarterly MDS assessment, documented the resident was cognitively intact and required assistance with ADLs. On 01/25/23 at 11:24 a.m., the resident's rm 413 had a temperature of 69.8 degrees F. The resident stated her room was chilly and even gets colder at night sometimes. 8. Res #37's quarterly MDS assessment, dated 11/18/22, documented the resident was cognitively intact and was independent with ADLs except for bathing. On 01/25/23 at 11:28 a.m., the resident's rm 404 had a temperature of 71.3. She stated her room stayed cold and got cooler at night. She stated there was a draft by the window. On 01/25/23 at 5:50 p.m., the maintenance man stated he did not document what room he obtained the temperatures in on the halls. He stated he obtained the temperatures in about four rooms on each hall. He stated he was having issues with the heat for two weeks in room [ROOM NUMBER] and he did what he could, then he called the heat and air repair yesterday. He stated when he had a complaint of temperature, he would get the temperature in that room or where the complaint was about. He stated he tried to keep the temperature at 74 to 75 degrees. He stated Hall 200 was the coldest hall in the whole building.

Based on record review, observation, and interview, the facility failed to ensure there was sufficient nursing staff to provide care in accordance with resident care plans for eight (#2, 13, 17, 21, 23, 30, 49, and #124) of 24 residents reviewed for staffing. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility. Findings: 1. Res #124's admission MDS assessment, dated 12/08/22, documented the resident was cognitively intact, required the assistance of two people with bathing, and had no rejection of care behaviors, The resident's bathing record documented the scheduled times for bathing were Tuesdays, Thursdays, and Saturdays. The record documented for the last 30 days, the resident had 14 opportunities for bathing. The record documented the resident received three showers, refused eight times, and missed three showers. On 01/23/23 at 5:27 p.m., the resident was asked if she received her baths as scheduled. The resident stated sometimes they skip her. She stated she has not had a bath in two weeks. The resident's hair was observed to be greasy and separated. On 01/25/23 at 4:15 p.m., the resident was asked if she ever refused to take her baths. The resident stated the only time she had refused was when they came to take her to the shower at 8:30 in the evening. She stated she did not want to go to bed with her hair wet. She stated most of the time no one had ever asked her if she wanted a bath. The resident's hair still observed greasy as earlier in the week. On 01/25/23 at 4:30 p.m., LPN #2 stated she just learned this week that the resident had been refusing baths. She stated she was not sure why she was refusing. On 01/27/23 at 2:16 p.m., LPN #1 stated CNAs the process was for the CNA's to fill out a bath sheet for a resident on their bath when they had a shower or when they refused. The LPN could not find any bath sheets for Res #124. On 01/25/23 at 4:41 p.m., CMA #2 stated the resident was easy going with showers and usually would not refuse, but she had not worked her hall recently. On 01/27/23 at 2:19 p.m., the DON stated she was not aware of refusals of bathing and residents not getting bathed as scheduled. 2. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they were hurting and their nose itched. The resident was asked if they could use their call light. They looked over at it and shook their head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what they needed. The resident stated they were hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under their right hand. The CNA at that time put the call light disc under the resident's hand. The CNA then left the room without repositioning the resident and without verbalizing her intent. Immediately after the CNA left the resident's room LPN #3 and LPN #4 entered the room with a tray which contained wound supplies. LPN #4 turned off the call light. The two nurses had a discussion between themselves, picked up the tray from the bedside table, then left the room. On 01/24/23 at 10:41 a.m., LPN #3 and LPN #4 came in the room with the wound supplies. The nurses were observed conducting incontinent care and wound care. On 01/27/23 at 3:02 p.m., the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light. 38495 3. Res #2 had diagnoses which included COPD, dementia, and depressive disorder. A care plan, last revised 11/11/22, documented bathing Tuesday, Thursday, Saturday on the 3-11 shift. Res #2 required one to two staff participation with bathing. Provide Res #2 with a sponge bath when a full bath or shower cannot be tolerated. Res #2 will often refuse showers. A five day assessment, dated 01/03/23, documented the resident was intact with cognition and required extensive assistance with bathing. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. The resident should have received 13 baths during the 30 day time frame. There were two documented baths, six refused baths, and five scheduled baths that were not documented for the resident. On 01/23/23 at 2:38 p.m., Res #2 stated the facility did not have enough staff with only one aide on the hall and they were run ragged. She stated she had to wait an hour for some one to get her water. She stated she did not get any baths last week. Resident #2 stated she was dependant on staff for her care. On 01/24/23 a skin monitoring shower review sheet, documented the resident refused a bath. This form was signed by the charge nurse that she was aware the resident refused a bath on 01/24/23. There were no other shower sheets that documented the resident had a shower or refused a bath. On 01/25/23 at 3:56 p.m., Res #2 stated she had refused bathing because she had one staff member she liked to bath her. Res #2 stated she did not think the staff had asked six times to bath her in the past 30 days. Res #2 stated she really did not like bed baths and preferred a staff member to take her to the shower. On 01/25/23 at 4:11 p.m., CNA #4 stated the facility did not have enough staff to get everything done. CNA #4 stated the facility needed two CNAs per hall. CNA #4 stated if someone called in no one else usually took their place. CNA #4 stated the baths were not getting done because there was not enough staff. CNA #4 stated they did try to get to the call lights as quick as they could, 10 to 15 minutes was the standard time. The CNA stated it was a struggle when we had to use the lift because another staff had to help. CNA #4 stated Res #2 will refuse a bath most of the time, but the staff can usually talk her into taking a bed bath most of the time. On 01/25/23 at 4:24 p.m., CNA #2 stated when a resident refused a bath the staff should give the resident another option or wait a little while and go back and ask again. CNA #2 stated if they still refuse a bath they are to tell the charge nurse and the nurse will go talk to the resident to see if the resident will take a bath. She stated resident #2 refused baths very frequently. She was pretty hit or miss on taking a bath. CNA #2 stated if the resident's sister did not want a bath then Res #2 would say no also. CNA #2 stated the staff member the resident wanted to bath her probably could get the resident to bathe, she worked evening and weekend shifts. 4. Res #21 had diagnoses which included respiratory failure with hypercapnia, neuropathy, and chronic pain. A quarterly assessment, dated 01/11/23, documented the resident was intact with cognition and required total assistance with bathing. The assessment documented the resident had rejected care during the look back period. A care plan, last reviewed 01/17/23, documented if the resident refused care, staff should re-attempt care at a different time if possible with a different staff member. Res #21 required total assistance for bathing when the resident wanted to bathe. Baths were scheduled Monday, Wednesday, and Friday on the 3-11 shift. The EHR bathing documentation for the last 30 days had the resident scheduled for bathing on Monday, Wednesday, Friday on the 3-11 shift and PRN. Two baths were documented as refused and one day was documented the resident was not available. From 12/27/22 to 01/24/23 the resident was scheduled for 12 baths. The resident had no documented baths during these dates. On 01/23/23 at 4:17 p.m., Res #21 was observed laying in her bed. Res #21 had on her call light. The resident stated the staff do not come quickly to answer the call lights in the facility. Res #21 stated she had been left on a bed pan for three to four hours before she was assisted off the bed pan. She stated she had gone unassisted while soiled in feces for for eight hours before, but that incident happened a while ago. Res #21 stated a few months ago she had called the police and they came to the facility because CNA #3 would not answer her call light. Res #21 stated CNA #3 did not come in her room now and she would not tell anyone else to answer the call light, she waited hours to do it. On 01/24/23 at 11:00 a.m., Res #21 stated they did not get baths as scheduled. Baths were few and far between. Res #21 stated she would rather get up and go to the shower than get a bed bath. On 01/25/23 at 4:17 p.m., CNA #4 stated when CNA #2 worked, she would make sure Res #21 was bathed. On 01/25/23 at 4:35 p.m., CNA #2 stated Res #21 would let her bathe the resident. Res #21 was very modest and had a lot of pain. CNA #2 stated when the resident had her pain medication she was more up for taking a bath and was a two person assist with her bathing. CNA #2 stated the staff also should complete a shower sheet besides documenting in the EHR. She stated the shower sheets where then turned in to the charge nurse. On 01/25/23 at 4:55 p.m., LPN #1 stated the CNA should fill out a skin monitoring shower review. If a resident refused a bath the CNA should document refused and then let the charge nurse know. LPN #1 stated the form then goes in the skin wound book until the corporate nurse took them out. 5. Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. An annual assessment, dated 12/21/22, documented the resident was intact with cognition and required extensive assistance with bathing. A care plan, last reviewed 12/27/22, documented the nurse is to ensure resident is taking showers as scheduled. If the resident refused for the CNA, the nurse was to attempt. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday, on the 3-11 shift and PRN. Res #30 had 13 scheduled baths and none were documented as given. The bathing record documented four unscheduled baths as refused. On 01/23/23 at 1:50 p.m., Res #30 stated CNA #3 took a long time to answer the call lights and sometimes the lights did not get answered. Res #30 stated CNA #3 told him to get his own coffee. Res #30 stated he was on the toilet an hour and 1/2 this past weekend, and did not know why it took so long. Res #30 reported they were so busy they shut the light off and did not come back. Res #30 stated the staff aggravated him because they think he does not need assistance. On 01/27/23 at 2:15 p.m., LPN #1 stated she was not able to find any bathing shower sheets for Res #30. On 01/27/23 at 2:20 p.m., the DON stated she was not aware of all the resident refusals regarding bathing. 6. Res #49 had diagnoses which included HTN, depression, and Alzheimer's disease. An annual assessment, dated 01/16/23, documented the resident was moderately impaired with cognition and was independent with most activities of daily living. On 01/23/23 at 1:46 p.m., Res #49 stated the staff did not come when you use the call light. Res #49 stated he did a lot for himself. 7. Res # 13 had diagnoses which included COPD, chronic pain syndrome, and seizures. A quarterly assessment, dated 12/20/22, documented the resident was intact with cognition and required extensive assistance with bathing. On 01/23/23 at 3:55 p.m., Res #13 stated the facility did not have enough CNAs. Res #13 stated her call light stayed on for an hour and 1/2 before. She stated the staff tell her she is independent and did not want to help her. She stated she had requested assistance getting to the shower room but the staff would not push her down there. 46909 8. Res #17 had diagnoses which included cervical spina bifida with hydrocephalus, recurrent depressive disorder, psychotic disorder with delusions, and anxiety disorder. A quarterly assessment, dated 11/08/22, documented the resident was cognitively intact and required moderate to extensive assistance with ADLs. The resident's bathing record, from 12/21/22 to 01/20/23, documented the resident had a bath/shower two times. On 01/24/23 at 7:46 a.m., Res #17 stated she had gone two weeks without a bath and/or shower. The resident stated it took too long for the aides to answer the call lights. On 01/25/23 at 5:33 p.m., LPN #1 stated the resident would only allow certain females to give her a bath. On 01/25.23 at 4:11 p.m., CNA #4 stated she worked day shift and most of the time there was not enough staff to finish everything. She stated there needed to be two aides on each hall but at this time there was only one on each hall and an aide that floats between halls. 9. The Resident Council minutes, dated 08/15/22, documented the residents voiced slow call light response times. The Resident Council minutes, dated 10/20/22, documented a resident voiced the call light response times on Hall 100 were too long. The facility's OHCA Quality of Care Monthly Report, for November 2022, documented staffing hours which did not meet the minimum requirement for the resident census for six 24 hour days. The Resident Council minutes, dated 12/30/22, documented the residents voiced they were waiting too long for a response to their call lights. The facility's OHCA Quality of Care Monthly Report, for December 2022, documented staffing hours which did not meet the minimum requirement for the resident census for two 24 hour days. On 01/27/23 at 1:36 p.m., the administrator stated the facility had been looking at hiring and staff retention in their quality assurance program. She stated they had started a peer mentoring program in which she hoped would help with the staffing issue.

Based on record review, observation and interview, the facility failed to ensure residents were treated with respect and dignity, and care in a timely manner for two (#23 and #26) of 24 residents reviewed for dignity and respect. The Resident Census and Conditions of Residents form documented 73 residents resident in the facility. Findings: 1. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they were hurting and their nose itched. The resident was asked if they could use their call light. They looked over at it and shook their head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what they needed. The resident stated they were hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under their right hand. The CNA at that time put the call light disc under the resident's hand. The CNA then left the room without repositioning the resident and without verbalizing her intent. Immediately after the CNA left the resident's room LPN #3 and LPN #4 entered the room with a tray which contained wound supplies. LPN #4 turned off the call light. The two nurses had a discussion between themselves, picked up the tray from the bedside table, then left the room. On 01/24/23 at 10:30 a.m., the administrator was walking down the hall, saw the surveyor near the door, came in the room, and ask the resident if they needed anything. The resident asked her to scratch their head. The administer scratched the resident's head then left the room. On 01/24/23 at 10:32 a.m., the DON came in the resident's room. The resident told the DON they were hurting and their face itched. The DON talked to the resident then left the room. On 01/24/23 at 10:36 a.m., CMA #1 came in the resident's room. The CMA stated she was giving the resident a liquid antianxiety medication and had already given the resident a pain medication at 9:00 a.m. On 01/24/23 at 10:41 a.m., LPN #3 and LPN #4 came in the room with the wound supplies. The nurses were observed conducting incontinent care and wound care. On 01/27/23 at 3:02 p.m., the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light. 46909 2. Res #26 was admitted to the facility with diagnoses of generalized muscle weakness, recurrent depressive disorder, anxiety disorder, and schizophrenia. An admission assessment, dated 01/09/23, documented resident #26 was cognitively intact and was independent with eating. On 01/23/23 at 5:10 p.m., an observation was made of Res #26 asking the kitchen staff for a grilled cheese sandwich while seated in the dining area. The kitchen staff refused to give Res #26 a grilled cheese sandwich, stating Res #26 had already had two grilled cheese sandwiches. Res #26 informed the kitchen staff he only had one grilled cheese sandwich, not two. The kitchen staff continued to argue with Res #26, stating he had two. Another kitchen staff spoke up and stated Res #26 had only one grilled cheese sandwich because he had given the second grilled cheese to another resident. On 01/24/23 at 10:20 a.m., an interview was conducted with Res #26. Res #26 stated that he asked for a second grilled cheese sandwich because one grilled cheese sandwich was not enough. The kitchen staff was observed to refuse to give him another sandwich. The resident stated that he did get another grilled cheese sandwich after another kitchen staff spoke up for him. On 01/26/23 at 12:00 p.m., an interview was conducted with the dietary manager. He stated Res #26 should have been given a second grilled cheese sandwich without hesitation. He also stated that the kitchen staff should never argue with any resident at any time.

Based on record review, observation, and interview, the facility failed to ensure resident call lights were in reach for one (#23) of 24 residents observed for call lights. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequelae of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to his sheet above his shoulder. At that time the resident stated he wanted to be moved because he was hurting and his nose itched. The resident was asked if he could use his call light. He looked over at it and shook his head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what he needed. The resident stated he was hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under his right hand. The CNA at that time put the call light disc under the resident's hand. On 01/27/23 at 3:02 the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light.

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls for one (#1) of three sampled residents reviewed for falls. This resulted in an actual harm to the resident. The DON identified 69 residents resided in the facility. Findings: Resident #1 had diagnoses which included, Alzheimer's disease. A quarterly resident assessment, dated 09/06/21, documented the resident's cognition was severely impaired, and was ambulatory without assistance. A care plan, updated 09/14/21, documented, Focus: .[name withheld] has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's .Focus: .[name withheld] has the Potential for fall r/t Alzheimer's .Interventions: .ENVIRONMENTAL CHECK: ASSESS ENVIRONMENT FOR FACTORS KNOWN TO INCREASE FALL RISK SUCH AS WET FLOOR SURFACES, WAXED FLOORS, CLUTTER, ETC. INTERVENE AS NECESSARY .Focus: .[name withheld] had an actual fall with Fracture of right knee d/t Poor comprehension [Date Initiated 10/27/21] . Interventions: .Keep brace on right knee on at all times, locked at zero degrees .Provide activities that promote exercise and strength building where possible .Provide 1:1 activities if bedbound . Fall risk assessments documented the resident was high risk for falls with the highest score being 105. An Oklahoma State Department of Health Incident Report Form, dated 10/13/21, read in parts, .Certain injuries .Resident observed on floor in hallway .Resident complained pain to right knee .Hematoma to forehead and skin tears to left hand and left arm noted .Resident transferred to ER for further evaluation per physician's orders . An Incident note, dated 10/13/21 at 2:00 p.m., read in parts, .This nurse called to hallway one. Resident lying on her back on floor. Part of hallway sectioned off with yellow tape. Glue on floor. Floor workers not in attendance at their work area at time. Resident lying [sic] on back with lower extremities on glue. Aide reports her shoes had been on glue when resident found on floor. Quarter size hematoma noted to forehead, small cut to bridge of nose noted. Skin tears to left arm and base of index and third finger on left hand. Bruising noted to right knee. Bruising also noted to palm of right hand at base of thumb. Physician in facility and assessed resident .Resident left in place on floor. 911 called. EMT's [sic] transferred resident using a blanket to lift resident onto gurney. Resident transferred to ER for evaluation .Intervention for fall is redirection of resident from the areas of remodel/repair in facility . A Quality Manager Progress Note, dated 10/18/21, read in parts, QM focus assessment r/t safety and recent fall on 10/13/21 .Returned to facility with DX Right patella fx WBAT and RLE immobilizer on .Bruising to forehead, nose and top lip fading .Has DX Alzheimer's and confusion noted .May forget her limitations with poor safety awareness .Placed nonskid socks on resident and order low air loss mattress with bolsters. Nonskid strips in place on floor at bedside. Call light in reach. Pathway in room is clear and free from clutter, has w/c for mobility and x1 assist for tranfers, w/c has right leg extender in place .Staff to offer frequent redirection and reorientations and check for incont and or offer toilet q 2 hrs and prn. An Oklahoma State Department of Health Incident Report Form, dated 10/13/21, Part C for 5 day and final reports, read in parts, The facility completed an initial investigation by interviewing the resident .and resident [name withheld] and staff. Facility also completed a focused assessment of the resident, an evaluation of footware [sic], medication, incident history, and environmental, chart and record review. Physician and family notified. Neuro checks initiated. Upon completion of investigation, facility determined the resident fell while ambulating independently in the hall .Facility will re-evaluated safety/fall precautions and update plan of care to include the appropriate safety/fall precautions. The facility will also educate the resident, family and appropriate staff members of the safety/fall risks, transfer status and devices in place. A Quality Tip Report, dated 10/18/21, read in parts, .Suggested solutions construction complete, staff complete environmental sweeps throughout facility/compliance rounds daily x1 wk then weekly x 90 days . On 10/28/21 at 12:33 p.m., the resident was observed laying in her bed, with a brace to her right knee and she was wearing non-skid shoes. Her wheelchair was in front of her bed and there were nonskid strips on the floor as well. The pathway to the door was clutter-free. At 5:05 p.m., the DON was asked to describe the resident's fall. She stated the floor repair was being done right outside of the resident's room. The resident came out of her room and walked directly into the yellow tape (placed around the section of floor being repaired) and became stuck in the glue on the floor. She stated the tape broke when the resident crossed over it and fell . The DON was asked how staff generally monitored the resident. She stated the resident was in always in direct view of staff. The DON was asked what was the result of the evaluation of safety and fall precautions mentioned in the incident report. She stated the facility had a falling star program which was updated. She stated there is a star in each resident's room that is on the falling star program. On the back of the star, interventions are listed and they are updated any time a resident had fall. She was asked what interventions were put into place to protect the residents from another accident with the floor repair. She stated the construction was completed the following day.

Based on record review and interviews, it was determined the facility failed to provide a safe environment related to smoking for four (#1, 3, 6 and #9) of eight sampled residents who were reviewed for smoking. Three residents required hospital treatment after a fire ignited in the facility from a resident who was using an electronic cigarette while her supplemental oxygen was in use. The facility identified 15 residents who smoked and resided in the facility. Findings: A policy and procedure titled, Smoking Policy and Procedure, dated 04/13/06 and revised on 12/15/08, documented: .Oxygen equipment is not permitted in smoking areas. Smoking is not permitted while in possession of or in the presence of oxygen equipment . Policy: To offer the resident the ability to smoke free of danger to self or others . Addendum 07-05-11 The resident may choose to utilize an electronic cigarette. Electronic cigarettes may be utilized in approved smoking areas, in resident rooms, and in non-public areas . 1. Resident #1 had [DIAGNOSES REDACTED]. An admission note, dated 02/08/20, documented the resident wanted to go out to smoke. The nicotine patch was removed. The resident was advised by staff to wait awhile after the removal of the patch before smoking but she refused. A care plan, dated 02/10/20, documented the resident had a history of [REDACTED]. She was no longer a smoker and used nicotine patches. The staff was to educate the resident she was not able to smoke while wearing the patch and would need to notify a nurse if she wanted to start smoking again. An incident report, dated 02/23/20, documented the resident had been vaping, using an electronic cigarette to smoke, in her room when it got hot, sparked and caught the resident's clothing, blankets, bedroom wall and oxygen concentrator on fire. The clinical record contained no documentation to indicate an assessment had been conducted to ensure the resident's capabilities or needs related to smoking. A nurse's note, dated 02/23/20 at 3:50 a.m., documented the resident was sent to the emergency room by ambulance due to having a fire extinguished in the resident's room. Oxygen was placed on the resident while waiting for the ambulance. A nurse's note, dated 02/23/20 at 9:30 a.m., documented the resident was admitted to the hospital with [REDACTED]. Steps taken by the facility to prevent reoccurrence included: ~ the smoking policy was updated on 02/24/20 to include, .Electronic cigarettes may be utilized in approved smoking areas, in resident rooms when neither resident utilizes O2 . ~ environmental rounds were conducted to ensure appropriate surge protectors were in place, fire extinguishers were replaced, and alarms were reset and tested ; ~ in-service training was conducted on 02/25/20 with all facility staff regarding the updated smoking policies and procedures, components of the smoking contract, the use of oxygen and residents who smoke, and changes to the smoking assessment and care plans; ~ the smoking assessments were updated to include the use of electronic cigarettes; ~ the smoking assessments and care plans for all residents who smoked were reviewed and updated, on or before 03/05/20, to reflect the current status of each individual resident; and ~ implementation of monthly safety rounds, environmental sweeps and clinical record audits continue to ensure ongoing compliance, education and safety. 2. Resident #3 had a [DIAGNOSES REDACTED]. A nurse's note, dated 02/17/20 at 11:35 p.m., documented the staff observed the resident smoking a cigarette while lying in bed in her room. The resident was educated on the dangers of smoking inside the facility and warned if the behavior continued she could have her smoking privileges revoked. A quality manager's note, dated 02/18/20 at 3:01 p.m., documented the resident was found to have her electronic cigarette in the dining room. The resident's cigarettes, lighter and electronic cigarette were locked in the medication room. A quality manager's note, dated 02/19/20 at 10:10 a.m., documented the social services director reviewed and had the resident sign the smoking contract. A nurse's note, dated 02/22/20 at 6:27 p.m., documented the resident had been caught smoking in her room again and her smoking privileges had been revoked for one week. A nurse's note, dated 02/24/20 at 10:04 p.m., documented the nurse was informed the resident was outside smoking. The resident was re-educated, all smoking paraphernalia was locked in the medication room and the DON was notified. On 03/05/20 at 1:35 p.m., the DON stated the resident no longer kept her cigarettes, lighter or electronic cigarette due to incidents involving failure to follow the smoking policy. On 03/09/20 at 10:40 a.m., the DON was asked about the resident's smoking behaviors. She stated the resident had been allowed to smoke again and a new smoking assessment had been completed due to the improvement in her behaviors. The DON stated she had spoken to the resident and believed she understood the serious implications of not following the smoking policy. At 4:00 p.m., the resident was observed smoking an electronic cigarette in her room. She stated she smoked about three cigarettes a day and vaped, using her electronic cigarette, all day long. The resident was asked if the facility was aware she smoked the electronic cigarette in her room. She stated yes, they stated as long as there was no oxygen in the room it was ok. At 4:20 p.m., the DON was asked if the resident's smoking privileges had been reinstated to include the use of the electronic cigarette in her room. She stated that had been the administrator's decision. At 4:30 p.m., the administrator was asked if the resident had lost her smoking privileges due to not following the smoking policy. She stated it was related to regular cigarettes, not an electronic cigarette. The administrator was asked what behaviors had been demonstrated in the past two weeks to ensure the resident, who had not followed the smoking policy multiple times before, would follow the smoking policy now and only use the electronic cigarette where oxygen was not in use. No response was provided. 3. Resident #6 had [DIAGNOSES REDACTED]. An incident report, dated 02/23/20, documented the resident had complaints of shortness of breath following a fire in the hall where she had resided in the facility. She was transported to the emergency room by ambulance then admitted to the hospital for [MEDICAL CONDITION] exacerbation. A nurse's note, dated 02/25/20 at 3:40 p.m., documented the resident was readmitted to the facility on three liters of oxygen with an oxygen saturation of 95 percent, coarse lung sounds and shortness of breath on exertion. 4. Resident #9 had [DIAGNOSES REDACTED]. A nurse's note, dated 02/23/20 at 5:00 a.m., documented the resident's oxygen saturation was at 83 percent on room air following a fire in the facility and she was taken to the emergency room by ambulance to be evaluated. A nurse's note, dated 02/23/20 at 9:37 a.m., documented the resident was admitted to the hospital with [REDACTED]. A nurse's note, dated 02/26/20 at 3:22 p.m., documented the resident was readmitted to the facility. A nurse's note, dated 02/27/20 at 7:12 a.m., documented the resident was readmitted to the hospital in the intensive care unit. On 03/10/20 at 10:50 a.m., the DON stated the resident had been readmitted to the facility from the hospital after being diagnosed and treated for [REDACTED]. She stated the hospital initially discharged the resident too early, her symptoms worsened and she had been sent back out.

Based on record review and interviews, it was determined the facility failed to ensure one (#1) of one sampled resident was free from abuse. The resident reported a CNA touched her inappropriately in her vaginal area. The facility identified 75 residents who resided in the facility. Findings: A policy and procedure titled, Resident Abuse, Neglect and Misappropriation of Property, dated (MONTH) (YEAR), documented: Policy The resident has the right to be free from verbal, sexual, physical, and mental abuse . The facility will not tolerate mistreatment, neglect or abuse of residents. Verbal, mental, sexual, or physical abuse .will not be tolerated . Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/12/19, documented the resident was independent in cognitive skills for daily decision making and required extensive assistance from two staff for toileting. The resident was always incontinent of both bowel and bladder. It was documented the resident had no [MEDICAL CONDITION] or behaviors. A care plan, revised on 08/31/19, documented the resident required extensive to dependent assistance of one to two staff for perineal care and changing clothing. An initial incident report, dated 11/07/19, documented the resident reported CNA #1 was very stern and made unrelated comments to the resident while providing incontinent care. A focused assessment was conducted and the report documented no injuries were observed. Notifications were made to the physician, resident's family member, police department and appropriate staff. CNA #1 was suspended pending the investigation. The report documented the police were notified at 3:00 p.m. The report was faxed to the OSDH at 6:31 p.m. A final incident report, faxed to OSDH on 11/09/19 at 2:07 p.m., documented, The facility completed an initial investigation by interviewing the resident (resident #1), family (initials deleted), and other residents (resident #2), (resident #3), (resident #4), (resident #5), (resident #6) and staff member (CNA #1) involved, and by completing a focused assessment on the resident, an evaluation of her medication, medical and incident history, and chart and record review. Residents (#2), (#3), (#4), (#5) and (#6) all stated that they feel safe in the facility and do not feel threatened by staff member in question. Focused assessments performed with no complaints or signs of abuse. (Physician) notified, Family (initials deleted) notified. (Local police department) notified. Staff member (CNA #1) suspended pending investigation. During further investigation, the facility reviewed residents ADL charting and staffing sheets and noted that staff member (CNA #1) has not been assigned to work on (resident #1) hall and has not provided any care. When staff member (CNA #1) was questioned, she stated the (sic) she has not worked residents hall in several months but that she does go to this area of the building to help with the 2 person assists and hoyer/sit-to-stand lifts. The facility then asked resident (#7) if (CNA #1) had provided any care to the resident recently and she stated no that she hasn't seen her in her room in a while. Resident (#8) was asked if CNA, (#1) had provided any peri-care to her recently and she stated no but she has helped be (sic) back to bed. Resident (#14) was asked as well and was unable to recall who (CNA #1) is. The facility then asked resident (#9) if she has had any issues with (CNA #1) and the way she gives peri-care and she stated no. Resident was then asked if she felt that she is too stern with her care and she stated no. Resident was asked if she ever thought that staff member (CNA #1) was ever in appropriate with her peri-care and again she stated no. Roommates (resident #10) and (resident #11) were both asked if they have had any concerns with (CNA #1) and the way she gives peri-care and they both stated no. When asked if they felt that (CNA #1) is too stern with her peri-care they again stated no. Both were asked if they believed she was ever inappropriate with her care and they stated no. Resident (#11) stated that CNA is really good with her peri-care and that she keeps their skin clean and well taken care of. The facility then questioned resident (#12) about (CNA #1) and her peri-care. She states that (CNA #1) is never too rough or inappropriate with her care. She states that CNA gives good care every time she is in her room. Focused assessments were completed on resident (#9), (#10), (#11), and (#12) with no signs/symptoms of abuse noted. Staff members (intials deleted), LPN, and (initials deleted), LPN, were questioned and states that (CNA #1) never works that hall unless she is helping transfer someone. Staff member (initials deleted) CNA was questioned and states that CNA (#1) only helps her with (resident #1) and her lift that she is able to provide peri-care with only turning assistance. Upon completion of the interviews and focused assessments, the facility was unable to substantiate the allegation of abuse. The suspended staff member has been reinstated. The facility has educated family (name deleted) and appropriate staff members of the residents perferences/choices for ADL care, the signs and symptoms of abuse, and the policies and procedures for reporting allegations of abuse, neglect and misappropriation. Residents #2, 3, 4, 5, 6, 10, and 11 resided on the hall where CNA #1 normally was assigned. Residents 7, 8, 9, 12, and 14 resided on the same hall as resident #1. A police report, dated 11/11/19, documented abuse by a caregiver occurred on 11/02/19. The officer reported he was dispatched to the facility on [DATE] at 3:35 p.m. The resident reported to the officer, while providing incontinent care with a wash cloth, CNA #1 inserted two fingers into her vagina and moved them in a circular motion. The resident told the CNA it hurt and she informed the resident she had to get her clean. When the resident stated again it was hurting, CNA #1 stated you were married for over [AGE] years, you should be use to it. The documentation of the facility's investigation was reviewed. An Incident Report Investigation documented, Interviewed staff (CNA #4), (CNA #1) (LPN #3) on 11/7. Also interviewed (initials deleted) CN[NAME] Residents interviewed 11/7 (#2), (#3), (#4), (#5), (#6) . The report documented residents #7, #8, #9, #10, #11 and #12 were interviewed on 11/09/19. An undated sheet included with the report documented: (CNA #4)- Reported 0630 (6:30 a.m.) on Sunday Rough with care gloved hand w/wipe inserted to vag to clean feces out named (CNA #1) specifically felt like using her fingers as 'male part' & was offended (CNA #1)- 'hasn't worked w/ her in months' (LPN #3)- (Resident #1) doesn't want (CNA #1) taking care of her While cloth wrapped around fingers & wiped in circle Reported to (name deleted). There was no documentation of interviews conducted with the resident, the resident's family member or the three staff members who the facility reported they interviewed in the incident report. There was no documentation of the focused assessments conducted on the four identified residents. The interviews with the five residents who did not reside on the same hall as resident #1 documented, safe and three of those five residents did not require assistance with incontinent care. Review of the facility's nursing staff schedule documented CNA #1 was scheduled to work from 11:00 a.m. to 11:00 p.m. on 11/02/19, 11/03/19, 11/04/19, 11/09/19, 11/10/19, and 11/11/19. The time and attendance detail for CNA #1 documented she worked all six shifts. On 11/13/19, at 10:40 a.m., LPN #1 was asked when she was informed of the allegation of abuse involving the resident and CNA #1. She stated around lunch time on 11/07/19 when the administrator asked her to be a witness while she interviewed the resident. LPN #1 stated following the interview, the resident's family member came to visit and was informed by the administrator of the incident. LPN #1 was asked what had been reported by the resident. She stated the resident reported CNA #1 was providing incontinent care and was too rough. The CNA then made a comment about the resident having been married for [AGE] years. LPN #1 was asked when the incident had occurred. She stated a couple of days before. The resident reported it to CNA #4 who then reported it to LPN #3. LPN #1 was asked if LPN #3 reported the abuse. She stated no, she did not report it. She was in-serviced. At 10:53 a.m., the administrator was asked when she was notified of the allegation of abuse. She stated the DON and she were informed on 11/06/19 around 11:35 p.m. by LPN #2. She was asked what was reported. The administrator stated CNA #4 had reported a statement made by the resident about CNA #1. The administrator stated it was an allegation of sexual abuse. She was asked to describe the allegation. The administrator then stated no, could she take the statement back, it was just physical abuse. There was not any sexual abuse, it was physical abuse during incontinent care. The administrator stated she notified the DON they would handle it in the morning since it was so late and CNA #1, the alleged perpetrator, was not on the schedule to work. At 12:07 p.m., LPN #3 stated CNA #4 had reported an allegation of abuse and the resident requested CNA #1 not provide care to her anymore. The LPN was asked if she had reported the allegation. She stated she failed to report it. She figured CNA #1 would not be providing care for her anymore. At 12:42 p.m., the DON was asked if she could provide the documentation of the focused assessments conducted on the identified residents. She stated no, the assessments were not documented because she had not found anything. If she had found something, she would have documented it. The DON was asked how she was able to show the assessments had been conducted. She stated, I understand that. At 2:20 p.m., the resident was asked to describe the incident which occurred with CNA #1. She stated the CNA was cleaning her during incontinent care and was more rough after the resident told her it hurt. The resident stated the CNA used two fingers and said she had to get it out of there to get her clean and could not leave her dirty. The resident stated the CNA then told her she was married for [AGE] years and was touched down there so it should not hurt. The resident was asked if she had reported it to anyone. She stated she reported it to the aide who came and asked what was wrong. The resident stated she no longer wanted CNA #1 providing care to her. The resident was asked when the incident occurred. She stated not this past Friday or Saturday but the weekend before. At 2:35 p.m., the resident's family member stated, on the evening of the incident she had been visiting the resident and left as they were starting to prepare her for a bath. CNA #1 and CNA #4 were in the resident's room providing care when the family member left for the evening. The family member was asked when she had been notified of the incident. She stated on 11/07/19 by the administrator. She stated the administrator was in a hurry that day to catch a flight and the DON was off most of the day for personal reasons. The facility still had not informed the resident's power of attorney. At 3:20 p.m., CNA #4 stated the resident reported to her, as her night shift ended the morning of 11/03/19, that on 11/02/19 CNA #1 was cleaning her during incontinent care, wrapped a wipe around two fingers and stuck it in her vagina. CNA #4 stated the resident showed her the motion the CNA made by moving her fingers in a circular motion. The resident reported CNA #1 was like a man with a penis. CNA #4 also stated the resident reported to her that CNA #1 had told her she was married for [AGE] years so it should not hurt. CNA #4 was asked if she reported the alleged abuse. She stated yes, she reported it to LPN #3. When she returned to work for her next shift and realized it had not been reported further, she reported it to LPN #2 who informed the administrator and DON. At 3:30 p.m., resident #2 was asked if she was interviewed by facility staff regarding CNA #1. She stated no. At 3:49 p.m., resident #12 was asked if she was interviewed by facility staff regarding CNA #1. She stated never. At 4:32 p.m., the DON was asked if the facility's abuse policy and procedures were followed. She stated no, they were not. She was asked if in-service was provided to the alleged abuser prior to her returning to work. The DON stated no, not with the abuser. The DON was asked how she concluded the abuse was unsubstantiated. She stated she asked two residents and one staff if the CNA had worked the residents hall and they stated no. The DON stated she had no information regarding the other interviews because she was gone when they had been conducted.

Based on observation, record review and interview, it was determined the facility failed to assess, monitor and intervene related to pain rated greater than five with wound care for one (#15) of three sampled residents who were reviewed for pain management. Resident #15 had received daily dressing changes for a stage 3 pressure ulcer of the left heel since 05/20/19. The resident's pain management regimen included orders for extended and immediate release medications to ensure the resident was comfortable. The resident had only received two doses of the immediate release pain medication in the previous six weeks. The resident exhibited verbal and physical signs of pain during a dressing change with no intervention to minimize the pain the resident had expressed. The facility identified 69 residents who resided in the facility and received pain medication. Findings: Resident #15 had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] ER Tablet Extended Release 60mg give 1 tablet by mouth two times a day for pain . A physician's orders [REDACTED].[MEDICATION NAME] 30mg Give 1 tablet by mouth every six hours as needed for breakthrough pain Note resident has [MEDICATION NAME] IR 30mg and [MEDICATION NAME] ER 30mg, she is to use the [MEDICATION NAME] IR for PRN use . A physician's orders [REDACTED].[MEDICATION NAME] ER Tablet Extended Release 30mg Give 1 tablet by mouth two times day for Severe pain . An annual assessment, dated 02/13/19, documented the resident was independent in cognitive skills for daily decision making and required limited assistance from staff with transfers and ambulation. She was occasionally incontinent and required supervision from staff with toilet use. It was further documented the resident required pain management and had a stage 3 pressure ulcer. A care plan, dated 02/15/19, documented, .goal .minimized pain through review date .Interventions .review for pain medication efficacy, assess whether pain intensity is acceptable .Focus .Skin Integrity . Interventions .Monitor for pain during treatments/wound care. Treat pain as indicated to ensure the resident is comfortable . The MAR, dated 04/2019, documented the resident rated her pain > five on 37 of the 60 opportunities she had received [MEDICATION NAME] ER 30mg. It was documented the resident had received one dose of the [MEDICATION NAME] sulfate tablet 30mg PRN during the month of April. It was received on 04/24/19 at 12:37 p.m., for a pain level of nine. The MAR, dated 05/2019, documented the resident had rated her pain > five on 45 of the 62 opportunities she had received [MEDICATION NAME] ER 30mg. It was documented the resident had received one dose of the [MEDICATION NAME] sulfate tablet 30mg PRN during the month May. It was received on 05/06/19 at 1:18 p.m., for a pain level of eight. A physician's orders [REDACTED]. Assess pain level and medicate as ordered prior to the dressing change. The TAR, dated 05/2019, documented the wound care had been performed daily from 05/20/19 through 05/31/19. The time of the wound care had been documented as 7:00 a.m. to 11:00 a.m. with no pain level documented prior to the dressing change. The MAR, dated 06/2019, documented the resident had rated her pain > five on 12 of the 21 opportunities she had received [MEDICATION NAME] ER 30mg. It was documented the resident had not received any doses of the [MEDICATION NAME] sulfate tablet 30mg PRN from 06/01/19 through 06/11/9. The TAR, dated 06/2019, documented the wound care had been performed daily from 06/01/19 through 06/10/19. The time of the dressing changes had been documented as 7:00 a.m. to 11:00 a.m. with no pain level documented prior to the dressing change. On 06/11/19 at 9:27 a.m., the resident was observed sitting in her wheelchair in her room. LPN #1 was observed drying her hands. The resident stated, They were supposed to give me pain meds a long time ago, at about 8:00 a.m. The LPN did not respond to the resident regarding her pain medication. LPN #1 was observed removing the old dressing from the left heel pressure ulcer. The resident was observed moaning as the dressing was removed. The LPN did not acknowledge the resident's physical signs of pain. LPN #1 wiped the pressure ulcer with a moistened gauze. The resident was observed grimacing and she grabbed the arms of the wheelchair. The LPN stated, I am almost done. The LPN applied Santyl to the pressure ulcer using a tongue depressor. The resident was observed grimacing, moaning out, and flinching her left lower extremity. LPN #1 did not acknowledge the resident's physical and verbal signs of pain. The LPN covered the pressure ulcer with a heel dressing and a sock. The resident stated, Boy, that hurts. LPN #1 stated she would ask CMA #1 to bring the resident some medication. LPN #1 was observed washing her hands. The resident stated, That hurts bad honey. LPN #1 was observed outside the resident's room sanitizing the bedside table and typing on the computer. The LPN was observed to dispose of the biohazard trash to the receptacle on hall 200. LPN #1 was not observed to inform the CMA of the resident's need for pain medication. At 9:43 a.m., resident #15 was observed sitting in her wheelchair in her room. She was asked what her current pain level was. She stated, About a 20. She stated she had hollered at the CMA a while ago but he had ignored her. The resident was asked if the wound care had been performed without being medicated for pain. She stated, Yes. She was asked how often the staff had performed the dressing change without the administration of pain medication prior to the wound care. The resident stated, Everyday. At 9:52 a.m., the resident was observed sitting in her wheelchair inside the doorway to her room. Hospitality aid #1 was observed to ask the resident if she needed anything. The resident stated she needed her to find the CMA because she needed her medication. At 9:58 a.m., CMA #1 was observed administering medications to the resident. At 11:51 a.m., CMA #1 was asked what training he had received on pain management. He stated training on the computer, in-services and the face assessment. He was asked the difference between ER and IR [MEDICATION NAME]. He stated extended and immediate release. He was asked which form he would administer for a resident in acute pain. He stated, IR for immediate. CMA #1 was asked when he had been made aware of resident #15's pain that day. He stated, I don't remember the exact time, I'm stressed. I don't pass meds on days much. He was asked how he was made aware of the resident's pain. He stated the hospitality aide had told him. He was asked what the resident's pain level had been and if the medication was effective. He stated he had actually forgot to ask the pain level but the medication was effective because the resident had not had anymore complaints of pain. CMA #1 then stated, I just realized I gave the ER and not the IR. At 2:47 p.m., the wound care nurse was asked what resident #15 had rated her pain before the wound care that day. She stated it was always a 10. She was asked if the resident had received pain medication prior to the dressing change. She stated, I don't believe so. She was asked if the resident had exhibited signs of pain during the treatment. She stated, She hollered out when taking the dressing off and when I was cleaning it. The wound care nurse was asked if she had told the CMA to administer the resident's pain medication following the wound care. She stated she had told the CMA to give her PRN pain medication before and after the dressing change. The wound care nurse was asked what she had done when the resident hollered out. She stated, I said 'I'm almost done. She was asked if she normally continued a dressing change when the resident was exhibiting signs of pain. She stated, I do with her because she is always in pain and takes pain meds around the clock. She stated, She always says, 'Just do it and get it done'. She was asked if the resident had said, 'Just do it and get it done' today. She stated, I don't remember. The wound care nurse was asked if she was aware of the pain medications ordered for the resident. She stated [MEDICATION NAME] ER 60mg twice a day and 30mg twice a day. She was asked if she was aware the resident also had an order for [REDACTED]. She stated yes because the resident was always in pain. She was asked if it would have been feasible to put the dressing change on hold until after the resident had been medicated for the pain. She stated, Yes. At 3:01 p.m., the DON was asked how often the staff was trained related to pain management. She stated the nurses were trained upon hire and every year. She stated she was not sure when the CMA's received the training. She was asked if the CMA's should be trained related to pain. She stated, Definitely. The DON was asked what their policy was related to pain management and wound care. She stated they had the resident rate their pain on a scale of 1-10, then checked the orders to verify when the last dose of pain medication had been administered. The wound care nurse would notify the CMA of the wound treatment, if the resident usually hurt. The DON was asked if she would have expected [MEDICATION NAME] ER or IR to have been administered prior to wound care. She stated, Immediate. She was asked if the resident stated she had not had her 8:00 a.m. dose of pain medication yet, what would she expect the nurse to have done. She stated the nurse should have asked the CMA to administer pain mediation then wait to do the dressing change. She was asked if the wound nurse started the dressing change and the resident hollered out, what would she expect the nurse to have done. She stated, Stop the dressing change, don't put anybody through pain that is unnecessary. The DON was asked if she had a resident who had been in constant pain, always rated her pain high and exhibited physical and verbal signs of pain during dressing changes, what actions would she expect from the staff. They would need to have administered all the PRN pain medication until it was exhausted and if the resident was still in pain then contact the physician. The DON was asked if the resident had orders to receive [MEDICATION NAME] ER routine and [MEDICATION NAME] IR PRN and the resident rated her pain from a seven to a ten, what would be expected from the staff. She stated the staff would be expected to have administered the ER then the PRN. She stated a change for the physician to review could be requested if the regimen was not effective.

Based on observation, interview and record review, it was determined the facility failed to: A. Ensure indwelling urinary catheters were not used without justification for use for one (#6) of six sampled residents with indwelling urinary catheters and failed to ensure the resident received care and services to prevent urinary tract infections. Resident #6 developed seven urinary tract infections from admission on 01/13/15 through 05/13/15. The Resident Census and Condition report identified nine residents with indwelling urinary catheters. B. Ensure blood pressure medications were not administered for one (#3) of four sampled residents reviewed who had parameters to hold blood pressure medications for low blood pressures. The facility identified 12 resdient's who received blood pressure medications with ordered parameters. C. Coordinate care with hospice for one (#11) of three residents reviewed for hospice service. This had the potential to affect 11 residents who received hospice services. D. Change an indwelling catheter per physician order for [REDACTED]. The Resident Census and Condition report identified nine residents with indwelling urinary catheters; and E. Complete I/O monitoring for five (#6, #7, #13, #14 and #15) of six residents sampled with indwelling catheters and/or tube feedings. The Resident Census and Condition report identified nine residents with indwelling urinary catheters and four residents with tube feedings. Findings: A facility policy, titled Tube Feeding, documented "...Record the amount of formula and water on the I & O flow sheet..." A facility policy, titled Emptying Urinary drainage Bags, documented "...Record the time and amount of urine..." 1. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A telephone order, dated 01/13/15, documented, "...resident to admit...orders verified and clarified..." Hand written admission orders [REDACTED]. A nurse's note, dated 01/13/15 at 8 p.m., documented, "...foley cath patent...Dr. (name deleted) was in facility...verified and clarified orders..." A nurse's note, dated 01/25/15 at 7:00 p.m., documented, "Res c/o pain c urination. N.O. rec. to D/C foley. (1910) (7:10 p.m.) removed res foley s diff Res tolerated well. (2100) (9:00 p.m.) Res. voided incont, x3 s diff..." A nurse's note, dated 01/26/14 at 12:15 a.m., documented, "C/O SOB, congestion...States she wants to go to hospital...Transferred to (hospital name deleted) per ambulance." A urinalysis, dated 01/26/15, documented the specimen had a large amount of blood, 2+ protein, trace Leukocyte Esterace, 50+ RBC's (reference range 0-2), 10-14 WBC's (reference range 0-4), and moderate bacteria (reference range - none). A physician's order, dated 01/26/15 at 6 a.m., documented, "...Foley cath - May change weekly if needed." An admission assessment, dated 01/26/15, documented the resident was independent in cognitive skills for daily decision making, and required two person physical assist with transfers and bed mobility. She was continent of bowel and bladder with one person assist with toileting. The assessment documented she did not have an indwelling urinary catheter. An untimed nurse's note, dated 01/27/15, documented, "...foley patent c dark yellow urine...catheter just placed when in ER. requested lab from ER visit will await culture for UA then call doctor for ATB unless become symptomatic per doctor request." A nurse's note, dated 01/27/15 at 10:55 p.m., documented, "...Res c/o foley catheter, checked placement et did cath care found cath to be in place, urine output 1600 ml c a tint of blood - scant tiny clots..." A nurse's note, dated 01/27/15 01/28/15 at 11:45 p.m., documented, "Resident transferred to (hospital) ER for lower abdominal pain. Resident returned from (hospital) ER with orders for UTI..." A review of treatment administration records was conducted. A January 2015 treatment administration record was not available for review. There was no documentation to show catheter care was provided for the resident. A care plan, dated 02/05/15, documented: "The resident has Urinary Tract Infection... Goal The resident's urinary tract infection will resolve without complications... Interventions ...Offer toileting every 2 hours and as needed, also providing incontinent care as needed... Monitor/document/report to MD PRN for s/sx of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes..." The care plan did not contain any documentation regarding use of an indwelling urinary catheter or catheter care. A treatment administration record for February 2015 documented catheter care was to be done every shift. Catheter care was not documented as provided on the 11 p.m. -7 a.m. shift on 02/10/15 and 02/11/15, or on the 7 a.m. - 3 p.m. shift on 02/13/15. No catheter care was documented after 7 a.m. on 02/14/15. The treatment record also documented, "Foley cath may (change) weekly if needed." There were no catheter changes documented. A nurse's note, dated 02/13/15 at 8 a.m., documented, "Res c/o L waist + flank pain. Res states pain is 10/10 and wants to be sent to ER. Res sent via ambulance to (hospital) ER for eval + TX..." A patient transfer form, dated 02/13/15, documented the resident was transferred to a local hospital with a primary chief complaint of, "Severe pain L flank pain." The resident's pain was rated as a 10 on a scale of 1-10. A urinalysis, dated 02/13/15 at 9:35 a.m., documented the specimen had a large amount of blood, 1+ protein, a large amount of Leukocyte Esterase, 50+ RBC's and 50+ WBC's. A urine culture, collected on 02/13/15, documented the growth of greater than 100,000 col/ml of Escherichia coli. An emergency room Note, dated 02/13/15, documented: "...History of Present Illness:...female with concern for today's history of left flank pain...She has a history of indwelling Foley and recurrent urinary tract infections...No treatment prior to arrival...Departure Diagnosis: [REDACTED]. An Emergency Department Nurse's note, dated 02/13/15, documented: "...Stated Complaint Elaboration I am having (L) flank pain. I think I have another bladder infection. Objective Assessment...Foley catherter. Urine cloudy... Pain Intensity 6..." A physician's order from the hospital, dated 02/13/15 at 11:00 a.m., documented, "[MEDICATION NAME] 300mg po BID x 7 days Dx: UTI." A nurse's note at 12:15 p.m., documented the resident returned to the facility. A nurse's note, dated 02/14/15 at 12:15 a.m., documented, "...Severe headache...Res started [MEDICATION NAME] 300mg for UTI (on 2-13-14) (sic) Foley patent & draining...tea colored urine...6A - Res...request to go to ER..." An emergency room note, dated 02/14/15 at 6:42 a.m., documented: "...Chief Complaint: Headache... History of Present Illness:...concern for this morning's history of generalized headache. Fever...She was seen in the emergency room yesterday with concern for left flank pain. She has a history of indwelling Foley, and received initial [MEDICATION NAME] followed by [MEDICATION NAME] for possible UTI....She was hospitalized ...last year with concern for [MEDICAL CONDITION] Physical Exam...06:55 Temp 101.5... ED Course...Concern for possible obstructive stone versus meningitis versus [MEDICAL CONDITION] (kidney infection)... Departure Diagnosis: [REDACTED]. Condition: Serious..." The note documented the resident was transferred to another hospital. A nurse's note, dated 03/02/15 at 8 p.m., documented the resident was readmitted to the facility from the hospital. The note documented the resident had a foley catheter. On an Evaluation for Justification of Indwelling Catheter, dated 03/02/15, the facility had circled "yes" for the following indications for the use of an indwelling urinary catheter: ..."Inability to manage the retention/incontinence with intermittent catheterization... Is there documented history of resident being unable to void after a catheter was removed in the past?.." A nurse's note, dated 03/18/15 for the 3 p.m. to 11 p.m. shift, documented, "Resident c/o pain to peri area and stated spasm to the lower abd. and stated I am getting UTI. Dr. (name deleted) notified. Urine sample obtained and sent to (hospital) and new order to start Bactrim DS..." A urinalysis, dated 03/18/15, documented the specimen had a large amount of blood, 1+ protein, was positive for [MEDICATION NAME], had a large amount of Leukocyte Esterace, 30-49 RBC's (reference range - 0-2), 50+ WBC (reference range - 0-4), and many bacteria (reference range - none). A urine culture, dated 03/18/15, dcoumented the growth of greater than 100,000 col/ml (colonies/milliliter) of Escherichia Coli. A urinalysis, dated 03/25/15, documented the specimen had 3+ blood (reference range - negative), 2+ Leukocyte Esterase (reference range - negative), 2+ bacteria (reference range - none seen), and 20-40 WBC's (reference range - none seen). A urine culture, dated 03/26/15, documented the growth of greater than 100,000 CFU/ML (colony forming units/milliliter) of Pseudomonas Aeruginosa and 10,000 - 100,00 CFU/ML of Proteus Mirabilis. A TAR dated 04/01/15 - 04/30/15 documented no catheter care was provided. The TAR documented the catheter was changed on 04/07/15 and was to be changed on the 7th of each month. A urine culture, dated 04/01/15, documented the growth of greater than 100,000 col/ml of Escherichia Coli. A nurse's note, dated 04/17/15 on the 3 p.m. to 11 p.m. shift, documented, "Resident tearful, c/o burning sensation upon voiding and pain on (lower) quadrant of abd, Dr (name deleted) paged. Order received to obatin UA c C&S if indicated..." A urine culture, collected on 04/17/15, documented the growth of greater than 100,000 col/ml of Escherichia Coli and Providencia Stuartii. A physician's progress note, dated 04/21/15, documented, "...Today at 8 AM she summoned me to...get a urology consult...Past Medical History:...Has recently been hospitalized at (hospital name deleted) for UTI and CKD ([MEDICAL CONDITION])... Monthly physician orders, signed and dated 04/28/15, did not include any orders for an indwelling urinary catheter. An untimed nurse's note, dated 05/12/15, documented, "Received new orders for UA c culture...to obtain 5-13-15..." A urine culture report, dated 05/13/15, documented the growth of greater than 100,000 Col/ml of Escherichia Coli and Pseumonomas aeruginosa. A TAR dated 05/01/15 - 05/31/15 documented no catheter care was provided. "Cath care q shift and prn" was added to the TAR on 05/19/15. "Change foley cath monthly" was added to the TAR on 05/19/15. "Change foley drainage bag twice a month" was added to the TAR on 05/19/15. There was no documentation to indicate the catheter had been changed in May. An I/O form, dated May, 2015, documented the I/O had only been monitored for 35 of the 60 shifts. On 05/19/15 at 9:30 a.m., LPN #1 was asked how long had the resident had an indwelling urinary catheter. She stated she was just going to check on it because she had just asked for the catheter to be taken out due to pain. The LPN was asked what was the [DIAGNOSES REDACTED]. She stated she wouldn't know without looking. She was then asked to review the resident's chart for the current order. She stated she could not find an order. She was asked if there was an order would it be on the monthly physician orders. She stated, "Yes." At 9:35 a.m., CNA #3 was asked who was responsible for recording I/O's. He stated the aides were responsible to collect the readings and they give the information to the nurses. He was asked what is done if an I/O is not submitted at the end of the shift. He stated the nurse will follow up or have the next shift get the reading. At 10:15 a.m., the resident was asked if staff provided catheter care. She stated, "No, and just now I was told if I needed to be cleaned down there to ask. When I was in the hospital they cleaned it everyday." She was asked how many urinary tract infections had she had since her admission. She stated, "Every month since I have been here." The resident was asked if she had to go to the hospital because of any infections. She stated, "Yes, I was there for ten days." She was asked what she remembered about her hospitalization . She stated they told me the culture grew out e-coli in my urine and in my blood. On 05/19/15 at 10:25 a.m., CNA #1 was asked how often she provided catheter care for the resident. She stated everyday. She was asked if she documented completion and where could that documentation be found. She stated she did not do any documentation because there was nowhere to document. CNA #1 was asked if she had completed catheter care for the resident this shift. She stated, "No." She was then asked to observe the task. She did not notify surveyor when she provided the catheter care. At 10:30 a.m., the DON was asked who was responsible for completing catheter care. She stated, "The nurses." She was asked how often catheter care was done. She stated every shift. The DON was asked where it was documented. She stated on the TAR. On 05/19/15, a care plan, dated 03/18/15, was provided. The care plan documented: "Res has a DX of UTI Goal UTI will be resolve/resolving x 14 days Plan of Approach 1) Offer toileting every two hours and as needed. 2) Check frequently for incontinence episodes. 3) Give Prompt perineal care, assist as needed... Evaluation and Progress 3/18/15 - Bactrim DS Q day x 10 days. - UACSII (UA and Culture and Sensitivity if indicated) - Cath care q shift - (Change) F/C (foley catheter) Q month - (Change) drainage bag 2x month." On 05/19/15 at 12:55 p.m., the Interim DON was asked why this care plan was not with the care plans provided yesterday. She stated the MDS Coordinator had another file that she keeps. The DON was asked how the care plan could be completed without any orders. She stated it must have been on the MAR or TAR. On 05/19/15 at 4:30 p.m., Physician #1 was asked for the [DIAGNOSES REDACTED]. He stated he would have to look at the chart. The physician reviewed the chart. He stated, "No, I don't." 2. Resident #15 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/17/15, documented the resident was independent with cognitive skills for daily decision making and required minimal assist with transfers, ambulation, dressing and grooming. He was continent of bowel and had an indwelling urinary catheter. An I/O form, dated May, 2015, documented the I/O had only been monitored for 38 of the 60 shifts. On 05/21/15 at 10:00 a.m., LPN #4 was asked how I/O's were monitored. He stated at the end of shift the aides will turn in the count. He was asked how he ensured the I/O's are documented. He stated he tries to be responsible and get them all documented. He was asked why there were so many blanks on the current I/O forms. He stated human error, it doesn't mean it wasn't done. 3. Resident #7 had [DIAGNOSES REDACTED]. A care plan, dated 10/16/14, documented "...Focus... The residentsis (sic) at risk fordehydration (sic) r/t Diuretic use and hydration received via feeding tube... Interventions...Monitor and document intake and output as per facility policy..." A monthly intake and output flow sheet, dated January 2015, documented no output was monitored for three days on the 11:00 p.m., to 7:00 a.m., shift, 14 days on the 7:00 a.m., to 3:00 p.m., shift and 11 days on the 3:00 p.m., to 11:00 p.m., shift. A quarterly assessment, dated 03/22/15, documented the resident was severly impaired in cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, locomotion, dressing, hygiene and bathing. She had a [MEDICAL CONDITION] and an indwelling urinary catheter. She had a feeding tube for nourishment. A monthly intake and output flow sheet, dated April 2015, documented no input was monitored five days on the 11:00 p.m., to 7:00 a.m., shift, and three days on the 3:00 p.m., to 11:00 p.m., shift. No output was monitored on six days on the 11:00 p.m., to 7:00 a.m., shift, three days on the 7:00 a.m., to 3:00 p.m., shift and nine days on the 3:00 p.m., to 11:00 p.m., shift. On 05/20/15 at 10:35 a.m., RN #1 was asked who is responsible for monitoring the Input and Output. She stated, "The nurse, I record the output after the aides empty the catheter." She was then shown the records and asked why there would be blanks. She stated, "I would think it was not documented by the nurse." 4. Resident #3 had [DIAGNOSES REDACTED]. An admission assessment, dated 10/02/14, documented the resident was independent in cognitive skills for daily decision making. She required supervision for transfers. She required limited assistance of one person for dressing and hygiene. She required extensive assistance of one person for bathing. A care plan, dated 10/02/14, documented, "...PROBLEM... RESIDENT HAS DX OF [MEDICAL CONDITION] AND IS AT RISK FOR ABNORMAL BLOOD PRESSURES... PLAN OF APPROACH...6) ADMINISTER MEDS AS ORDERED BY PHYSICIAN... EVALUATION AND PROGRESS... 10/7/14 B/P prior to [MEDICATION NAME] given hold if SBP < 110..." A medication administration record, dated, 03/01/15, documented "[MEDICATION NAME] TAB 30MG Sub for: [MEDICATION NAME] 1 BY MOUTH THREE TIMES DAILY--HOLD IF SBP <110... 03/08/15 1 PM... 90/46... 03/08/15 8 PM...93/50... 03/25/15 8 PM...108/64... 03/28/15 8 PM...103/60..." The medication administration record documented the [MEDICATION NAME] was given. A physician's monthly order, dated April 2015, documented "[MEDICATION NAME] TAB 30MG For: [MEDICATION NAME] 1 BY MOUTH THREE TIMES DAILY--HOLD IF SBP <110..." A medication administration record, dated 04/01/15, documented "[MEDICATION NAME] Tab 30mg (one) by mouth TID Hold if SBP <110... 04/04/15...105/57..." The medication administration record documented the [MEDICATION NAME] was given. On 05/19/15 at 10:15 a.m., CMA #1 was asked how the facility ensured medications with ordered parameters are held. She stated, "Circle the MAR, chart the reason why it was held and report it to my charge nurse." At 10:20 a.m., LPN #1 was asked how the facility ensured medications with ordered parameters are held. She stated, "It is documented on the MAR when to hold the medications." 5. Resident #11 had [DIAGNOSES REDACTED]. A monthly physician's order, dated May 2015, documented, "...CODE STATUS/HOSPICE...01/07/14***DNR***(Hospice name deleted)..." On 05/20/15 at 1:35 p.m., the ADON was asked for the resident's hospice chart. There were two (named hospice) staff members at the nurses' desk. The ADON asked the hospice staff if they had the resident's hospice records. The hospice staff stated to the ADON that the resident was no longer on hospice services. The ADON asked the hospice staff how long the resident had been off of services. The hospice staff stated the resident had been off of services for over two months. At 2:00 p.m., the corporate quality manager was asked how the facility coordinates care with hospice. She stated, "They report to the nurses when they come out." She was asked how the facility monitors who is currently on hospice. She stated, "By the orders." She was asked how the facility would be notified by hospice that a resident would be discharged from services. She stated she would call the hospice to clarify when the resident was removed from services. At 2:20 p.m., the corporate quality manager approached the survey team and stated, "I clarified with hospice that she was discharged back in February 2015." 6. Resident #13 had [DIAGNOSES REDACTED]. A care plan dated, 11/10/14, documented, "...Focus The resident has Indwelling foley Catheter: Date Initiated: 11/10/2014... Interventions... CHANGE FOLEY CATH DRAINAGE BAG 2X MONTH CHANGE FOLEY MONTHLY..." A care plan dated, 11/12/14, documented, "...Focus The resident has potential fluid volume overload/DEFICIT r/t Disease process, Kidney failure... Interventions... Monitor and document intake and output as per facility policy...11/12/2014..." A quarterly assessment, dated 02/01/15, documented the resident had an indwelling urinary catheter. A treatment record dated, 02/01/15-02/28/15, documented, "...CHANGE FOLEY CATHETER MONTHLY 7-3..." There were circled initials on 02/03/15. The treatment record documented, "2-3-15 NO 18 Fr Catheters in facility..." A treatment record dated, 03/01/15-03/31/15, documented, " FOLEY CATHETER D/T [MEDICAL CONDITION]- CHANGE FOLEY CATHETER MONTHLY...7-3... CHANGE CATH DRAINAGE BAG 2X MONTHLY...7-3..." There was no documentation in the clinical record to show the catheter was changed in the month of February or March 2015. A monthly physician's order, dated May 2015, documented, "...FOLEY CATHETER D/T [MEDICAL CONDITION]- CHANGE FOLEY CATHETER MONTHLY...CHANGE CATH DRAINAGE BAG 2X MONTHLY..." On 05/20/15 at 9:30 a.m., the corporate clinical director was asked who is responsible for ensuring the facility has the supplies that are needed for resident care. She stated the supply clerk is and if the supplies are not there the facility can order them locally and pick them up that day. At 10:30 a.m., LPN #1 was asked who required intake and output documentation. She stated, "Foley cath and Peg tubes." She was asked when a resident had an indwelling catheter why would a F or FC be documented for the intake and output. She stated, "I have no idea. We have some with a leg bag and they empty their own bags, so we document that they emptied it by the number of times." She was asked what occurs when there are no supplies to do resident care. She stated, "It happens. I go to the person who orders it and they will get it." She was shown the clinical record documentation that the catheter was not changed in February. She stated, "It is the day shift that changes it but I didn't change it that month because I had asked multiple times for the supplies and didn't get them. I even made the Administrator aware at that time. Sometimes we can't change his foley because he goes to [MEDICAL TREATMENT] and I have asked that it be changed to a day that he is here because I can't get everything done before he leaves." She stated the catheter should have been changed in March because it was scheduled for a Sunday. There was no documentation in the clinical record of intake or output monitoring since October 2014. 8. Resident #14 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/19/15, documented the resident was severely impaired in cognitive skills for daily decision making. The May 2015 monthly physicians orders documented, "...04/09/15 FOLEY CATHETER TO GRAVITY DRAIN D/T [MEDICAL CONDITION] - CHANGE MONTHLY." A care plan, dated 04/20/15, documented, "Focus...The resident has foley catheter... Interventions...Monitor and document intake and output as per facility policy..." An intake and output record, dated April 2015, documented,the resident's output was not monitored four times on the 7:00-3:00 shift, seven times on the 3:00-11:00 shift, and 15 times on the 11:00-7:00 shift. An intake and output record, dated May 2015, documented the resident's output was not monitored seven times on the 7:00-3:00 shift, 11 times on the 3:00-11:00 shift and four times on the 11:00-7:00 shift. On 05/20/15, at 3:20 p.m., the resident was observed with an indwelling urinary catheter. On 05/21/15, at 8:25 a.m., LPN #1 was asked who monitors urinary output and records it. She stated, "The aides keep track of it and report it to us, the charge nurse, and we record it." She was asked should the output be monitored and recorded. She stated, "Yes."

Based on interview and record review, it was determined the facility failed to ensure one (#1) of four sampled residents received transportation to a scheduled [MEDICAL TREATMENT] appointment. A patient transfer form from the facility documented resident #1 was transferred to the hospital with increased confusion, sedated, and possible fluid overload. The facility identified four residents who received [MEDICAL TREATMENT]. Findings: The policy, Social Services, documented, "Policy: It is the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental or psychosocial well-being of each elder. These services are offered to assist the elder and his/her family in the maintenance and improvement of each elder's ability to control everyday physical needs, mental needs and psychosocial needs." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission resident assessment, dated 04/29/14, documented the resident to be cognitively intact and needed limited assistance of one person with activities of daily living (ADLs). Discharge instructions from hospital #1, dated 04/20/14, documented, "...Discharge Instructions to Nursing Home...You have a [DIAGNOSES REDACTED]. You should weigh daily and keep a daily record contact your provider if weight changes > (greater than) 2-3 lbs (pounds) overnight..." A nurse's note, dated 04/22/14 at 7:25 p.m., documented, "[MEDICAL TREATMENT] is on Tues (Tuesday), Thurs (Thursday), et (and) Sat (Saturday)..." An admission coordinator note, dated 04/23/14 at 3:00 p.m., documented, "...Transportation scheduled with (transport company) with 6:00 a.m. P/U (pick up) scheduled for 4/24/14. [MEDICAL TREATMENT] scheduled at ([MEDICAL TREATMENT] name) on T (Tuesday)- Th (Thursday)- Sat (Saturday) with arrival time of 6:45 a.m.- machine time at 7 am with 3 1/2 hrs. (hours) run time to be finished and ready for P/U at 10:45 a.m. Spoke with (transport company) to confirm info (information) and schedule." The May 2014 physician's orders [REDACTED]. Skilled daily nurses notes, dated 05/12/14 through 05/19/14, were reviewed. "[MEDICAL TREATMENT]" was not checked off on the front of the daily notes. The handwritten narratives on the back sides of the daily notes contained no entries regarding [MEDICAL TREATMENT]. A skilled daily nurses note, dated 05/19/14, documented, "...add- resident with 4 + (plus) [MEDICAL CONDITION]." The patient transfer form from the facility, dated 05/19/14, documented, "...Chief complaint/ reason for visit Full code (increased) confusion/sedated/possible fluid overload..." On 05/28/14 at 3:00 p.m., RN (registered nurse) #1 was asked if she provided care to resident #1. She stated, "Yes." She was asked what sent resident #1 to the emergency room . She stated, "Fluid overload. He was very [MEDICAL CONDITION]." At 3:05 p.m., the admission coordinator was given a list of the sampled resident names. She was asked for the last MDS (minimum data set) and the care plans for each resident. At 3:10 p.m., the social services director was asked if she transported residents to their medical appointments. She stated, "Yes." She was asked if she kept a log of when she transported residents. She stated, "Yes." She stated she had an appointment book with resident names written in on the day they needed transportation. She was asked if she had ever taken resident #1 to any of his [MEDICAL TREATMENT] appointments. She stated, "The (facility responsible for the transportation) takes him to his appointments and to his [MEDICAL TREATMENT]." She was asked the policy for when a resident needed transportation on a Saturday or Sunday. She stated the nurse would call her and she would take them. She was asked if she had ever been called to take resident #1 to [MEDICAL TREATMENT] on a Saturday. She stated, "No." She was asked if she made the arrangements with the transportation facility for his transportation to [MEDICAL TREATMENT]. She stated, "No, that was the admissions coordinator." She was asked if there was a policy on the transportation of residents to appointments. She stated, "No." At 4:30 p.m., the DON (director of nursing) was asked if she was notified when resident #1 did not have a ride to his [MEDICAL TREATMENT] appointment on 05/17/14. She stated she received a text message at 9:05 a.m. from the charge nurse, LPN (licensed practical nurse) #2, stating the transportation facility was not there to pick up resident #1. She stated she told the charge nurse, LPN #2, to find a staff member to take resident #1 to [MEDICAL TREATMENT]. She stated the charge nurse stated it was too late for him to go that the [MEDICAL TREATMENT] facility and that it closed at 11:00 a.m. The DON was asked if the physician or family for resident #1 was notified of the resident not receiving [MEDICAL TREATMENT] on Saturday 05/17/14. She stated, "I'm not sure." The DON was asked for documentation for the physician order [REDACTED]. At 4:30 p.m., the ADM (administrator) was asked the policy for when a transporter does not show up to transport a resident to an appointment. He stated, "We take them. A staff member could take them." The ADM was asked for documentation that LPN #2 tried to reach the transportation facility. He stated there was probably not any documentation. At 4:50 p.m., the ADM provided the MDSs and care plans for the requested residents. All the care plans for resident #1 had the date initiated as 05/28/14. At 5:30 p.m., the DON stated there was no documentation that the physician or family was notified of resident #1 not having [MEDICAL TREATMENT]. She stated there was no documentation for a physician's orders [REDACTED].#1 to the emergency room .

Based on observation, review of clinical records, and staff and resident interviews, it was determined the facility failed to monitor and intervene in the management of pain for five ( #6, #9, #17, #18 and #41) of 17 sampled residents whose pain regimens were reviewed. This resulted in actual harm for resident #9 who experienced multiple delays in the administration of his [MEDICATION NAME] from one to ten days. The facility identified 74 residents who received pain medications. Findings. 1. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 11/26/13 and last updated 01/07/14, documented, "...PROBLEM Resident at risk for pain... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS 12/3/13 (12/03/13) [MEDICATION NAME] 25mcg/1 (hour): apply i/i patch Q 3D...Visualize patch Q shift..." A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 25 mcg/hr... amt. rec'd 10...amt. on hand 0... Nurse applying patch (name deleted) Date 12/24/13... amt remaining 3... Nurse applying patch (name deleted) Date 12/28/13... amt remaining 2..." A TAR, dated December 2013 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q 72..." The TAR documented a new [MEDICATION NAME] Patch was placed and the old one removed on 12/09/13, 12/12/13, 12/15/13, 12/18/13, 12/21/13, 12/24/13 and 12/28/13. There were 96 hours between the change of the patch on 12/24/13 and the change of the patch on 12/28/13. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength (blank)... amt. rec'd (blank)...amt. on hand (blank)... Nurse applying patch (name deleted) Date 2/05/14... amt remaining 0... +10 2/11/14 1230 am (02/11/14 at 12:30 a.m.) Nurse applying patch (name deleted) Date 2/11/14... amt remaining 9..." Nurse applying patch (name deleted) Date 2/17/14... amt remaining 7... Nurse applying patch (name deleted) Date 2/21/14... amt remaining 6..." Nurse applying patch (name deleted) Date 3/1/14... amt remaining 5..." A TAR, dated February 2014 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q 72..." The TAR documented a new [MEDICATION NAME] Patch was placed and the old one removed on 02/02/14, 02/05/14, 02/11/14, 02/14/14, 02/17/14, 02/21/14 and 02/26/14. No [MEDICATION NAME] was signed out on the 26th and the count was correct on the sign out sheet. There were 144 hours between the patches applied on 02/05/14 and 02/11/14; 96 hours between the patches applied on 02/17/14 and 02/21/14; and 192 hours between the patches applied on 02/21/14 and 03/01/14. A quarterly assessment, dated 02/21/14, documented the resident was independent in cognitive skills for daily decision making. He required supervision with bed mobility, transfers, locomotion and eating. He required limited assistance with dressing and extensive assistance with hygiene and bathing. The resident had limited range of motion in his bilateral lower extremities. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength (blank)... amt. on hand 5... Nurse applying patch (name deleted) Date 3/4/14... amt remaining 4... Nurse applying patch (name deleted) Date 3/8/14... amt remaining 3...(error circled) Nurse applying patch (name deleted) Date 3/9/14... amt remaining 2... Nurse applying patch (name deleted) Date 3/12/14... amt remaining 1... Nurse applying patch (name deleted) Date 03/15/14... amt remaining 0...3-24 (03/24/14 rec'd 10..." Nurse applying patch (name deleted) Date 03/25/14... amt remaining 9..." A TAR, dated March 2014 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q 72..." The TAR documented a new [MEDICATION NAME] was placed and the old one removed on 03/01/14, 03/04/13, 03/12/14, 03/15/14, 03/21/14 and 03/25/14. No [MEDICATION NAME] was signed out on the 21st and the count was correct on the sign out sheet. There were 96 hours between the patches applied on 03/04/14 and 03/08/14; and 240 hours between the patches applied on 03/15/14 and 03/25/14. A monthly physician's orders [REDACTED]. On 03/26/14 at 9:45 a.m., the DON and Corporate RN were shown the TAR's. The corporate RN stated, "We did a pain assessment last night. He didn't get the patches." At 10:00 a.m., the resident was asked if he experienced pain. He stated I've had problems with my back for a long time. It's been pretty bad this month. He was asked if he had been getting his pain patch changed every 72 hrs. He stated, "There's been often times I haven't gotten it." At 10:35 a.m., the resident was asked if his pain had impacted his activities of daily living. He stated, "Some days I'm pretty bad like with my pain. Yes, when I'm hurting my day consists of just staying in bed and being quiet." 2. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 10/29/13 and last updated 01/27/14, documented, "...PROBLEM Resident at risk for chronic pain R/T dx of chronic pain, chronic real failure and chronic A-fib... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS 9/26/13 (09/26/13) [MEDICATION NAME] 25mcg/hr apply i/i patch Q 3D...Visualize patch Q shift..." A quarterly assessment, dated 01/15/14, documented the resident was independent in cognitive skills for daily decision making. He required extensive assistance with bed mobility, transfers, dressing, hygiene and bathing. He required set up only with eating and total assistance with locomotion. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength (blank)... amt. on hand (blank)... Nurse applying patch (name deleted) Date 1-19/14 (01/19/14)... amt remaining 3... Nurse applying patch (name deleted) Date 1/20/14 (01/20/14)... amt remaining 2... Nurse applying patch (name deleted) Date 1-23-14 (01/23/14)... amt remaining 1... Nurse applying patch (name deleted) Date 1-26-14 (01/26/14)... amt remaining 0... Nurse applying patch (name deleted) Date 1-31-14 (01/31/14) Rec'd 10 patches... amt remaining 9... A TAR, dated January 2014 documented, "[MEDICATION NAME] DIS 25MCG/HR Sub For: [MEDICATION NAME] Apply 1 patch every 3 days (72 hours)...Chronic Pain..." The TAR documented a new [MEDICATION NAME] Patch was placed and the old one removed on 01/01/14, 01/04/14, 01/07/14, 01/10/14, 01/13/14, 01/16/14, 01/19/14, 01/20/14, 01/23/14, 01/26/14 and 01/31/14. A nursing observation/comment, dated 01/20/14, on the back of the TAR, documented, "[MEDICATION NAME] fell off. New patch placed..." There were 120 hours between the change of the [MEDICATION NAME]es on 01/26/14 and 01/31/14. A monthly physician's orders [REDACTED]. On 03/26/14 at 4:15 p.m., the corporate nurse was asked why the [MEDICATION NAME] was not changed for 120 hours. She stated, "It wasn't in house." On 03/27/14 at 9:10 a.m., the resident was asked if his pain ever keeps him from performing activities of daily living. He stated, "Yes." 3. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 10/29/13 and last updated 01/27/14, documented, "...PROBLEM Resident at risk for pain... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS 9/13/13 (09/13/13) [MEDICATION NAME] 100 mcg/hr patch apply i/i patch to skin Q 72 (hours)..." A quarterly assessment, dated 01/17/14, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance with bed mobility and dressing. She required total assistance with locomotion, hygiene and bathing. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 100... amt. on hand (blank)...carry over 6 Nurse applying patch (name deleted) Date 1-26-14 (01/26/14)... amt remaining 5... Nurse applying patch (name deleted) Date 1-29-14 (01/29/14)... amt remaining 4... Nurse applying patch (name deleted) Date 2-5-14 (002/05/14)... amt remaining 3..." A TAR, dated January 2014 documented, "[MEDICATION NAME] Patch 100 patch apply i/i topically every 3 days (72(hours))...order date 12/11/13..." The January TAR documented the [MEDICATION NAME] Patch was placed on 01/29/14. A TAR, dated February 2014 documented, "[MEDICATION NAME] DIS 100MCG/HR For: [MEDICATION NAME] Apply 1 patch every 3 days (72 hours)..." The February TAR documented the [MEDICATION NAME] Patch was placed and removed on 02/05/14. There were 144 hours between the changes of the [MEDICATION NAME]es. A monthly physician's orders [REDACTED]. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 100... amt. on hand (blank)...carry over 8 Nurse applying patch (name deleted) Date 2-23-14 (02/23/14)... amt remaining 7... Nurse applying patch (name deleted) Date 2-26-14 (02/26/14)... amt remaining 6... Nurse applying patch (name deleted) Date 3-1-14 (03/01/14)... amt remaining 5... Nurse applying patch (name deleted) Date 3-4-14 (03/04/14)... amt remaining 4... Nurse applying patch (name deleted) Date 3-7-14 (03/07/14)... amt remaining 3... Nurse applying patch (name deleted) Date 3-11-14 (03/11/14)... amt remaining 2... Nurse applying patch (name deleted) Date 3-14-14 (03/14/14)... amt remaining 1... Nurse applying patch (name deleted) Date 3-17-14 (03/17/14)... amt remaining 0... Nurse applying patch (name deleted) Date 3-21-14 (03/21/14)... amt remaining 9...received 10..." A TAR, dated March 2014 documented, "[MEDICATION NAME] 100 mcg/hr patch i/i patch Q 72..." The TAR documented the [MEDICATION NAME] Patch was placed and removed on 03/01/14, 03/04/14, 03/07/14, 03/11/14, 03/14/14, 03/17/14, 03/21/14 and 03/24/14. There were 96 hours between the changes of the [MEDICATION NAME]es on 03/07/14 and 03/11/14; and on 03/17/14 and 03/21/14. On 03/26/14 at 2:45 p.m., ADON #3 was asked about the missed doses of [MEDICATION NAME]. She stated, "Truthfully I think it was a new nurse and she just missed them." 4. Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED]. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 25... amt. rec'd 5... Nurse applying patch (name deleted) Date 9/20/13 (09/20/13)... amt remaining 4... Nurse applying patch (name deleted) Date 9/24/13 (09/24/13)... amt remaining 3... Nurse applying patch (name deleted) Date 9/27/13 (09/27/13)... amt remaining 2... Nurse applying patch (name deleted) Date 10-1-13 (10/01/13)... amt remaining 1..." Nurse applying patch (name deleted) Date 10-4-13 (10/04/13)... amt remaining 0..." A TAR, dated September 2013 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q3D..." The TAR documented the [MEDICATION NAME] Patch was placed and removed on 09/20/13, 09/24/13, 09/27/13. There were 96 hours between the application of the [MEDICATION NAME]es applied on 09/20/13 and 09/24/13; and 09/27/13 and 10/01/013. A care plan, initiated 11/19/13 and last updated 01/25/14, documented, "...PROBLEM Resident at risk pain... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS [MEDICATION NAME] 25mcg patch apply i/i patch topically Q3D... 11/19/13 DC [MEDICATION NAME]..." A quarterly assessment, dated 02/12/14, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance with transfers, bed mobility and eating. She required extensive assistance with ambulation, dressing, hygiene and bathing. On 03/27/14 at 9:30 a.m., the DON was asked about the missed doses of [MEDICATION NAME]. She stated, "They were missed." 5. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 09/30/13, documented "Problem: (Resident name deleted) is at risk for decline in cognitive function R/T (related to) [DIAGNOSES REDACTED]. Problem: (Resident name deleted) is at risk for pain r/t stage IV (four) pressure ulcer and chronic pain. Goal: Will have pain relieved within 1 hr (hour) of intervention. Plan of Approach: 1) Pain assessment form completed and in chart . Update PRN (as needed)... 3) Nursing to monitor for s/s (signs/symptoms) of pain, verbal and nonverbal (moaning, grimacing, increased restlessness, guarding, agitation, etc.)... Evaluation and Progress: [MEDICATION NAME] 25 mg per peg QID (four times a day)10/29/13 - [MEDICATION NAME] 50 mg Give 1/2 tab to = 25 mg per PT (peg tube) Q (every) 6 (hours) routinely for pain X 60 days & renew..." A quarterly assessment, dated 12/23/13, documented the resident was severely impaired in cognitive skills for daily decision making. The resident was totally dependent and required two person physical assist for bed mobility, transfers and bathing. She was totally dependent and required one person physical assist for dressing, eating and hygiene. She had impairment in range of motion on both sides of both the upper and lower extremity. The monthly physician's orders [REDACTED]...01/30/14 [MEDICATION NAME] HCL ([MEDICATION NAME]) tab (tablet) 50mg for [MEDICATION NAME]: 1/2 tab (25 mg) by mouth every 6 hours X 60 days & renew..." The March 2014 MAR indicated [REDACTED]. On 03/17/14 and 3/18/14 at 6PM, the medication was circled and initialed (documented as refused by the resident). On 03/18/14 at 12 noon the entry was a circle with no initials. The reverse side of the MAR indicated [REDACTED]." Review of the 'Individual Patient's Narcotics Record' documented the resident received the medication only three times on 03/17/14, did not receive the medication at all on 03/18/14 and received the ordered medication only two times on 03/19/14. On 03/24/14 at 5:20 p.m., the DON was asked if she could locate any additional documentation to show the medication was administered as ordered. She stated the facility had a CMA who was taking care of ordering medications and that when she left, the medication aides were supposed to order medications but that didn't work out. On 03/25/14 at 10:00 a.m., the resident was observed lying on her left side in the bed. Both her upper and lower extremities were contracted with her arms drawn up at the elbows and her legs drawn up at the knees. She had an indwelling catheter in place draining dark yellow colored urine to gravity. The resident had three pressure ulcers, one on her right ischium, one on the second toe on her right foot and one on her left inner leg. The resident had a PEG (percutaneous enteral gastrostomy) tube in place and received bolus feedings every four hours. She was unable to answer any questions and was sobbing and turning her head away when approached by the surveyor.

Based on record review and interviews, it was determined the facility failed to ensure; ~ significant medication errors did not occur for four (#18, #9, #17 and #41) of six sampled residents who received [MEDICATION NAME]es. This resulted in actual harm for resident #9, who experienced multiple delays in the administration of his [MEDICATION NAME] from one to ten days. The facility identified five residents who received [MEDICATION NAME]es; and ~ significant medication errors did not occur for four (#2, #6, #12 and #13) of 15 sampled residents whose medications were reviewed. This had the potential to affect all 78 residents who resided in the facility. Findings: 1. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 11/26/13 and last updated 01/07/14, documented, "...PROBLEM Resident at risk for pain... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS 12/3/13 (12/03/13) [MEDICATION NAME] 25mcg/1 (hour): apply i/i patch Q 3D...Visualize patch Q shift..." A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 25 mcg/hr... amt. rec'd 10...amt. on hand 0... Nurse applying patch (name deleted) Date 12/24/13... amt remaining 3... Nurse applying patch (name deleted) Date 12/28/13... amt remaining 2..." A TAR, dated December 2013 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q 72..." The TAR documented a new [MEDICATION NAME] Patch was placed and the old one removed on 12/09/13, 12/12/13, 12/15/13, 12/18/13, 12/21/13, 12/24/13 and 12/28/13. There were 96 hours between the change of the patch on 12/24/13 and the change of the patch on 12/28/13. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength (blank)... amt. rec'd (blank)...amt. on hand (blank)... Nurse applying patch (name deleted) Date 2/05/14... amt remaining 0... +10 2/11/14 1230 am (02/11/14 at 12:30 a.m.) Nurse applying patch (name deleted) Date 2/11/14... amt remaining 9..." Nurse applying patch (name deleted) Date 2/17/14... amt remaining 7... Nurse applying patch (name deleted) Date 2/21/14... amt remaining 6..." Nurse applying patch (name deleted) Date 3/1/14... amt remaining 5..." A TAR, dated February 2014 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q 72..." The TAR documented a new [MEDICATION NAME] Patch was placed and the old one removed on 02/02/14, 02/05/14, 02/11/14, 02/14/14, 02/17/14, 02/21/14 and 02/26/14. No [MEDICATION NAME] was signed out on the 26th and the count was correct on the sign out sheet. There were 144 hours between the patches applied on 02/05/14 and 02/11/14; 96 hours between the patches applied on 02/17/14 and 02/21/14; and 192 hours between the patches applied on 02/21/14 and 03/01/14. A quarterly assessment, dated 02/21/14, documented the resident was independent in cognitive skills for daily decision making. He required supervision with bed mobility, transfers, locomotion and eating. He required limited assistance with dressing and extensive assistance with hygiene and bathing. The resident had limited range of motion in his bilateral lower extremities. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength (blank)... amt. on hand 5... Nurse applying patch (name deleted) Date 3/4/14... amt remaining 4... Nurse applying patch (name deleted) Date 3/8/14... amt remaining 3...(error circled) Nurse applying patch (name deleted) Date 3/9/14... amt remaining 2... Nurse applying patch (name deleted) Date 3/12/14... amt remaining 1... Nurse applying patch (name deleted) Date 03/15/14... amt remaining 0...3-24 (03/24/14 rec'd 10..." Nurse applying patch (name deleted) Date 03/25/14... amt remaining 9..." A TAR, dated March 2014 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q 72..." The TAR documented a new [MEDICATION NAME] was placed and the old one removed on 03/01/14, 03/04/13, 03/12/14, 03/15/14, 03/21/14 and 03/25/14. No [MEDICATION NAME] was signed out on the 21st and the count was correct on the sign out sheet. There were 96 hours between the patches applied on 03/04/14 and 03/08/14; and 240 hours between the patches applied on 03/15/14 and 03/25/14. A monthly physician's orders [REDACTED]. On 03/26/14 at 9:45 a.m., the DON and Corporate RN were shown the TAR's. The corporate RN stated, "We did a pain assessment last night. He didn't get the patches." At 10:00 a.m., the resident was asked if he experienced pain. He stated I've had problems with my back for a long time. It's been pretty bad this month. He was asked if he had been getting his pain patch changed every 72 hrs. He stated, "There's been often times I haven't gotten it." At 10:35 a.m., the resident was asked if his pain had impacted his activities of daily living. He stated, "Some days I'm pretty bad like with my pain. Yes, when I'm hurting my day consists of just staying in bed and being quiet." 2. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 10/29/13 and last updated 01/27/14, documented, "...PROBLEM Resident at risk for chronic pain R/T dx of chronic pain, chronic real failure and chronic A-fib... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS 9/26/13 (09/26/13) [MEDICATION NAME] 25mcg/hr apply i/i patch Q 3D...Visualize patch Q shift..." A quarterly assessment, dated 01/15/14, documented the resident was independent in cognitive skills for daily decision making. He required extensive assistance with bed mobility, transfers, dressing, hygiene and bathing. He required set up only with eating and total assistance with locomotion. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength (blank)... amt. on hand (blank)... Nurse applying patch (name deleted) Date 1-19/14 (01/19/14)... amt remaining 3... Nurse applying patch (name deleted) Date 1/20/14 (01/20/14)... amt remaining 2... Nurse applying patch (name deleted) Date 1-23-14 (01/23/14)... amt remaining 1... Nurse applying patch (name deleted) Date 1-26-14 (01/26/14)... amt remaining 0... Nurse applying patch (name deleted) Date 1-31-14 (01/31/14) Rec'd 10 patches... amt remaining 9... A TAR, dated January 2014 documented, "[MEDICATION NAME] DIS 25MCG/HR Sub For: [MEDICATION NAME] Apply 1 patch every 3 days (72 hours)...Chronic Pain..." The TAR documented a new [MEDICATION NAME] Patch was placed and the old one removed on 01/01/14, 01/04/14, 01/07/14, 01/10/14, 01/13/14, 01/16/14, 01/19/14, 01/20/14, 01/23/14, 01/26/14 and 01/31/14. A nursing observation/comment, dated 01/20/14, on the back of the TAR, documented, "[MEDICATION NAME] fell off. New patch placed..." There were 120 hours between the change of the [MEDICATION NAME]es on 01/26/14 and 01/31/14. A monthly physician's orders [REDACTED]. On 03/26/14 at 4:15 p.m., the corporate nurse was asked why the [MEDICATION NAME] was not changed for 120 hours. She stated, "It wasn't in house." On 03/27/14 at 9:10 a.m., the resident was asked if his pain ever keeps him from performing activities of daily living. He stated, "Yes." 3. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated 10/29/13 and last updated 01/27/14, documented, "...PROBLEM Resident at risk for pain... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS 9/13/13 (09/13/13) [MEDICATION NAME] 100 mcg/hr patch apply i/i patch to skin Q 72 (hours)..." A quarterly assessment, dated 01/17/14, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance with bed mobility and dressing. She required total assistance with locomotion, hygiene and bathing. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 100... amt. on hand (blank)...carry over 6 Nurse applying patch (name deleted) Date 1-26-14 (01/26/14)... amt remaining 5... Nurse applying patch (name deleted) Date 1-29-14 (01/29/14)... amt remaining 4... Nurse applying patch (name deleted) Date 2-5-14 (002/05/14)... amt remaining 3..." A TAR, dated January 2014 documented, "[MEDICATION NAME] Patch 100 patch apply i/i topically every 3 days (72(hours))...order date 12/11/13..." The January TAR documented the [MEDICATION NAME] Patch was placed on 01/29/14. A TAR, dated February 2014 documented, "[MEDICATION NAME] DIS 100MCG/HR For: [MEDICATION NAME] Apply 1 patch every 3 days (72 hours)..." The February TAR documented the [MEDICATION NAME] Patch was placed and removed on 02/05/14. There were 144 hours between the changes of the [MEDICATION NAME]es. A monthly physician's orders [REDACTED]. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 100... amt. on hand (blank)...carry over 8 Nurse applying patch (name deleted) Date 2-23-14 (02/23/14)... amt remaining 7... Nurse applying patch (name deleted) Date 2-26-14 (02/26/14)... amt remaining 6... Nurse applying patch (name deleted) Date 3-1-14 (03/01/14)... amt remaining 5... Nurse applying patch (name deleted) Date 3-4-14 (03/04/14)... amt remaining 4... Nurse applying patch (name deleted) Date 3-7-14 (03/07/14)... amt remaining 3... Nurse applying patch (name deleted) Date 3-11-14 (03/11/14)... amt remaining 2... Nurse applying patch (name deleted) Date 3-14-14 (03/14/14)... amt remaining 1... Nurse applying patch (name deleted) Date 3-17-14 (03/17/14)... amt remaining 0... Nurse applying patch (name deleted) Date 3-21-14 (03/21/14)... amt remaining 9...received 10..." A TAR, dated March 2014 documented, "[MEDICATION NAME] 100 mcg/hr patch i/i patch Q 72..." The TAR documented the [MEDICATION NAME] Patch was placed and removed on 03/01/14, 03/04/14, 03/07/14, 03/11/14, 03/14/14, 03/17/14, 03/21/14 and 03/24/14. There were 96 hours between the changes of the [MEDICATION NAME]es on 03/07/14 and 03/11/14; and on 03/17/14 and 03/21/14. On 03/26/14 at 2:45 p.m., ADON #3 was asked about the missed doses of [MEDICATION NAME]. She stated, "Truthfully I think it was a new nurse and she just missed them." 4. Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED]. A [MEDICATION NAME] Patch Count/Destruction Sheet, documented "... Patch Strength 25... amt. rec'd 5... Nurse applying patch (name deleted) Date 9/20/13 (09/20/13)... amt remaining 4... Nurse applying patch (name deleted) Date 9/24/13 (09/24/13)... amt remaining 3... Nurse applying patch (name deleted) Date 9/27/13 (09/27/13)... amt remaining 2... Nurse applying patch (name deleted) Date 10-1-13 (10/01/13)... amt remaining 1..." Nurse applying patch (name deleted) Date 10-4-13 (10/04/13)... amt remaining 0..." A TAR, dated September 2013 documented, "[MEDICATION NAME] 25 mcg/hr patch i/i patch Q3D..." The TAR documented the [MEDICATION NAME] Patch was placed and removed on 09/20/13, 09/24/13, 09/27/13. There were 96 hours between the application of the [MEDICATION NAME]es applied on 09/20/13 and 09/24/13; and 09/27/13 and 10/01/013. A care plan, initiated 11/19/13 and last updated 01/25/14, documented, "...PROBLEM Resident at risk pain... GOAL Will have pain relieved within 1 hr of intervention... EVALUATION AND PROGRESS [MEDICATION NAME] 25mcg patch apply i/i patch topically Q3D... 11/19/13 DC [MEDICATION NAME]..." A quarterly assessment, dated 02/12/14, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance with transfers, bed mobility and eating. She required extensive assistance with ambulation, dressing, hygiene and bathing. On 03/27/14 at 9:30 a.m., the DON was asked about the missed doses of [MEDICATION NAME]. She stated, "They were missed." 5. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 02/10/14, documented the resident's cognitive skills for daily decision making were severely impaired. He required limited one person assistance with transfers, dressing, toilet use, personal hygiene and bathing. He required supervision set-up assistance with eating. He was frequently incontinent of bladder and occasionally incontinent of bowel. A physician's telephone order, dated 03/19/14 at 3:31 a.m., documented "[MEDICATION NAME] ophthalmic 0.3%, II gtts ou TID x 10 days DX [MEDICAL CONDITION]" A March 2014 treatment record, documented the resident was to receive [MEDICATION NAME] at 8:00 a.m., 2:00 p.m. and 8:00 p.m., with a starting date of 03/19/14. The treatment record documented the resident did not receive the 8:00 p.m. dose on 03/19/14, the 2:00 p.m. and 8:00 p.m. dose on 03/21/14 and the 8:00 p.m. dose on 03/24/14. A care plan, dated 03/19/14 documented, "...Problem Needs eye drops due to: B [MEDICAL CONDITION] Goal Infection will resolve within time frame of ABX drops (10D)... Plan of Approach...1) Eye drops as ordered... Evaluation and Progress 1 [MEDICATION NAME] ophthalmic 0.3% II gtts ou TID x 10 D..." There was no documentation in the nurses notes related to the telephone order dated 03/19/14. On 03/26/14 at 3:40 p.m., an interview was conducted with the DON. She was asked if resident #12 had a medication error report for the above dates the [MEDICATION NAME] antibiotic was not given. She was asked when the medication arrived in the facility. She stated she would check on it and let the surveyor know. At 3:45 p.m., the DON informed the surveyor a medication error report had not been done for the [MEDICATION NAME] medication that was not given on the above dates. She stated she called the pharmacy and was told by the pharmacist, the medication was picked up from the pharmacy on 03/19/14 at 7:30 p.m. She was asked if the resident should have received his 8:00 p.m. dose on 03/19/14. She stated, "Yes." She was asked if the doses on 03/21/14 and 03/24/14 were given. She stated, "No." 6. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 09/30/13, documented "Problem: (Resident name deleted) is at risk for decline in cognitive function R/T (related to) [DIAGNOSES REDACTED]. Problem: (Resident name deleted) is at risk for pain r/t stage IV (four) pressure ulcer and chronic pain. Goal: Will have pain relieved within 1 hr (hour) of intervention. Plan of Approach: 1) Pain assessment form completed and in chart . Update PRN (as needed)... 3) Nursing to monitor for s/s (signs/symptoms) of pain, verbal and nonverbal (moaning, grimacing, increased restlessness, guarding, agitation, etc.)... Evaluation and Progress: [MEDICATION NAME] 25 mg per peg QID (four times a day)10/29/13 - [MEDICATION NAME] 50 mg Give 1/2 tab to = 25 mg per PT (peg tube) Q (every) 6 (hours) routinely for pain X 60 days & renew..." A quarterly assessment, dated 12/23/13, documented the resident was severely impaired in cognitive skills for daily decision making. The resident was totally dependent and required two person physical assist for bed mobility, transfers and bathing. She was totally dependent and required one person physical assist for dressing, eating and hygiene. She had impairment in range of motion on both sides of both the upper and lower extremity. The monthly physician's orders [REDACTED]...01/30/14 [MEDICATION NAME] HCL ([MEDICATION NAME]) tab (tablet) 50mg for [MEDICATION NAME]: 1/2 tab (25 mg) by mouth every 6 hours X 60 days & renew..." The March 2014 MAR indicated [REDACTED]. On 03/17/14 and 3/18/14 at 6PM, the medication was circled and initialed (documented as refused by the resident). On 03/18/14 at 12 noon the entry was a circle with no initials. The reverse side of the MAR indicated [REDACTED]." Review of the 'Individual Patient's Narcotics Record' documented the resident received the medication only three times on 03/17/14, did not receive the medication at all on 03/18/14 and received the ordered medication only two times on 03/19/14. On 03/24/14 at 5:20 p.m., the DON was asked if she could locate any additional documentation to show the medication was administered as ordered. She stated the facility had a CMA who was taking care of ordering medications and that when she left, the medication aides were supposed to order medications but that didn't work out. On 03/25/14 at 10:00 a.m., the resident was observed lying on her left side in the bed. Both her upper and lower extremities were contracted with her arms drawn up at the elbows and her legs drawn up at the knees. She had an indwelling catheter in place draining dark yellow colored urine to gravity. The resident had three pressure ulcers, one on her right ischium, one on the second toe on her right foot and one on her left inner leg. The resident had a PEG (percutaneous enteral gastrostomy) tube in place and received bolus feedings every four hours. She was unable to answer any questions and was sobbing and turning her head away when approached by the surveyor. 7. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. CAD. A quarterly assessment, dated 12/17/13, documented the resident was moderately impaired in cognitive skills for daily decision making. He required extensive assistance of one person for eating, transfers, dressing, personal hygiene and bathing. He did not walk in his room or the corridor and used a wheelchair for mobility. He had limitation in range of motion of his lower extremity on both sides. The assessment documented the resident had one stage 3 pressure ulcer. A care plan, dated 11/07/13, documented "...Problem: (Resident name deleted) has a current dx (diagnosis) of UTI (urinary tract infection). Goal: UTI will be resolved/resolving X 14 days... Plan of Approach:...7) Administer medication per physician order... 10) Monitor res (resident) for s/s AR (adverse reactions) to ATB (antibiotics)... 11) Monitor res for effectiveness & document Q shift. Report to PCP (primary care provider)/Charge Nurse PRN. 12) Monitor res temp Q shift & document. Report to charge nurse/PCP PRN (as needed). Evaluation and Progress:...2/24/14 Bactrim D2 - (two) equivalent PO (by mouth) BID (two times a day) X 14 days if suspension available (sic)..." A physician's telephone order, dated 02/24/14, documented "Bactrim D2 - two tab equivalent PO BID X 14 days if suspens. (suspension) unavailable." A February 2014 MAR indicated [REDACTED]. The physician's orders [REDACTED]. The medication was not documented as administered until 02/28/14. The reverse side of the MAR indicated [REDACTED]." A count sheet for the antibiotic documented the initial dose of Bactrim was administered on 02/28/14 at 9:00 a.m., and the final dose was administered on 03/06/14 at 8:00 a.m. On 03/25/14 at 10:15 a.m., the resident was observed as he received catheter care for an indwelling catheter. He was lying supine and was repositioned in bed with assistance. He was verbally able to converse with some periods of confusion. He was oriented to person and place only. On 03/24/14 at 5:20 p.m., the surveyor asked the DON if she could locate any additional documentation to show the medication was administered as ordered. She stated the facility had a CMA who was taking care of ordering medications on the 7-3 shift and that when she left, the medication aides were supposed to order medications but that didn't work out. She stated "I think we were supposed to start the Bactrim on the 25th of February after the [MEDICATION NAME] was finished." 8. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A physician's orders [REDACTED]." A care plan, dated 7/22/13, documented "...Problem: Receives [MEDICAL CONDITION] medication Q day... Goal: Will not have symptoms of side effects to receiving [MEDICAL CONDITION] medication. Pharmacist will review drug regimen monthly. Plan of Approach: 1) Give all meds as ordered... ...Problem: (Resident name deleted) has a dx of hypertension and is at risk for abnormal blood pressures, falls and pain/discomfort... Goal: Will have blood pressure within normal range... Plan of Approach...6) Administer meds as ordered by physician... Evaluation and Progress...7/19/12 [MEDICATION NAME] 100 mg 1/2 tab po BID... Problem: (Resident name deleted) is at risk for shortness of breath, painful respirations, [MEDICAL CONDITION], chest pain, abnormal blood pressures and irregular heart rate and rhythm. Has DX of: [MEDICAL CONDITION], A-FIB, [MEDICAL CONDITION] FLUTTER. Goal: Will have minimal to no s/s of difficult breathing, shortness of breath, upper respiratory infections, [MEDICAL CONDITION], chest pain and irregular heart rate and rhythm and will not have abnormal blood pressure Q day X 90 days... Plan of Approach:...2) Observe for shortness, difficulty breathing... 10) Measure and record I/O Q shift. 11) Observe for [MEDICAL CONDITION] and report findings..." A physician' s order, dated 09/04/13, documented " ..Trazadone 50 mg 1/2 tab (25 mg) po q hs (hour of sleep)..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 01/10/14, documented the resident was independent in cognitive skills for daily decision making and had no behaviors. He required supervision/set-up help only for transfers, locomotion, dressing and eating. he was independent with personal hygiene and required extensive assistance of one person for bathing. He was continent of bowel and bladder. A physician's orders [REDACTED]..[MEDICATION NAME] 40 mg one tab po q am (Give with 80 mg to = 120 mg). " The February 2014 MAR, documented the resident was to receive the KLOR CON (potassium chloride) 20 meg at 8:00 a.m., 1:00 p.m., and 8:00 p.m. The same document showed the resident did not receive the 8:00 a.m., or 1:00 p.m., dose on 02/08/14 and that he refused the 8:00 a.m., dose and 1:00 p.m., dose on 02/07/14, 02/09/14 and 02/10/14. The reverse side of the MAR indicated [REDACTED]"2/6/14 1P Wasted Res refused 1 Pm [MEDICATION NAME] No Potassium" and "02/9 12N Waiting for [MEDICATION NAME] to arrive ordered 2/8." The March 2014 MAR indicated [REDACTED]. The medication was not administered on 03/24/14 for the 9:00 p.m. dose. The reverse side of the MAR indicated [REDACTED]. There was no documentation of the resident refusals or why he refused the medication. The March 2014 MAR indicated [REDACTED]. The same MAR indicated [REDACTED]. The reverse side of the MAR indicated [REDACTED]" and "3/11/14 Bupron ([MEDICATION NAME]) 150 mg med unavailable ordered from pharmacy." The March 2014 MAR indicated [REDACTED]. The same MAR indicated [REDACTED]. A physician's telephone order, dated 03/19/14, (no time on order) documented "[MEDICATION NAME] 500 mg one po TID X 7 days infected area Rt (right) 1st finger..." A care plan, dated 03/19/14, documented "...Infection to R (right) 1st finger. Goal: Infection will resolve within 7D (7 days) with Abx (antibiotic) treatment. Plan of Approach: 1) Administer Abx as ordered. 2) Insure (sic) area stays clean. Evaluation and Progress: [MEDICATION NAME] 500 mg PO (by mouth) TID (three times a day) X 7 D (for 7 days)..." According to the MAR, the [MEDICATION NAME] was to be administered at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The March 2014 MAR, documented the initial dose of the medication was not administered until 03/20/14 for the 2:00 p.m. dose. The same sheet documented the resident did not receive the 8:00 p.m., dose for 3/20/14, the 8:00 a.m., dose for 03/21/14, the 8:00 p.m., dose for 03/24/14 and the 2:00 p.m., and 8:00 p.m., doses for 03/26/14. A facility antibiotic count sheet for the [MEDICATION NAME] 500 mg, documented the initial dose was administered on 03/20/14 at 1345 (1:45 p.m.). The resident only received two doses on 03/21/14 and 03/24/14 and only one dose on 03/26/14. There were six pills remaining on 03/26/14 according to the count sheet when all the antibiotic should have been completed. On 03/26/14 at 1:40 p.m., the surveyor showed the DON all of the documentation of the medications not administered. She stated "The meds should be available, there's no reason why they can't get them from the pharmacy." At 3:50 p.m., resident #13 was interviewed. He was alert and oriented to person, place, time and event. He was well groomed and dressed appropriately for the season. The surveyor asked him if he had received his Trazadone on 03/14/14 through 03/16/14. He stated, "They said they didn't have it, so that's why they couldn't give it to me." The resident further stated, "They are not ordering the medications like they should. That has been a problem for the last six months. All the time they say the med wasn't available. The problem with the [MEDICATION NAME] and Potassium is I don't get the morning dose til 10:00 in the morning, then they want to give the next dose at 2:00 in the afternoon, that's too early and that's why I refuse it when I do. "

Based on observation, record review, and interview, it was determined the facility failed to provide supervision to prevent falls for two (#1 and #3) of three sampled residents whose clinical records were reviewed for falls. Resident #1 sustained falls that resulted in actual harm from a fracture of the upper and lower extremities. This had the potential to affect 88 residents identified by the facility who were at risk for falls. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, dated 01/09/13, documented "... Problem Resident is at risk for fall r/t: Fall 01/09/13 @ 2100...01/12/13 R distal ulna Fx...Goals Minimize injuries related to falls through next period reporting 90 days...Interventions 1. Call bell within reach 2. Assure proper footware 3. Encourage resident to ask for assistance with transfers, bed mobility, ambulation etc.. 4. Keep pathway clear and free of clutter. 5. Observe for wet, slippery floors. 6. Observe for side effects from medicines. 7. Observe for changes LOC. 8. Keep areas well lit. 9. Refer to therapy as needed... 10. Bed in low position c bolsters 11. Bed Alarm 12. Floor mat alarm 13. Falling star hung on w/c bed and walker. 01/17/13 @ 12 noon Res found lying on floor in her room...01/17/13 @ 0840 Res found on floor in res room at bedside... Interventions -Continue current safety interventions...- Continue above safety interventions -Res to wear R distal ulnar soft splint at all times X 5 wks, & then rtn to MD. Family consent for self release, alarmed seat belt for w/c, Frequent observations of Res. (check mark) check Batteries & function on safety alarms..." A care plan, dated 01/18/13, documented "...Problem cont'd from 01/17/13 Goal fall...Evaluation and Progress -DC Fall Mat alarm; /staff assist c transfers -walker removed from room; sent c POA/(name deleted) -w/c self release seat belt /alarmed, c Falling Star updated on w/c, cushion in w/c -Falling Star Posted in room. -Assist Res c eating (secondary to) R hand dominant -Offer fluids freq-Risk Mag Mat placed at bedside. -(name deleted), signed consent for w/c restraint belt & care plan voices understanding for all safety interventions - Remove w/c seat belt q 2 hrs & prn for ADL's (secondary to) unaware of safety limitations-Assist c po food & flds (secondary to) R arm Fx- R dominant hand... A physician's orders [REDACTED]." A care plan, dated 01/23/13, documented "...PROBLEM (name deleted) needs a restraint to reduce risk of injury due to orthostasis, RT arm fx, dementia GOAL (name deleted) will have no injuries r/t use of restraint daily. PLAN OF APPROACH 1) self-release w/c belt alarm restraint when up in w/c r/t lower leg weakness, impaired balance, unaware of limitations-to prevent injury from: 2) Release every 2 hrs and prn for Adl's 3) Attempt restraint reduction 2 x year. 4) Encourage participation in activities of facility assist to and from. 5) monitor for adverse effects, constipation, decline in adl's skin, pain, weight..." A nurse's note, dated 03/19/13 at 12:30 a.m., documented "...Res' ( Resident's) bed alarm sounding, CNA rushed to resident's room and found resident on the floor & (and) notified to this nurse. Then this nurse observe the resident on the floor supine- HTTA (Head To Toe Assessment) completed No redness or hematoma to the head noted- Neuro (check mark) (checks) initiated WNL (Within In Normal Limits) for this resident- up on ROM's Res c/o (complains of) RUE pain & start moaning (Bilateral) hands grips but (Right) hand weak d/t (due to) pain (Bilateral) PERRLA (Pupils Equally Reactive To Light and Accomodation) Hydro ( Hydocodone) 5/325mg (Milligrams) two tabs (tablets) po given for pain and brought the resident to the nurses station for closer supervision..." An incident report form, dated 03/19/13, documented the resident was observed on the floor, which resulted in a fracture of the right humerus. Safety interventions were in place and bed canes were added to the bed. A care plan update on 03/19/13 documented, "...Problem (name deleted) has a history of falls with injury. Fall score 105...03/19/13 @ 0300 Res obs'd on floor in room...New intervention: Bed cane x1, bolster overlay and send to (name deleted) ER to eval R LE pain per family request..." A nurse's note, dated 03/20/13 at 10:00 a.m., documented "... Focused charting r/t Res obs'd (observed) on floor supine, in Res room...Staff reports this am, Res holding (Right) arm & resists staff assessing same...Res refuses movement-passive & active of (Right) arm, saying 'no' - holds arm to chest, c elbow flexed as if sling was in place...(name family member deleted) here; requests "I want her sent out to ER (emergency room ) to evaluate arm pain..." A physician' s order, dated 03/20/13 at 11:55 a.m., documented "...Transport via (ambulance) to (name deleted) ER to eval R arm pain & cough c congestion per family request ..." An emergency room report, dated 03/20/13, documented "...HPI ...Chief Complaint: fall right arm pain...Rad Impression...Radiograph of the right humerus was obtained. I viewed the images myself on the PACS (Picture Archiving and Communication Systems Software) system. My interpretation of the images is: Fracture proximal humerus. The radiologist interpretation had no significant clinical variation from my reading..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nurse's note, dated 04/04/13 at 2:00 p.m., documented, "...(family member name deleted) states 'Seems like her pain in hips & (upper) legs is getting worse; when she is moved she rubs her hip and says no-no-no.' 'Today the (Right) hip hurts more; the other day it was the (Left) hip...I think we should go to the ER.'..." An emergency room report, dated 04/04/13, documented "...HPI...Chief Complaint: Hip injury...HISTORY OF PRESENT ILLNESS: Patient is an [AGE] year-old demented female who lives at the nursing home. She comes in with family members who state that she will bear weight and is complaining of pain. Patient had a fall several weeks ago and fractured her right proximal humerous. Since that time she has not wanted to walk. She hasn't specifically complained of any pain but seems to moan when she is moved or her legs are moved. The family cannot tell if it is a left or the right hip. Patient seems to complain with movement of either hip. Patient rubs the left leg but complains that the right leg is moved. Patient is demented and unable to give any history...Rad Impression Radiograph of the right hip and pelvis was obtained. I viewed the images myself on the PACS system. My interpretation of the images is: Fracture right femoral neck." A physician's orders [REDACTED]. A physicians order, dated 04/12/13, documented "...PT Clarification order: PT 5-6 x wk x 60 days for therapeutic exercise...gait training and wheelchair mobility..." A physician's orders [REDACTED]. A care plan update on 04/25/13, documented "...Cont (continue) POC p sig (change) ..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nurse's note, dated 05/14/13 at 6:00 p.m., documented, "... Summoned to room by housekeeping responding to bed alarm. Res (Resident) observed lying on floor. Hips & (and) BLE (Bilateral Lower Extremity) on fall mat. Assessment completed. ROM to all extrem (extremeties) s (without) c/o (complaints of) pain. Observed hematoma to back of head c abrasion...On call Dr. notified order received to send to ER for eval..." An event/incident report, dated 05/14/13, documented houskeeping responded to an alarm and observed the resident on the floor. This fall resulted in a hematoma to the back of the resident's head with an abrasion. The incident report documented initial actions taken were, "... Staff Intervention..." Investigative actions documented, "...Notes: (For use by Q A Committee/Designee) -(name deleted) ER eval (no) neg findings, -Personal clip alarm and alarmed self- release seat belt to w/c (wheelchair)..." An emergency room report, dated 05/14/13, documented "...HPI...Chief Complaint: Fall ... HISTORY OF PRESENT ILLNESS: Pt. brought in by EMS from the NH after an unwitnessed fall prior to arrival, when patient sustained tender hematoma in the back of her head. Pt is a poor historian due to advanced memory changes. Family is in the room providing information..." A nurse's note, dated 05/14/13, at 9:00 p.m., documented, "...Returned from (name deleted hospital). (No) new orders. Cont to monitor. Family c res on return Neuro conts & WNL for res..." A care plan update on 05/14/13 at 6:00 p.m., documented, "...res obs'd on floor on fall mat...New notify PT/OT of fall, clip alarm and alarmed self release seat belt to w/c falling star and staff updated..." A care plan, dated 05/14/13, documented, "...PROBLEM Res needs a w/c waist restraint to prevent injury (secondary to) dementia & high risk falls while in w/c w/c waist restraint r/t unaware of safety limitations impulsivity c movement when (up) in w/c DX: Alz Dementia GOAL (no) injuries r/t use of restraint q d PLAN OF APPROACH 1. Restraint w/c waist used when (up) in w/c to prevent injury r/t falls 2. Visual (checks) q 30 & release q 2 hr prn for toileting & position x's 3 Monitor for possible less restrictive measures 4 Encourage (increased) participation of activities in facility 5 Place activity calendar in room..." A physician's note, dated 05/21/13, documented, "...Self release w/c waist restraint when (up) in w/c r/t dementia, unaware of limitations/safety & impulsive movement/activities Dx: Dementia Release q 2hrs/prn for ADL's..." A nurse's note, dated 06/14/13 at 9:15 a.m., documented "...resident was observed lying on her back @ foot of bed; body check done ROM adequate for this resident (upper) and (lower) extremeties...Assisted up into w/chair (wheel) by CNA's (certified nurses aides) chair -alarm in place and activated..." An event/incident report, dated 06/14/13, documented the resident was observed lying on her back at the foot of her bed. The incident report documented initial actions taken were, "...First Aid... Other Check Chair & bed alarm freq make sure its on..." Investigative actions documented, ...Notes: (For use by Q A Committee/Designee) -All meals in DR (Dining room) ----> (at) assisted tables - Sign posted in room to inform staff - Res (Resident) in public area in w/c unless in bed nap/sleep..." A care plan, dated 06/14/13 at 9:15 a.m., documented, "... Approach ... New All meals in DR (Dining room) ----> (at) assisted tables - Sign posted in room to inform staff - Res in public areas of NH in w/c to (increase) visual (checks); in bed to sleep-nap only per family request..." The significant change assessment, dated 07/12/13, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited one person assistance with transfers and did not ambulate. A nurse's note, dated 07/27/13 at 7:00 p.m., documented, "...Found Res on floor by nurses' station, on right side. Laceration to right side of head. left res on floor & notified ambulance to transport Res to E.R. Safety alarms on and activated @ time of incident. Res transported to E.R. via ambulance...." An event/incident report, dated 07/27/13, documented the resident was found on the floor, which resulted in a laceration to the right side of her head. The incident report documented initial actions taken were, "...First Aid...Other ER Investigative actions documented, ...Notes: (For use by Q A Committee/Designee) -ER/(hospital name deleted) for eval/treat (evaluation/treatment) head lac (laceration) -Place soft seat belt/alarmed below blouse, jacket/sweater. -New order for Vistaril 25mg po q (every) 1600 (4:00 p.m.) for anxiety/agitation..." An emergency room report, dated 07/27/13, documented "...History of Present Illness... Chief Complaint: Fall... HPI comments PATIENT BROUGHT IN VIA EMS FOR FALL FROM WHEELCHAIR. SHE LIVES AT GRACE LIVING FACILITY AND fell A FEW MONTHS AGO AND SUFFERED A HIP AND SHOULDER FRACTURE. SHE HIT HER HEAD ON THE FLOOR. SHE HAS SEVERE DEMENTIA AND CANNOT OFFER ANY MORE HISTORY ABOVE WHAT CAN BE OBTAINED FROM THE FAMILY...Wound Procedures laceration: suture description: dermabond length in cm: 0.5..." A care plan, dated 07/27/13, documented "...Approach...New (hospital name deleted) ER for eval & treat head lac via ambulance...New: place soft seatbelt c alarm below blouse and jacket..." A treatment record, dated 07/01/13-07/31/13, documented "...SELF RELEASE WHEELCHAIR WAIST RESTRAINT WHEN UP IN WHEELCHAIR R/T DEMENTIA, UNWARE OF LIMITATIONS/SAFETY; RELEASE EVERY 2 HOURS AND PRN. FOR ADL'S..." The treatment record had no documentation dated 07/05/13 on the 3:00 p.m.-11:00 p.m. shift and no documentation for 07/14/13 through 07/31/13 on 7:00 a.m.-3:00 p.m. and 3:00 p.m.-11:00 p.m. shifts. The resident sustained [REDACTED]. A care plan, dated 08/09/13, documented "... Problem (name deleted) has a fall score of 105 and is at at risk for falls r/t decreased mobility, HTN, Osteoarthritis Goals Resident will not have any significant injuries r/t falls noted x 90 days...Plan of Approach Fall assessment to be completed in chart. Up date prn. If score is 25 or greater, initiate falling star program. (1) Place star on back of w/c and above bed. 2) Keep call light in reach when in room 3) Answer call light promptly 4) Keep areas well lit and free of clutter 5) Educate family that despite interventions not all falls are preventable Risk manager mat Low bed Bed alarm Self release/alarm seat belt in w/c clip/personal alarm bed canes x 2..." A care plan, dated 08/09/13, documented "...PROBLEM (name deleted) needs a restraint to prevent injury due to: confusion GOAL will have no injuries r/t use of restraint daily PLAN OF APPROACH 1. Seat belt Restraint when in chair: to prevent injury from: falling 2. Visual check every 30 min, release q 2 hrs x 10 min for toileting & position changes 3 Monitor for possible less restrictive measures 4 Encourage participation of activities in facility. assist to and from. 5 Place activity calendar in view, in residents room..." A treatment record, dated 08/01/13-08/31/13, documented "...SELF RELEASE WHEELCHAIR WAIST RESTRAINT WHEN UP IN WHEELCHAIR R/T DEMENTIA, UNWARE OF LIMITATIONS/SAFETY; RELEASE EVERY 2 HOURS AND PRN. FOR ADL'S..." The treatment record had no documentation dated 08/07/12 on the 3:00 p.m. -11:00 p.m. shift and 08/25/13 and 08/26/13 on the 7:00 a.m. -3:00 p.m. shift. A nurse's note, dated 09/27/13 at 11:00 p.m., documented "...This nurse called to Hall 2 to attend to resident on the floor. Found 2 nurses applying first aid to resident to stop scalp bleeding. The nurses indicated that the need was to call for ambulance transport to Hospital and get vital signs..." An event/incident report, dated 09/27/13, documented the resident was found face down on the floor, which resulted in a large laceration above the right eye. The incident report documented initial actions taken were, "...Staff education...First Aid...Other Resident to ER Investigative actions documented, ...Notes: (For use by Q A Committee/Designee) -Staff education Med (Medical) Review..." An emergency room report, dated 09/27/13, documented "...HPI...Chief Complaint: Fall ...History of Present illness: Patient is a [AGE] year-old female with a history of advanced dementia who is on hospice and has DNR. Patient fell at the nursing home...DIFFERENTIAL Diagnosis: [REDACTED]. A nurse's note, dated 09/28/13 at 12:15 a.m., documented "...Spoke to family (name deleted) ...at 12:10 a.m. and checked the wheelchair at her request verfying the operation of the safety release wheelchair waist restraint and working alarm..." A treatment record, dated 09/01/13-09/30/13, documented "...SELF RELEASE WHEELCHAIR WAIST RESTRAINT WHEN UP IN WHEELCHAIR R/T DEMENTIA, UNWARE OF LIMITATIONS/SAFETY; RELEASE EVERY 2 HOURS AND PRN. FOR ADL'S..." The treatment record had no documentation dated 09/27/13 and 09/28/13 on the 3:00 p.m.-11:00 p.m. shift. The resident sustained [REDACTED]. A nurse's note, dated 10/01/13 at 12:35 p.m., documented, "...(Right) eye remains swelling & bruises- unable to assess eyes d/t res doesn't want to open eyes..." A nurse's note, dated 10/01/13 at 6:55 p.m., documented "...Dr. (name deleted) is on call for Dr. (name deleted). He called the facility and verbally gave me orders for sending to ER at (hospital name deleted) by emergency transport...Vitals @ time fo transport...(pulse) 113...(temperature) 103.9 (degrees) F (Fahrenheit). R eye closed and red." A nurse's note, dated 10/01/13 at 12:25 a.m., documented a nurse from the hospital called and reported the resident was admitted under observation for urinary tract infection and facial cellulitis. A physician's orders [REDACTED]." The quarterly assessment, dated 10/11/13, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive two-person assistance with transfers and did not ambulate. A care plan meeting, dated 10/15/13 at 10:45 a.m., documented "...Careplan meeting with POA (name deleted). Review restraints mitts during IV PICC line use. Review of past falls-Review of previous fall interventions-. (Name deleted) explained restraints to POA. Reviewed. Hx of falls..." On 10/18/13 at 9:00 a.m., the Interim DON provided a written time line of the resident's monthly treatment records related to the use of restraints. The time line documented the resident was in the hospital from 03/21/13 through 03/25/13. When the resident returned from the hospital there was no order for the soft waist safety belt. The time line documented the resident was in the hospital from 04/04/13 through 04/11/18. The soft waist restraint was discontinued on 04/11/13. There was no order found documenting the waist restraint was reordered since return on 03/25/13. The timeline documented the soft waist safety belt was reordered on [DATE]. The timeline documented there was no monitoring of the seat belt from 07/14/13 through 07/31/13. On 10/18/13 at 10:00 a.m., the DON was shown the care plan which did not include an update for the fall on 09/27/13. She acknowledged it was not updated. She was asked if the resident had been wearing a soft waist safety belt with an alarm since she returned from the hospital on [DATE]. She stated the resident did not have an order for [REDACTED]. A careplan meeting was held with the family on 10/15/13 and at that time the family requested the soft waist safety restraint be put back in place. She stated a clarification order dated 10/15/13 will be written for the safety belt. The DON was asked if there was any documentation to show the safety belt was used on 10/15/13 through 10/18/13. She stated, "No." A physicians order, dated 10/18/15, documented "...Clarification order: On [DATE]th Self Release seat belt c alarm when up in w/c r/t lower leg weakness impaired balance, & Dementia Release self release belt q 2 (hours) & prn for ADL's..." At 5:10 p.m., a confidential interview was conducted with a family visitor. He/she was asked how often the staff checked on the resident when he/she was in the facility. He/she stated he/she was in the facility visiting eleven and twelve hours a day from March 2013 through June 2013 and since October 7, 2013. He/she stated the staff checks on the resident two or three times a day when he/she is in the facility. He/she stated when the resident is wet, he/she turns on the call light and it takes so long for the staff to answer he/she has to "go out into the hall before anyone will come into the room to assist the resident with incontinent care." At 5:20 p.m., the resident was observed in bed holding her call light. The resident was unable to use the call light on command. 2. Resident #3 had [DIAGNOSES REDACTED]. An incident report, dated 03/11/13, documented the resident was found on the floor beside her bed. The resident reported she hit her head and complained of right arm and right leg pain. She was sent to the emergency room . Identified possible contributing factors included environmental issues, resident health/mental status, and a wet floor under the safety mat beside her bed. Initial actions taken were to educate the resident to use the call light, staff education (not specified of what), a head-to-toe-assessment, neurology checks per facility policy, and range of motion checks. The preventative intervention identified was to send the resident to the ER and to administer pain meds as ordered by the ER physician. The incident report did not indicate adaptive equipment had been used by the resident prior to the fall or placed on the resident after the fall. An incident report, dated 03/15/13, documented the resident was found on the floor in another resident's room. The possible contributing factor identified was the health/mental status of the resident. Initial actions taken at that time were to perform neurology checks per facility policy. Interventions to be care planned and implemented included the initiation of Macrobid 100 milligrams (mg) by mouth twice a day for 10 days for a urinary tract infection (UTI). On 03/18/13 the Macrobid was begun. The incident report did not indicate adaptive equipment had been used by the resident prior to the fall or placed on the resident after the fall. An incident report, dated 07/03/13, documented the resident was found on the floor after she attempted to ambulate. It further documented the resident did not push her call light. There were no injuries. The possible contributing factor identified was resident non-compliance. The initial action was to provide resident education. Interventions identified to prevent falls in the future included continuation of previous safety interventions (as outlined in the care plan) and continuation of a 10-day round of antibiotics, which had been initiated on 06/28/13 for a UTI. The incident report did not indicate adaptive equipment had been used by the resident prior to the fall or placed on the resident after the fall. An incident report, dated 07/06/13, documented the resident was found on the floor beside her bed. The physician was in the facility at the time and ordered a portable x-ray of the right extremity to be done. The initial action taken was to perform resident education. The intervention identified to prevent future falls was to complete the x-ray. The incident report did not indicate adaptive equipment had been used by the resident prior to the fall or placed on the resident after the fall. The quarterly assessment, dated 08/19/13, documented the resident was cognitively intact and needed supervisory to limited assistance with most activities of daily living. An incident report, dated 10/01/13, documented the resident's roommate called for help and the resident was found sitting on the floor. The report documents the initial actions taken were to perform resident education, assess neurological checks, and asses the resident's ROM. The interventions identified to prevent future falls were to inspect equipment for functioning and to replace the nonfunctional bed alarm. The incident report did not indicate adaptive equipment had been placed on the resident after the fall. The care plan, last updated on 10/02/13, documented the resident had had multiple falls. The care plan interventions were to complete a falls assessment and update as needed, keep the call light in reach when the resident is in the room, answer call lights promptly, keep areas well lit and room free of clutter, encourage the use of nonskid shoes, report falls immediately to the physician and family, observe for adverse side effects to resident's medications, measure and record vital signs routinely, toilet every two hours, and if a fall occurs: a) place a body alarm if not already in use; b) place a star on back of wheelchair and above bed; c) complete a pain assessment as needed. The interventions mentioned in the incident reports were present in the care plan as well. On 10/18/13 at 5:50 p.m., the resident was interviewed. She stated she had fallen out of bed recently and has had some "tumbles" in the past. She stated, "They don't answer call lights after ten or eleven at night." She stated she has soiled her pants because they don't answer her call light. She stated they check on her two times a day. The resident was observed as she sat on the side of her bed. Her pajama pants were around her ankles on the floor and there was a strong smell of urine around her. On 10/18/13 at 6:30 p.m., the director of nurses (DON) was shown the resident's incident reports related to falls and asked about the resident's falls. She was asked if "resident education" was a progressive intervention for a resident who had had previous falls (three in 02/2013). She stated, "We needed to go further." She was asked if a round of antibiotics was an appropriate intervention for the fall which occurred on 03/15/13. She stated, "Yes, the resident had a UTI." She was reminded of the fall on 07/03/13, which occurred while the resident was already on antibiotics for a UTI, and asked if that intervention was an appropriate intervention at that time. The DON stated, "Yes." She was reminded that the resident had a history of [REDACTED]. She was asked what new intervention was initiated to prevent the resident from falling while the second UTI was treated. She did not answer. The DON was asked if another intervention besides resident education might have been appropriate after the 07/06/13 fall. She stated a concave mattress or bed bolsters would have been appropriate. She was asked about the 10/01/13 fall. She was asked what intervention was put in place at the time of discovery of the nonfunctional bed alarm. She did not answer.

Based on observation, clinical record review, policy review and staff interview, it was determined the facility failed to prevent severe weight loss resulting in actual harm for two (#5 and #7) of six sampled residents with weight loss. Resident #5 had a 12 pound or 8.8% severe weight loss in one month and an 18 pound or 13.04% severe weight loss in six months. Resident #7 had an 11 pound or 8% severe weight loss in one month and a 23 pound or 15.54% severe weight loss in three months. The facility failed to: ~ provide supplements and snacks, ~ monitor meal intake, ~ maintain protein levels, ~ notify the physician of severe weight loss and/or refusals of meals and supplements, ~ repond to dietary recommendcations, ~ monitor weight as ordered by the physician, and/or ~ offer meal replacements when the resident consumed less than 50% of the meal. This had the potential to affect seven residents identified by the facility who had weight loss in the past six months. Findings: A facility policy titled, Weight Loss Risk Assessment Policy, documented, "... It is the goal of Grace Living Centers to identify those residents who may be at risk for weight loss and provide intervention to help prevent weight loss... The weight loss risk assessment tool... may be completed upon admission, re-admission, quarterly, and upon any significant change in the resident's condition... The information to complete the form will be obtained from the resident's medical record, interview of the resident, resident's family, and/or staff. (Information to be obtained may include:) Assess changes in appetite... has the resident had an acute illness (pneumonia,[MEDICAL CONDITION], uti, etc.) or recent hospitalization ... Any mental illnesses: dementia, depression, [MEDICAL CONDITION] Is the resident on a restrictive diet... or mechanically altered diet (pureed, ground meat, etc.)... Any wounds Stage II or greater regardless of cause... How much of the meal does the resident consume... Is the resident experiencing any pain... Does the resident require assistance with their meal: cueing, encouragement to eat, or does the resident have to be fed... The doctor may be notified and informed of the assessment and obtain orders for prevention such as appetite stimulant or lab to assess nutritional values... At risk residents... consult with the dietary manager for interventions such as nourishments, super cereal, or a referral to the registered dietitian... Nursing may weigh the resident at least bi-monthly or more frequently if ordered by the doctor... Develop and/or update the care plan with the resident being at risk for weight loss and the interventions to prevent the loss..." 1. Resident #5 was admitted to the facility on [DATE] with dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. A care plan, initiated on 12/29/10, documented, "... Problem:(resident's) status /changes may bring about weight loss... Goal: ... Will attain and/or maintain her weight for the next 90 days... Plan of Approach: monitor intake each meal and offer replacement if she consumes less than 50%..." A monthly weight record, dated 04/07/11, documented the resident weighed 138 lbs. A physician's telephone order, dated 04/29/11, documented, "... Regular diet... Bedtime snack..." A monthly weight record, dated 05/09/11, documented the resident weighed 136 lbs. A monthly weight record, dated 06/01/11, documented the resident weighed 124 lbs. This represented a severe weight loss of 12 pounds or 8.8% in one month. A physician's telephone order, dated 06/13/11, documented, "... Health Shake: Give (one) by mouth three times daily between meals as supplement..." A Diet Record, dated July 2011, documented: Breakfast: refused one meal and one replacement / no documentation for two meals Lunch: refused six meals and six replacements / no documentation for two meals Dinner: refused seven meals and seven replacements / no documentation for three meals There was no documentation of health shakes given three times a day between meals for July 2011. Bedtime snacks were documented as accepted four times, refused three times and not documented 24 times for the month of July 2011. A Diet Record, dated August 2011, documented, Breakfast: refused one meal and one replacement / no documentation for one meal Lunch: refused one meal and one replacement / no documentation for one meal Dinner: refused six meals and six replacements / no documentation for five meals. There was no documentation of health shakes given three times a day between meals for August 2011. There was no documentation of bedtime snacks given in August 2011. A laboratory report form, dated 08/05/11, documented, "... Total Protein 5.5 (Low) (Normal Value) 6.3 - 8.2 (grams per deciliter)... [MEDICATION NAME] 2.9 (Low) (Normal Value) 3.9 - 5.0 (grams per deciliter)..." A facility form, titled "Notification of Significant Weight Change", dated 08/10/11, documented, "... Current weight 129... Amount of loss: 11% 6 months... Previous Interventions: Bedtime snack, health shakes between meals, MVI (multivitamin) c minerals... New Interventions: No other interventions - remains above IBW (ideal body weight)..." A monthly weight record, dated 09/08/11, documented the resident weighed 127 lbs. A Diet Record, dated September 2011, documented: Breakfast: refused one meal and one replacement / no documentation for two meals Lunch: refused one meal and one replacement / no documentation for one meal Dinner: refused 11 meals and 11 replacements / no documentation for 10 meals A supplement record, dated September 2011, documented the resident refused a health shake between meals 33 times out of 60 opportunities. There was no documentation of a bedtime snack given in September 2011. A quarterly assessment, dated 09/18/11, documented the resident did not experience any weight loss for the previous three months. A monthly weight record, dated 10/10/11, documented the resident weighed 120 lbs. This represented a 7 pound or 5.5% severe weight loss in one month and an 18 pound or 13.04% severe weight loss in six months. A facility form, titled "Dietitian Consultant Nutritional Recommendations", dated 10/13/11, documented,"... Wt. loss 5% in 1 month. Recommend consideration of appetite stimulant to increase intake & stabilize wt..." There was no documentation that indicated the physician was notified of the severe weight loss and the dietitian's recommendation for the appetite stimulant. A facility form, titled "Notification of Significant Weight Change", dated 10/24/11, documented, "... Amount of loss: 11.8 % (in) 6 months... Current Diet: Regular Diet... Previous Interventions: Health Shake TID between meals, MVI c minerals, HS snack... New Interventions: No new interventions - remains above IBW..." A Diet Record, dated October 2011, documented: Breakfast: refused one meal and one replacement / no documentation for one meal Lunch: refused two meals and two replacements / no documentation for one meal Dinner: refused two meals and two replacements / refused five meals and no replacements were offered / no documentation of 15 meals. Health shakes were refused 22 times and not documented 55 times out of 93 opportunities during October 2011. There was no documentation of a bedtime snack offered in October 2011. A monthly weight record for 11/10/11 documented the resident weighed 120 lbs. This represented a 16 pound or 11.76% severe weight loss in six months. A Dietary Consultant Nutritional Documentation form, dated 11/10/11, documented, "... Follow-up Weight Loss 11% in 6 months..." For the comment section of the form, the facility documented, "cont." No new interventions for weight loss were documented on the form. A Diet Record, dated November 2011, documented: Breakfast: refused five meals and five replacements / no documentation of one meal Lunch: refused two meals and two replacements / no documentation of two meals Dinner: refused 13 meals and 13 replacements / refused three meals with no replacement documented / no documentation of four meals. Health shakes were refused 36 times or not documented 22 times out of 90 opportunities for the month of November 2011. No bedtime snacks were documented for November 2011. On 11/28/11 at 10:00 a.m., LPN #1 was asked if she was aware of the resident's weight loss. She stated she was not aware. She was asked who monitored weight loss. She stated, "The dietitian and the dietary manager." On 11/29/11 at 8:45 a.m., the resident was observed eating breakfast. At the conclusion of the meal, she had eaten less than 50%. On 12/07/11 at 9:30 a.m., the DON was asked to review the dietary records for the resident. She was asked if she was aware of the meal and supplement documentation for the resident which indicated she was not routinely receiving diet supplements, snacks and meal replacements. She stated she was not aware. She was asked if she was aware of the dietitian's recommendation for an appetite stimulant for the resident in October 2011. She stated she was not aware. 2. Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Admission physician's orders [REDACTED]. on admit then (weekly) x 4... Pureed diet with honey thickened liquids... Tab-a-Vit (one) po daily supplement... Bedtime snack..." A Treatment Record, dated May 2011, documented the resident's admission weight was 148 lbs. on 05/06/11. Weekly weights for the remainder of the month were not documented. An initial plan of care, completed on 05/07/11, documented, "... Weight: 148 lbs.... (Potential for) Weight Loss... Dietary to determine food likes and dislikes... Supplement or meal replacement to be offered for meal percentage less than 50%... [MEDICATION NAME] as ordered by the physician, assess results with physician... Assist with meals as needed to increase intake... House snacks to be offered in addition to meals... Weigh resident according to facility protocol..." A Meal Service Record, dated May 2011, documented: ~ 05/06/11 (day of admission): no meals or replacement meals documented. No snacks were documented. ~ 05/07/11: no documentation for breakfast or lunch. Dinner meal documented as 60% consumed. 100% of the replacement was consumed. No snacks were documented. ~ 05/08/11: no meals or replacements documented. No snacks were documented. The resident consumed less than 50% for 14 of 21 meals from 05/09/11 through 05/15/11. The resident refused the meal replacement offered 12 times. No snacks were documented. A nurse's note, dated 05/15/11 at 9:00 p.m., documented, "... Has been spoon fed this pm. Slow c eating. Much encouragement needed. Total 720 cc thickened liquid consumed. Ate 50% of puree fruit and 3/4 cup of applesauce..." A nurse's note, dated 05/19/11 at 11:00 a.m., documented, "...Appetite poor..." A nurse's note, dated 05/22/11 at 7:30 p.m., documented, "... Refused to eat, drank 2 sips of supplement, refused more..." A physician's telephone order, dated 05/24/11, documented, "... Magic Cup c meals for extra calories..." A physician's telephone order, dated 05/25/11, documented, "... D/C Tab-a-Vit... MVI c minerals (one) po daily (for) wound... Vit C 500 mg (one) po BID x 30 days (for) wound..." An untimed nurse's note, dated 05/28/11, documented, "... appetite poor..." An untimed nurse's note, dated 05/30/11, documented, "... appetite poor, fluids encouraged..." An untimed nurse's note, dated 05/31/11, documented, "... Drinks Ensure when offered..." At the conclusion of the month, the May 2011 Meal Service Record documented the resident consumed an average of 22% of her meals and 41% of meal replacements during the month of May 2011. No bedtime snacks or Magic Cups were documented for the month of May 2011. A monthly weight record, dated 06/01/11, documented the resident's weight was 142.4 lbs. This represented a 5.6 pound or 3.7% weight loss in less than one month. A nurse's note, dated 06/17/11 at 8:00 a.m., documented, "... Drinks 100% but won't open mouth for food..." A monthly nutrition note, dated 06/18/11, documented, "... Wt: 142 wt... (down) 6% in 1 month... appetite poor..." The form also documented the resident was consuming less than 50% of meals and 50% of supplements. An untimed nurse's note, dated 06/18/11, documented, "... appetite poor..." A nurse's note, dated 06/19/11 at 8:00 a.m., documented, "... Spoon fed, appetite poor..." An untimed nurse's note, dated 06/20/11, documented, "... Appetite poor, fluids encouraged..." An untimed nurse's note, dated 06/21/11, documented, "... Appetite & fluid intake poor..." A nurse's note, dated 06/24/11 at 8:00 a.m., documented, "... Spoon fed by staff - appetite poor. Will drink but won't open mouth for puree diet..." At the conclusion of the month, the ADL sheet for June 2011 documented the resident consumed an average of 26% of her meals and 57% of meal replacements for the month. Seven times meal replacements were not documented when the resident ate less than 50%. 12 times meals and meal replacements were not documented. There were no bedtime snacks or Magic Cups documented for the month of June 2011. A monthly weight record, dated 07/01/11, documented the resident weighed 136 lbs. This represented a 6.4 pound or 4.49% weight loss in one month. An untimed nurse's note, dated 07/03/11, documented, "... Pain management (continues) for R femur fracture. Moans when transferred, changed or moved. Routine pain meds given x 3 in 24 hrs. Appetite poor, fluids given..." At 5:00 p.m., nurse's notes documented, "... Res refused p.m. meal & meal replacement... (9:00 p.m.) Res refuse HS supplement offered..." A monthly nutrition note, dated 07/14/11, documented, "... Wt:135 Wt...(down) ... 5% in 1 month... (down) 9% x 2 months..." The form also documented the resident was consuming less than 50% of meals and 50% of supplements. At the conclusion of the month, the July 2011 ADL sheet documented the resident consumed an average of 14% of her meals and 71% of meal replacements. Three times meal replacements were not documented when the resident ate less than 50%. Meals and meal replacements were not documented 32 times. A Diet Supplement Record, dated July 2010, documented the resident refused a Magic Cup 20 times. 60 times the Magic Cup was not documented. No bedtime snacks were documented for the Month of July 2011. A monthly weight record, dated 08/05/11, documented the resident weighed 125 lbs. A re-weigh, dated 08/12/11, confirmed the resident weighed 125 lbs. This represented an 11 pound or 8% severe weight loss in one month, and a 23 pound or 15.54% severe weight loss in three months. A monthly nutrition note, dated 08/16/11, documented, "... Wt:125 Wt...(down)... 8% in 1 month... (down) 18% x 3 months..." The form also documented the resident was consuming less than 50% of meals and 50% of supplements. A monthly nutrition note, dated 08/23/11, documented, "... Resident c wt (loss) present. Receives shakes c meals & between @ this time. Unstageable area present per 8-13 report. Eating 50-60% avg. @ meals. (Nursing) note 8-18 reflects family's desire to admit resident to (hospice name deleted). Cont. c current (interventions) @ this time.." There was no documentation that indicated the resident received shakes with meals or between meals, other than the meal replacement offered if less than 50% of the meal was consumed. At the conclusion of the month, the August 2011 ADL sheet documented the resident consumed an average of 17% of her meals and 88% of meal replacements. Eight times meal replacements were not documented when the resident ate less than 50%. Meals and meal replacements were not documented 15 times. A MAR, dated August 2011, documented the resident accepted bedtime snacks six times and refused snacks 18 times. Bedtime snacks were not documented seven times. A Diet Supplement Record, dated August 2011, documented the resident refused a Magic Cup 33 times. 51 times out of 93 opportunities the Magic Cup was not documented. A monthly weight record, dated 09/08/11, documented the resident weighed 122 lbs. This represented a 3 pound or 2.4% weight loss in one month, and a 20.4 pound or 14.32% severe weight loss in 3 months. A monthly nutrition note, dated 09/08/11, documented,"... Wt: 121.4 Wt...(down) ... 10.3% in 3 months... 14.3% in 6 months... Average monthly meal (percentage): 65 (%) avg... Wt. loss continues but has slowed since drop from July to Aug. Receives magic cups c meals for extra calories... Other appropriate nutritional (interventions) are in place..." A physician's telephone order, dated 09/29/11, documented, "... Add 1 scoopful [MEDICATION NAME] to juice or water and give by mouth 3x daily... Add 1 scoopful [MEDICATION NAME] to water or juice and give by mouth 2x daily..." At the conclusion of the month, the September 2011 ADL sheet documented the resident consumed an average of 18% of her meals and 76% of meal replacements. Meal replacements were not documented seven times when the resident ate less than 50%. Meals and meal replacements were not documented ten times. A MAR, dated September 2011, documented the resident accepted a bedtime snack one time, refused 21 times, and bedtime snacks were not documented eight times. A TAR, dated September 2011, documented the resident refused between meal snacks 54 times. Snacks were not documented 4 times. A Diet Supplement Record, dated September 2011, documented the resident refused a Magic Cup 50 times. The record indicated the resident was not offered a Magic Cup 40 times out of 90 opportunities. A nutrition note, dated 10/13/11, documented,"Wt = 133 (up) 11 (lbs) from Sept. Stg II area present per 10-1 report. Eating around 60% avg @ meals per records... receives shakes several times daily. No obvious cause of wt gain present... Plan: Reweigh to confirm gain..." A Dietitan Consultant Nutritional Recommendations form, dated 10/13/11, documented, "Reweigh to confirm gain..." There was no documentation that indicated another weight was obtained to confirm the 11 pound weight gain. A monthly nutrition note, dated 10/17/11, documented,"... Wt:132 (up) 8% in 1 month... Pressure ulcer -ischeal (left) Stage 2. Wt has (increased) 8% in one month... Average monthly meal % (less than) 50% meals (less than) 50% nourishments..." A nursing Monthly Summary, dated October 2011, documented the resident was totally dependent on staff for eating, refused food at times, had weight loss, and usually consumed less than 25%. The form also documented the resident's hydration status was "poor" and her acceptance of diet was "poor". At the conclusion of the month, the October 2011 ADL sheet documented the resident consumed an average of 20% of her meals and 43% of meal replacements. Five times meal replacements were not documented when the resident ate less than 50%. Meals and meal replacements were not documented 39 times. A MAR, dated October 2011, documented the resident refused a bedtime snack 21 times. There was no documentation of a bedtime snack ten times. A Diet Supplement Record, dated October 2011, documented the resident refused a Magic Cup four times. It documented the resident accepted 50% of a Magic Cup twice and 20% once. The Magic Cup was not documented 86 times out of 90 opportunities during the month of October 2011. A quarterly assessment, dated 11/01/11, documented the resident weighed 133 lbs. and had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A care plan, updated on 11/02/11, documented, "... weight loss: wt (gain) 11 (pounds) cont (plan of care)..." A care plan, updated on 11/07/11, documented, "... weight loss: cont (plan of care)..." A monthly nutrition note, signed by the dietary manager, dated 11/09/11, documented,"... Wt:120 Wt. (loss)... 6% in 1 month .... 4% in 3 months... 23% in 6 months... Significant weight loss 23% in 6 months... Average monthly meal % (less than) 50% meals (less than) 50% nourishments..." A nutrition note, signed by the dietitian, dated 11/10/11, documented, "Wt = 120 (down) 13 lb. (down) 9.8% x 1 month and 15.7% x 6 months per records. Oct wt was up from Sept wt of 122 lb. Eating around 70% avg - worst @ supper. Stg II area closed per recent skin report. Suspect Oct wt may have been erroneous. Plan: 1. D/C Vit C & [MEDICATION NAME] 2. (Weekly) weights x 4. If wts. continue to reflect loss in the future may consider other interventions to stabilize..." A Dietitian Consultant Nutritional Recommendations form, dated 11/10/11, documented, "D/C Vit C & [MEDICATION NAME] Weekly (weights) x 4..." A facility fax to the physician, dated 11/15/11, documented, "... Dietician (sic) (recommends) D/C Vit C & [MEDICATION NAME]. Weekly wts x 4. She has had 9.8% wt. loss..." The fax was not sent to the physician until 11/22/11. As of 11/30/11, there was no documentation of a response from the physician. There was no documentation to show weekly weights were done. At the conclusion of the month, the November 2011 ADL sheet documented the resident consumed an average of 47% of her meals and 19% of meal replacements. Three times a meal replacement was not documented when the resident ate less than 50%. Meal percentages and meal replacements were not documented 13 times. A Diet Supplement Record, dated November 2011, documented the resident refused a Magic Cup 45 times and accepted a Magic Cup five times. A Magic Cup was not documented 35 times out of 90 opportunities. There was no documentation of bedtime snacks given for the month of November 2011. On 12/01/11 at 9:00 a.m., LPN #1 was asked if the resident was on weekly weights. She stated she didn't know. She was asked who obtained weekly weights for the residents. She stated, "The restorative aide." At 9:15 a.m., the resident was observed being fed by staff. She was eating a pureed diet. She had consumed less than 30% of her meal. On 12/07/11 at 9:30 a.m., the DON was asked to review the dietary records for the resident. She was asked if she was aware of the meal and supplement documentation for the resident. She stated she was not. She was asked if weekly weights should have been done for the resident. She stated they should have. She stated the facility did not have a good process for monitoring weight loss in the residents.

Based on record review and staff interviews, it was determined the facility failed to ensure there were pharmacey services in place to ensure the accurate administration of medications for five (#17, 18, 20, 21 and #24) of 21 sampled residents who received medications. This resulted in actual harm to resident #18 who required hospitalization after receiving another resident's medications. This had the potential to affect 83 of 83 residents who resided in the facility. Findings: 1. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/17/11, documented, "Problem At risk for adverse reactions due to takes 9 or more meds routinely Goal (Resident) will be free of adverse reactions due to multiple medications for the next 90 days Plan of Approach 1) Administer medications as ordered by physician... 2) Monitor for S/S of adverse actions... Pharmacist to review drug regimen monthly and make recommendations to physician 3) Notify physician immediately of reactions noted..." An admission assessment, dated 03/24/11, documented the resident's cognition was moderately impaired. A nurse's note, dated 04/27/11 at 6:00 p.m., documented "...CMA (#1) reported mistakenly given his roommate med to (resident). (Physician) notified and ordered to check B/P at 10 pm and 6 am if SBP < 80 to call (physician), and also to check FSBS at 10 pm and 6 am today and tomorrow to call if FSBS less than 60 mg/dl (deciliter). B/P 110/60 P78 R18 at this time. A nurse's note, dated 04/27/11 at 10:00 p.m., documented, "checked B/P 91/60 P65 FSBS 40 (physician) notified and to give juice with sugar and to recheck it after 1 hr." A nurse's note, dated 04/27/11 at 11:00 p.m., documented "...FSBS= 40, B/P = 91/60 P54 1130pm notified (physician) ordered to1. Check FSBS q 1 (hr), if FSBS does not improve or <60 after food intake send to (hospital)-ER for tx et eval. 2. Check B/P couple times per tonight. Resident ate apple juice (with) 3 packets of sugar & drank orange juice (with) 3 packets of sugar." A nurse's note at 12:30 a.m., documented, "FSBS = 52 ...Drank a glass of orange juice c 3 packets of sugar et ate ice cream. A nurse's note at 1:30 a.m., documented, "FSBS = 49...Drank 2 milkshakes with 4 packs of sugar." A nurse's note at 2:20 a.m., documented, "FSBS=29, called 911, EMT ambulance staff came in at 0230am. Notified family at 220am. Resident left via ambulance to (hospital)-ER..." An emergency room Note, dated 04/28/11 at 3:00 a.m., documented, "History of Present Illness... Patient is a [AGE] year-old male who presents to the emergency room with a low blood glucose fingerstick... The patient received amaryl 4 mg and coreq 6.25mg. Nursing home has been observed (sic) the patient for the last several hours. Patient's sugar has been waxing and weaning. Patient has never received any oral medications for diabetes or hypertension in the past... Patient Progress Notes Patient presented to the emergency room with a low glucose of 29. Patient was given 1 amp of D50. Glucose went up to 112. Patient was given 8 ounces of ensure and peanut butter crackers. Repeat fingerstick was 91." A History and Physical Exam, dated 04/29/11, documented: "Date of Service: 04/29/11 Admit Diagnosis: [REDACTED]. History of Present Illness: The patient is a [AGE] year-old male who yesterday at Grace Living Center was accidentally given a dose of his room-mates medicine including Amaryl 4 mg and Coreg 6.25 mg. I was called regarding this situation last night. I asked them to check his blood sugar every hour through the night. When they found that they were not able to keep his blood sugar above 50 they transferred him to the emergency room . The emergency room found that his blood sugar was 28. He was given an amp of D50. His sugar improved slightly to 112. His blood sugar was rechecked this morning at 619 hours (6:19 a.m.). and found to be 36. He was given another amp of D50..." A Discharge Summary, dated 05/02/11, documented: "Date of Admission: 04/29/2011 Date of Discharge: 05/02/2011 Admission Diagnoses: [REDACTED]. Hospital Course: This [AGE] year-old male with a history of neurogenic bladder, functional decline, who resides at Grace Living Center was accidentally given a dose of his roommates Amaryl which resulted in refractory [DIAGNOSES REDACTED]. He was admitted to the hospital in spite of IV fluids with D10 running constantly and multiple administrations of glucagon and D50 amps. He continued to drop into the 30s and 40s intermittently. He was checked frequently for the first couple of days Megace was started as well as prednisone and blood sugars normalized on the last couple of days of his hospital stay..." On 12/07/11 at 2:25 p.m., a request was made for the April 2011 MAR. The corporate MDS coordinator stated," I looked for it yesterday and could not find it." On 12/07/11 at 4:40 p.m., the Corporate MDS coordinator was asked for the April 2011 MAR. He stated, "These are the MARs for August and October. We can't find April." 2. Resident # 17 was admitted to the facility with [DIAGNOSES REDACTED]. A medication incident report, dated 01/27/11, documented the resident was to receive Vancomycin suspension 250 mg. po four times a day for nine days. The resident received the medication for six days when the medication ran out. The report documented a CMA did not notify the nursing staff that more Vancomycin needed to be ordered. The resident did not receive the last three days of Vancomycin as ordered by the physician. The report documented, "...What is the actual effect of the incident on the resident? The Vancomycin was ineffective because full cycle was not given." On 12/07/11 at 2:00 p.m. and on 12/08/11 at 11:00 a.m., the corporate nurse was asked to provide February 2011 physician's orders [REDACTED]. No documents were located by the facility. The corporate nurse was asked if the facility generated a medication error incident report to OSDH. She stated they had not. 3. Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 09/04/11, documented she was cognitively intact. She was totally dependent on staff for transfers, dressing, hygiene and bathing. She was always incontinent of bowel and bladder. A physician's orders [REDACTED]. A nurse's note, dated 10/24/11 at 7:00 a.m., documented, "Focused assessment r/t FSBS 56..." A Medication Incident Report, dated 10/24/11, documented, "... What was physician's orders [REDACTED]. What was given? Novolin 70/30 40 units am &16 units pm. Reason for incident: Order not noted. What is the actual effect of the incident on the resident? Low blood sugar..." A Diabetic Record, dated October 2011, documented Novolin 70/30 40 units was administered 13 times and Novolin 70/30 16 units was administered 11 times after the order to discontinue. On 12/07/11 at 10:30 a.m., the DON was asked how the facility ensured the phyisician orders were noted in a timely manner. She stated, "We have a new procedure now, I don't know how they were doing it then. They should have been checked daily." 4. Resident # 20 was admitted to the facility on [DATE] at 1:30 p.m., with [DIAGNOSES REDACTED]. Physician's admission orders ... Lopressor 50 mg po BID AC... Femara 2.5 mg po q day... Miralax 17 Gms po q day..." A MAR, dated August 2011, documented: ~ the resident did not receive a first dose of Lopressor until 7:00 a.m. on 08/12/11. ~ the resident did not receive a first dose of Femara until 08/13/11. ~ the resident did not receive a dose of Miralax on 08/12/11 and 08/14/11. On 11/29/11 at 11:00 a.m., the DON was asked how the facility obtained medications for new residents. She stated if the medications were ordered during weekday business hours, they could be delivered to the facility. She stated if it was after hours, a holiday, or the weekend, a nurse would leave the facility to pick up the medications at the pharmacy. She was asked if there was always enough staff on site to allow a nurse to leave. She stated if there was not enough staff, then the ADON or the DON would pick up the medications. She further stated not all new medications would be obtained after hours. She stated primarily pain medications, insulin and blood pressure or cardiac medications would be obtained after hours. She was asked why medications would not be available to a new resident admitted at 1:30 p.m. on a Thursday. She stated she did not have an answer for that. On 12/07/11 at 10:30 a.m., LPN #1 was asked how the nurses obtained medications for new residents. She stated, "Whoever is available goes to pick them up." She was asked if there was ever a time when there were no staff available to pick them up. She stated she couldn't recall a time when someone could not pick up medications. On 12/07/11 at 5:15 p.m., the resident was asked if she received her medications on the day of admission. She stated she did not get her blood pressure medication as ordered that night. 5. Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. The April 2011 MAR indicated [REDACTED]. Medication Incident Reports, dated 04/28/11, documented, "...What was the physician's orders [REDACTED]. Lipitor 20 mg ...Reason for incident: Missed doses on the 25th, 26th, 27th ...How was the incident discovered? Nurse checked the MAR..." "...What was the physician's orders [REDACTED]. Acetaminophen - codeine 12 mg/ml ...Reason for incident: Missed doses on the 25th, 26th, 27th ...How was the incident discovered? Nurse checked the MAR..." "...What was the physician's orders [REDACTED]. Ketoprotein (sic) 75mg ...Reason for incident: Missed doses on the 25th, 26th, 27th ...How was the incident discovered? Nurse checked the MAR..." The medications were omitted on 04/25/11, 04/26/11 and 04/27/11 by CMA #1. On 12/08/11 at 11:00 a.m., the personnel director was asked how new CMAs were oriented to the facility. She stated they went through general orientation and then spent six days orienting on a medication cart. She was asked if CMAs were given any written policies and procedures related to medication administration. She stated they were not. She was asked if there was a specific training schedule for CMAs that a mentor could follow. She stated there was not. She was asked if there was a competency checklist for new CMAs. She stated there was not. She was asked how many days a new CMA would observe the mentor CMA before actually giving medications independently. She stated that varied from mentor to mentor. At 2:00 p.m. CMA #2 was asked about her training with CMA #1. She stated CMA #1 never trained with a CMA on the day shift, but was assigned to work the evening shift with her. She stated she was assigned to CMA #1 and another new CMA to mentor on the evening shift. She stated she had to go back and forth between the two CMAs on two different halls throughout the shift. She stated this occurred on more than one shift. She stated during this time, CMA #1 was passing medications independently and largely without supervision. She stated CMA #1 had never worked as a CMA before. CMA #2 stated she was upset about training two new CMAs at once, since she had only worked at the facility for three weeks herself. She stated she was not instructed on how to train a new CMA. She stated while CMA #1 was giving medications, he made multiple errors including giving medications to the wrong resident, omitting medications and mishandling of narcotics.

Based on record review and staff interviews, it was determined the facility failed to ensure residents were free of significant medication errors by failing to: a. ensure one (#18) of 21 sampled residents who received medications did not receive another resident's medications. This resulted in actual harm to the resident who required hospitalization . This had the potential to affect 83 of 83 residents who resided in the facility. b. ensure one (#21) of two sampled residents who received insulin injections, received them as ordered by the physician. The resident received insulin injections for 13 days, after the insulin had been discontinued by the physician. The facility identified four residents who received routine insulin. c. administer a full course of antibiotics for one (#17) of six sampled residents who received antibiotic therapy. This had the potential to affect 48 residents who received antibiotics in the past year. Findings: A policy titled, "Medication Error and Adverse Drug Reaction Reporting", documented, "Policy: Significant medication errors and adverse drug reactions are assessed, documented and reported as appropriate to the resident's attending physician, the Quality Assessment and Assurance Committee, the pharmacy and Food and Drug Administration MedWatch Program. Definitions: Medication Error/Discrepancy: An incorrect medication prescribed, dispensed or administered to a resident; an omission of a vital medication due to a prescribing, dispensing or administering error; medication administered to an individual with a documented allergy to that medication. Adverse drug reaction: A undesirable or unattended harmful effect occurring as a result of a medication; an allergic reaction in a patient with no documented history of an allergy to the medication. Significant: Medication errors and adverse drug reactions that: require discontinuing of a medication or modifying the dose require hospitalization result in disability require treatment with a prescription medication result in cognitive deterioration or impairment are life threatening result in death Procedures: In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the resident's safety and welfare. The Director of Nursing is immediately notified of any medication error. The Director of Nursing will decide if the error warrants notifying the attending physician and/or pharmacist. The physician's orders [REDACTED]. The incident is described on the shift change report to alert staff of the need to monitor the resident. The following information is documented in the resident's medical record and on the incident report (Form PS-178 Medication Error Report): Factual description of the error or adverse reaction Name of physician and time notified Physician's subsequent orders Resident's condition 24 to 72 hours or as directed The administrator must receive a copy of the medication error report..." 1. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/17/11, documented, "Problem At risk for adverse reactions due to takes 9 or more meds routinely Goal (Resident) will be free of adverse reactions due to multiple medications for the next 90 days Plan of Approach 1) Administer medications as ordered by physician... 2) Monitor for S/S of adverse actions... Pharmacist to review drug regimen monthly and make recommendations to physician 3) Notify physician immediately of reactions noted..." An admission assessment, dated 03/24/11, documented the resident's cognition was moderately impaired. A nurse's note, dated 04/27/11 at 6:00 p.m., documented "...CMA (#1) reported mistakenly given his roommate med to (resident). (Physician) notified and ordered to check B/P at 10 pm and 6 am if SBP < 80 to call (physician), and also to check FSBS at 10 pm and 6 am today and tomorrow to call if FSBS less than 60 mg/dl (deciliter). B/P 110/60 P78 R18 at this time. A nurse's note, dated 04/27/11 at 10:00 p.m., documented, "checked B/P 91/60 P65 FSBS 40 (physician) notified and to give juice with sugar and to recheck it after 1 hr." A nurse's note, dated 04/27/11 at 11:00 p.m., documented "...FSBS= 40, B/P = 91/60 P54 1130pm notified (physician) ordered to1. Check FSBS q 1 (hr), if FSBS does not improve or <60 after food intake send to (hospital)-ER for tx et eval. 2. Check B/P couple times per tonight. Resident ate apple juice (with) 3 packets of sugar & drank orange juice (with) 3 packets of sugar." A nurse's note at 12:30 a.m., documented, "FSBS = 52 ...Drank a glass of orange juice c 3 packets of sugar et ate ice cream. A nurse's note at 1:30 a.m., documented, "FSBS = 49...Drank 2 milkshakes with 4 packs of sugar." A nurse's note at 2:20 a.m., documented, "FSBS=29, called 911, EMT ambulance staff came in at 0230am. Notified family at 220am. Resident left via ambulance to (hospital)-ER..." An emergency room Note, dated 04/28/11 at 3:00 a.m., documented, "History of Present Illness... Patient is a [AGE] year-old male who presents to the emergency room with a low blood glucose fingerstick... The patient received [MEDICATION NAME] 4 mg and coreq 6.25mg. Nursing home has been observed (sic) the patient for the last several hours. Patient's sugar has been waxing and weaning. Patient has never received any oral medications for diabetes or hypertension in the past... Patient Progress Notes Patient presented to the emergency room with a low glucose of 29. Patient was given 1 amp of D50. Glucose went up to 112. Patient was given 8 ounces of ensure and peanut butter crackers. Repeat fingerstick was 91." A History and Physical Exam, dated 04/29/11, documented: "Date of Service: 04/29/11 Admit Diagnosis: [REDACTED]. History of Present Illness: The patient is a [AGE] year-old male who yesterday at Grace Living Center was accidentally given a dose of his room-mates medicine including [MEDICATION NAME] 4 mg and [MEDICATION NAME] 6.25 mg. I was called regarding this situation last night. I asked them to check his blood sugar every hour through the night. When they found that they were not able to keep his blood sugar above 50 they transferred him to the emergency room . The emergency room found that his blood sugar was 28. He was given an amp of D50. His sugar improved slightly to 112. His blood sugar was rechecked this morning at 619 hours (6:19 a.m.). and found to be 36. He was given another amp of D50..." A Discharge Summary, dated 05/02/11, documented: "Date of Admission: 04/29/2011 Date of Discharge: 05/02/2011 Admission Diagnoses: [REDACTED]. Hospital Course: This [AGE] year-old male with a history of [MEDICAL CONDITION] bladder, functional decline, who resides at Grace Living Center was accidentally given a dose of his roommates [MEDICATION NAME] which resulted in refractory [DIAGNOSES REDACTED]. He was admitted to the hospital in spite of IV fluids with D10 running constantly and multiple administrations of [MEDICATION NAME] and D50 amps. He continued to drop into the 30s and 40s intermittently. He was checked frequently for the first couple of days [MEDICATION NAME] was started as well as [MEDICATION NAME] and blood sugars normalized on the last couple of days of his hospital stay..." On 12/07/11 at 2:25 p.m., a request was made for the April 2011 MAR. The corporate MDS coordinator stated," I looked for it yesterday and could not find it." On 12/07/11 at 4:40 p.m., the Corporate MDS coordinator was asked for the April 2011 MAR. He stated, "These are the MARs for August and October. We can't find April." 2. Resident # 17 was admitted to the facility with [DIAGNOSES REDACTED]. A medication incident report, dated 01/27/11, documented the resident was to receive [MEDICATION NAME] suspension 250 mg. po four times a day for nine days. The resident received the medication for six days when the medication ran out. The report documented a CMA did not notify the nursing staff that more [MEDICATION NAME] needed to be ordered. The resident did not receive the last three days of [MEDICATION NAME] as ordered by the physician. The report documented, "...What is the actual effect of the incident on the resident? The [MEDICATION NAME] was ineffective because full cycle was not given." On 12/07/11 at 2:00 p.m. and on 12/08/11 at 11:00 a.m., the corporate nurse was asked to provide February 2011 physician's orders [REDACTED]. No documents were located by the facility. The corporate nurse was asked if the facility generated a medication error incident report to OSDH. She stated they had not. 3. Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 09/04/11, documented she was cognitively intact. She was totally dependent on staff for transfers, dressing, hygiene and bathing. She was always incontinent of bowel and bladder. A physician's orders [REDACTED]. A nurse's note, dated 10/24/11 at 7:00 a.m., documented, "Focused assessment r/t FSBS 56..." A Medication Incident Report, dated 10/24/11, documented, "... What was physician's orders [REDACTED]. What was given? [MEDICATION NAME] 70/30 40 units am &16 units pm. Reason for incident: Order not noted. What is the actual effect of the incident on the resident? Low blood sugar..." A Diabetic Record, dated October 2011, documented [MEDICATION NAME] 70/30 40 units was administered 13 times and [MEDICATION NAME] 70/30 16 units was administered 11 times after the order to discontinue. On 12/07/11 at 10:30 a.m., the DON was asked how the facility ensured the physician orders [REDACTED]. She stated, "We have a new procedure now, I don't know how they were doing it then. They should have been checked daily."

Based on observation, clinical record review and staff interview, it was determined the facility failed to: a. provide pain medication and anxiety medication in a timely manner for one (#20) of 11 sampled residents who experienced pain. This resulted in actual harm to the resident who called 911 for help in obtaining pain medication. The resident census and condition report identified 18 residents were on a pain management program; b. assess, monitor and intervene for one (#7) of one sampled residents with a rash of unknown origin; and c. assess, monitor and intervene for one (#15) of one sampled resident with excoriation. This had the potential to affect four residents identified by the facility with a rash and 38 residents identified by the facility with urinary incontinence. Findings: 1. Resident # 20 was admitted to the facility on [DATE] at 1:30 p.m., with [DIAGNOSES REDACTED]. Physician's admission orders ... [MEDICATION NAME] 5/325 mg (one or two) po q 6 hrs. prn [MEDICATION NAME] 0.5 mg po q 12 hrs. prn anxiety..." A MAR, dated August 2011, indicated the resident received [MEDICATION NAME] 5/325 mg. and [MEDICATION NAME] 0.5 mg. on 08/12/11 at 12:00 a.m. This was approximately 11 hours after admission to the facility. There was no documentation that indicated the resident received [MEDICATION NAME] and [MEDICATION NAME] on 08/11/11. On 11/29/11 at 11:00 a.m., the DON was asked how the facility obtained medications for new residents. She stated if the medications were ordered during weekday business hours, they could be delivered to the facility. She stated if it was after hours, a holiday, or the weekend, a nurse would leave the facility to pick up the medications at the pharmacy. She was asked if there was always enough staff on site to allow a nurse to leave. She stated if there was not enough staff, then the ADON or the DON would pick up the medications. She further stated not all new medications would be obtained after hours. She stated primarily pain medications, insulin and blood pressure or cardiac medications would be obtained after hours. She was asked why medications would not be available to a new resident admitted at 1:30 p.m. on a Thursday. She stated she did not have an answer for that. On 11/30/11 at 2:00 p.m., the DON was asked to provide the care plan and MDS, which were not located in the clinical record. They were not provided. On 12/07/11 at 10:30 a.m., LPN #1 was asked how the nurses obtained medications for new residents. She stated, "Whoever is available goes to pick them up." She was asked if there was ever a time when there were no staff available to pick them up. She stated she couldn't recall a time when someone could not pick up medications. On 12/07/11 at 11:00 a.m., the corporate nurse was asked to provide the care plan and MDS, which were not in the clinical record and had not been provided. They were not provided. On 12/07/11 at 5:15 p.m., the resident was asked if she received her medications on the day of admission. She stated on the day of admission, she requested pain medication for post operative pain. She recalled she asked for it around 1:30 p.m. and was told the medication would have to be obtained from the pharmacy. She stated she did not receive a dose of pain medication, even after multiple requests for it. She stated she was told no one was available to pick up the medication. She stated she did not get medication for anxiety, even though she requested that as well. She stated by 10:00 p.m., she was so distraught she called 911 and reported she was in extreme pain and could not get any pain medication from the facility. She stated the 911 operator called the facility and talked to a nurse, who's name she did not recall. The resident stated she finally got her first dose of pain medication at approximately midnight on 08/12/11. She stated she got a first dose of anxiety medication at midnight on 08/12/11. 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. An initial care plan, dated 05/05/11, documented, "... Skin Integrity... Perform head to toe skin assessment... Apply lotion to dry skin, use moisture barrier as needed..." A Resident Data Collection Status Upon Admission form, dated 05/06/11 at 5:15 p.m., documented, "...Skin Condition: Indicate below all body marks such as old or recent scars (surgical and other), bruises, discolorations, abrasions, pressure ulcers or any questionable markings. Indicate size, depth (in cms), color and drainage... Comments: R hip/femur (dressings). Multiple bruises noted all over body. [MEDICAL CONDITION] in (lower extremities) & feet. Extensive bruising to groin & inner thighs..." There was no documentation on the admission form to indicate the resident had a rash or itching. A detailed admission nurse's note did not document a rash or itching. Skilled daily nurses' notes, dated 05/07/11, 05/08/11 and 05/09/11 documented the resident had a rash and was itching. An admission assessment, dated 05/13/11, documented the resident had a surgical wound. No other skin conditions were identified on the assessment. A Resident Overall Care Plan, dated 05/24/11, documented, "... (resident) is at risk for infection R/T... impaired skin integrity... Plan of Approach... Nursing will monitor skin routinely for [MEDICAL CONDITION], infections, dehydration, rashes, callouses... dry skin, itchy skin ... abrasions and lacerations..." A nurse's progress note, dated 09/11/11, documented, "... Skin Condition... intact (dressing) to heel..." There was no documentation of a rash. A physician's telephone order, dated 10/12/11, documented, "... [MEDICATION NAME] 25 mg po q 6 hr itching..." There was no documentation that indicated the resident was itching. There was no documentation of assessment of a rash. There was no documentation the resident had abrasions and lacerations from scratching. There was no documentation on the monthly MARs that indicated [MEDICATION NAME] was ever given for itching. A nurse's progress note (Monthly Summary for October 2011), dated 10/17/11, documented, "... Skin Condition Treated: Sore on the Rt cheek of butt..." There was no documentation on the monthly summary of a rash or itching. A quarterly assessment, dated 11/01/11, documented the resident had a stage 4 pressure ulcer. No other skin problems were identified. On 11/29/11 at 5:00 p.m., the resident was observed scratching her inner thighs and trunk continually while in the dining room. On 11/30/11 at 2:00 p.m., incontinent care was observed. The resident had a red rash between her thighs, near her groin and in patches around her waist. She had small patches of rash on her trunk. She had patches of rash behind her knees and on her buttocks. During the incontinent care, the resident continually scratched her inner thighs, her perineum and her trunk. She had long, chipped fingernails and had abraded the skin between her thighs. The CNAs attempted to keep her from scratching, but as soon as they released her hands, she began scratching again. The resident was grinding her teeth while she scratched herself. CNA #2 and CNA #3 were asked how long the resident had the rash. They stated the resident had the rash for months and she would scratch all the time if she could reach it. They were asked if they had reported the rash and the severe itching to the nurses. They stated they had, but the nurses stated the resident "was always like that." At 2:20 p.m., during wound care, LPN #1 and LPN #4 were asked about the resident's rash. They stated the rash had been there for a long time and the resident was always scratching. They were asked why the resident's rash and itching had not been treated. They stated they would check the physician's orders [REDACTED]. On 12/01/11 at 9:00 a.m., LPN #1 was asked if the physician had been contacted about the resident's rash. She stated the physician had ordered [MEDICATION NAME] to be applied to the rash. She was asked if the resident's itching had been treated. She stated she didn't think so. On 12/07/11 at 2:30 p.m., the DON was asked about the resident's rash and severe itching. She stated the resident had the rash for months and the physician had just evaluated her and ordered cortisone and routine [MEDICATION NAME]. A physician's telephone order, dated 12/07/11, documented, "DC [MEDICATION NAME] Topical [MEDICATION NAME] BID... [MEDICATION NAME] 0.1% ointment BID to rash... Give [MEDICATION NAME] 25 mg po BID x 7 days..." On 12/08/11 at 10:30 a.m., LPN #4 was asked if she performed weekly head to toe skin assessments on the resident. She stated she did. She was asked why none of the weekly skin assessment forms documented the resident had a rash. She stated her usual practice was to document only pressure ulcers. She stated she was recently instructed by the DON to document all skin conditions, including bruises and rashes on the weekly skin assessments. 3. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Resident-Data Collection form, dated 09/13/11, documented "...excoriated groin and buttocks..." A nurse's note dated 09/13/11, documented "...skin (warm and dry), no breakdown but has excoriated butts and groin..." A Skin Assessment Weekly Summary, dated 09/10/11 - 09/16/11, documented "...pressure ulcer stage 1 8.5 x 6 x 0...on admission 9/13/2011." A 14 day assessment, dated 09/25/11, documented the resident's cognition was severely impaired. He required extensive assistance with transfers. He was totally dependent on staff for dressing, hygiene and bathing. He was occasionally incontinent of bowel and frequently incontinent of bladder. A Resident-Data Collection form, dated 10/29/11, documented, "...Stage II size of dime L buttocks, coccyx red..." A nurse's note, dated 10/29/11, documented, "...stage II to lt buttocks size of dime dry no drainage area rough/dry, coccyx red..." A physician fax, dated 11/07/11, documented, "...resident with open areas to buttocks may we have order for apply [MEDICATION NAME] healing ointment..." A physician fax, dated 11/16/11, documented, "...resident has excoriated butts and groin has been on [MEDICATION NAME] healing ointment may we get an order for [REDACTED]. On 12/09/11 at 10:15 a.m., LPN #4 was asked if the areas documented on the data collection form was a pressure sore or excoriation. She stated, "It was excoriated but when he came back from the hospital it was open so we had to call it a Stage II."