Every finding on record at The Grove Post Acute

Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the two-compartment preparation sink had an air gap. * The facility failed to ensure food was free from gray fuzz. * The facility failed to ensure food items were dated. * The facility failed to ensure cutting boards were not heavily marred and chipped. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. These failures had the potential to cause foodborne illnesses to the 85 medically vulnerable resident population who consumed food prepared in the kitchen.Findings: 1. According to the USDA Food Code 2022, Section 5-402.11 Backflow Prevention showed improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in contamination of food, utensils, equipment, or other food-contact surfaces. It may also adversely affect the operation of equipment such as ware washing machines. According to the USDA Food Code 2022, Section 5-402.11 Backflow Prevention, Air Gap showed an air gap between the water supply inlet and the flood level rim of the plumbing, fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.Review of the Facility's P&P titled Air Gap dated 5/2025, showed it is the responsibility of the maintenance department to maintain appropriate air gaps in food preparation and service areas. The maintenance department is responsible for inspecting air gaps annually, or more often, if needed, to ensure proper working order to prevent backflow. The P&P further showed air gaps should be at least 2 times the diameter of the waste pipe to prevent backflow. On 8/19/26 at 0945 hours, an observation of the kitchen's two-compartment sink and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the two-compartment sink did not have an air gap. Further observation showed the two-compartment sink had water backing up with green food particles. The Maintenance Director verified the findings and stated he would have to use a device to drain the water. On 8/19/26 at 1352 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the facility had a plumber checked if the two-compartment sink had an air gap and verified it did not. 2. Review of the facility's P&P titled Food Safety and Food Storage, revised 11/2024 showed it is the policy of the facility that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. The P&P further showed facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery and/or receipt and ensure timely and proper storage. On 8/18/26 at 0810 hours, an observation and concurrent interview was conducted with [NAME] 1. A box of strawberries was observed with gray fuzz. [NAME] 1 verified findings and stated she would discard the box of strawberries. 3. Review of the facility's P&P titled Food Safety and Food Storage, revised 11/2024 showed the facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery and/or receipt and ensure timely and proper storage.c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable) and/or discarded. On 8/18/26 at 0815 hours, an observation and concurrent interview was conducted with [NAME] 1. The following undated drinks were observed in the Walk-In Refrigerator:- four cups of shake;- five cups of apple nectar juice; and - six cups of soy milk. [NAME] 1 verified the findings and stated the drinks should be labeled with the date. 4. According to the USDA Food Code 2022 4-501.12, Cutting Surfaces, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. Review of the facility's P&P titled Cutting Boards revised on 6/2025 showed cutting boards will be clean and sanitized after use. Cutting boards that have deep scores or are not able to be sanitized are not used or are reconditioned. The P&P further showed to replace when the boards begin to have breaks, corrosion, open seams, cracks and chipped areas as the boards can no longer be sanitized properly. On 8/18/26 at 0831 hours, an observation and concurrent interview was conducted with [NAME] 1. Two brown cutting boards and three green cutting boards were observed heavily marred and chipped. [NAME] 1 verified findings and stated she would replace the cutting boards 5. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils:(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch;(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 8/18/26 at 0834 hours, an observation and concurrent interview was conducted with [NAME] 1. One muffin tin was observed with dried brown food particles. [NAME] 1 verified findings and stated the muffin pan should be cleaned. On 8/20/26 at 1435 hours, an interview was conducted with the Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services. The Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services were informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and include the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility's Assessment Review dated 2/3/26, did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment; a plan to maximize recruitment and retention of the direct care staff; and a contingency plan for staffing needs. On 8/20/26 at 1621 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with the Administrator. The Administrator verified the Facility Assessment Review dated 2/3/26, and verified there were no direct care staff, direct care representatives, residents' representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there were no documentation of a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs in the Facility Assessment. The Administrator stated he cannot remember of the current guidance with regards to the Facility Assessment. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest guidance from CMS.

Based on observation, interview. medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection control program. * The facility failed to implement the facility's control measures to minimize the risk for growth and transmission of Legionella (a [NAME] of bacteria that naturally lives in fresh water and soil, and can cause serious lung infections if it grown in man-made water systems and enters the lungs) bacteria. * The facility failed to ensure two of two industrial washing machines used by the facility for the resident's clothing and linens were maintained in a sanitary condition. * The facility failed to ensure Dietary Aide performed hand hygiene between handling of the dirty and clean dishes during a dishwashing observation. These failures posed the risk of contamination and transmission of microorganisms, including Legionella and other potentially harmful pathogens, which could result in the residents being exposed to infectious agents and increasing the risk for waterborne infection, including Legionnaires' disease (a serious type of pneumonia caused by Legionella bacteria), especially among the vulnerable population of residents in the facility. Findings: 1. According to CDC's Overview of Water Management Programs dated 3/15/24, the seven steps of a Legionella Water Management Program are: establish a Water Management Program team, describe the building water systems, identify areas where Legionella could grow and spread, decide where to apply and how to monitor control measures, establish interventions when control measures are not met, ensure the program runs as designed and is effective, and document and communicate all the activities. In general; the principles of effective water management include ensuring adequate disinfection, maintaining devices to prevent sediments, scale, corrosion, and biofilm, maintaining water temperatures to limit Legionella growth, and preventing water stagnation. According to CDC's Controlling Legionella in Potable Water Systems dated 1/3/25, identifies sediments and biofilms as key factors affecting Legionella growth and recommends regular cleaning and maintenance of water-system components, including aerators, showerheads, hoses and filters. According to CDC's Considerations for Reducing Risk: Water in Healthcare Facilities dated 2/6/26, healthcare facilities should maintain a water management program that identifies hazardous conditions and corrective actions to minimize the growth and spread of waterborne pathogens. It specifically recognized sinks, faucets, HVAC humidifiers, showers, and other fixtures as components of healthcare facility premise plumbing. Review of the CMS QSO 25-14-NH titled Revised LTC Surveyor Guidance: Significant Revisions to Enhance Quality and Oversight of the LTC Survey Process, dated 3/10/25, under Water Management section, showed the facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program. Water management must be based on nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency) and include: - An assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread; and - Measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. Review of the facility's document titled Legionella Water Management Program dated 1/5/24, showed the following: - The Water Management Team shall establish procedures to confirm the Water Management Program has been implemented and monitored monthly (verification). Additionally, the Water Management Team shall establish documentation and communication procedures for all activities within the Program; - The Water Management Team shall meet monthly to confirm the program is properly managed and to discuss updates to regulations or the water management program; - A Water Management Team master binder containing all water management program documents and a list of the location of all program binders in the facility shall be maintained in the office of the Water Management Team lead; - Under the Control Points section, showed all water fittings (faucets at sink, shower heads, etc.) and AC vents will be monitored and cleaned during daily housekeeping routines. If biofilm is found on the fittings or water condensing on the air conditioning vents, corrective action must be taken; and HVAC vents will be checked monthly to ensure there is no water leaking from the vents which could be aerosolized and inhaled by the resident; and water heaters and HVAC will be checked quarterly to ensure there are no leaks, no stagnant water, or biofilm collecting on fittings, drip trays, and any other area where water can collect stagnate; and - Under the Control Point Monitoring section, showed control points need to be monitored. The frequency of monitoring is outlined in the Control Points section; each time a control point is checked, the date and time should be entered in a log sheet. Monitoring to include testing for Legionella bacteria, and the monitoring of preventive measures; and the log sheet must be kept in a central location, preferably in the Water Management Team binder. On 8/19/26 at 1550 hours, an interview and concurrent facility document review was conducted with the Administrator, IP, and Maintenance Director. When asked to show the facility's documentation of their control points or measures to prevent the growth of opportunistic waterborne pathogens such as Legionella, the Maintenance Director stated all water fittings such as faucets at sinks and shower heads were cleaned as part of the daily housekeeping routine. Review of the facility's document titled Control Measure Documentation, which was included the Water Management Team binder, showed the following: - In April 2026, the faucets in the front lobby and Rooms 1 to 3, and the shower in room [ROOM NUMBER] were checked and cleaned with no biofilm; - In May 2026, the faucets in Occupational Therapy room, the faucet and shower in room [ROOM NUMBER] and Station 1 shower room were checked and cleaned with no biofilm; - In June 2026, the faucets in Rooms 5 to 17, and Physical Therapy gym were checked and cleaned with no biofilm; and - In July 2026, the faucets in Rooms 18 to 32, DSD room, laundry room, breakroom restroom, and kitchen, and shower heads in Station 2 shower rooms were checked and cleaned with no biofilm. Review of the facility's document titled HVAC Air Filters Log Sheet 2026 showed the HVAC units 1 to 15 were checked (or replaced) on 1/7, 4/5, and 6/4/26. Further review of the Water Management Team binder did not show documentation of the daily monitoring and cleaning of the water fittings such as faucets at sink, shower heads, and AC vents will be monitored and cleaned during daily housekeeping routines. In addition, there was no documentation for the monthly checking of the HVAC vents to ensure there is no water leaking from the vents which could be aerosolized and inhaled by the residents. The Maintenance Director verified the above findings. The Maintenance Director stated he was in charge of the housekeeping department and the daily housekeeping routine including checking the faucets and shower heads in each room; however, he was unable to show documentation of the daily checking and monitoring of the water fittings. The Maintenance Director further stated he did not clean the HVAC vent daily, but he changed the air filters quarterly. When asked how often the facility's Water Management Program was reviewed, the Administrator stated the Water Management Team meets monthly during the QAPI meeting, and the team's most recent meeting was conducted on 7/22/26; however, they did not review the supporting documentation of the Water Management Program's control measures. 2. According to CDC's Guidelines for Environmental Infection Control in Healthcare Facilities revised 7/2019 the laundry equipment be used and maintained to the manufacturer's instructions to prevent microbial contamination of the system. Review of the manufacturer's manual titled Continental Laundry Solutions Equipment Manuals for Girbau washers (undated) showed to clean exterior stainless steel and internal surfaces using water and a mild detergent, then wipe dry with a soft cloth. Review of the facility's P&P titled Laundry dated 12/19/22, showed the facility launders lines and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. Laundry equipment will be used and maintained according to the manufacturer's instructions. On 8/18/26 at 1539 hours, an inspection of the laundry room-and concurrent interview was conducted with the Maintenance Director. Two industrial washing machines were observed in the facility's laundry area, and the following were observed: - Washer 1 was observed with a thick, hardened, white-colored sediment or deposit accumulated on the door frame near the washer opening; and - Washer 2 was observed with a thick, hardened, white-colored sediment or deposit accumulated on the door frame near the washer opening, and a visible rust and corrosion on the front panel. Review of the facility's document titled Washer Cleaning Log for 2026 showed the following dates when the washers were cleaned: 1/2, 1/19, 1/27, 2/6, 2/20, 3/5, 3/21, 4/4, 4/19, 5/1, 5/18, 6/5, 6/19, 7/4, 7/16, 8/15, and 8/17/26. The Maintenance Director verified the above findings. The Maintenance Director stated Washer 2 was leaking before, and a new gasket was put in, and he had to clean the washers regularly. 3. Review of the facility's P&P titled Dishwashing Procedure revised 8/2018 showed either two people are in the dish room, one on dirty side, one on clean side or if one person does both, they must wash their hands between dirty and clean areas. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/2020 showed dishes, trays, and utensils shall be handled with clean hands. On 8/18/26 at 0837 hours, an observation during the initial kitchen tour was observed. The Dietary Aide was observed with gloves on placing dirty dishes into the dishwasher. The Dietary Aide was then observed removing the clean dishes from the dishwasher without performing hand hygiene between the handling of the dirty and clean dishes. On 8/18/26 at 0842 hours, an interview was conducted with the Dietary Aide. The Dietary Aide verified she did not perform hand hygiene between the handling of the dirty to clean dishes. The Dietary Aide stated she should have removed her gloves and performed hand hygiene for infection control. On 8/20/26 at 1435 hours, an interview was conducted with the Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services. The Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic medications for one of five final sampled residents (Resident 12) reviewed for unnecessary medications. * The facility failed to accurately monitor the number of behavioral episodes in the monthly psychotherapeutic summary related to the use of the trazodone (antidepressant) medication for Resident 12. This posed the risk of affecting the evaluation of the effectiveness and continued need for the trazodone medication for Resident 12.Findings: Review of the facility's P&P titled Use of Psychotropic Medication revised 3/17/25, showed the effects of psychotropic medications on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis, such as (a) upon physical evaluation (routine and as needed), (b) during the pharmacist's monthly medication regimen review, (c) during MDS review (quarterly, annually, significant change), and (d) in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan. The resident's response to the medication(s), including progress towards the goal and presence/absence of adverse consequences, shall be documented in the resident's medical record. Medical record review for Resident 12 was initiated on 8/18/26. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed the following physician's orders dated 6/21/26:- to administer trazodone hydrochloride 50 mg one tablet by mouth at bedtime for depression manifested by inability to sleep;- to monitor hours of sleep every shift for depression manifested by inability to sleep, trazodone use, and- to monitor for side effect related to the use of antidepressant medications as follows: dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension, dark urine, yellow skin, nausea and vomiting, lethargy, drooling, dizziness, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for falls. Initials indicate absence of signs and symptoms of side effects, every shift for trazodone use. Review of Resident 12's MAR for July 2026 showed Resident 12 was administered the trazodone medication from 7/1 to 7/31/26 at 2100 hours, and Resident 12 slept zero to two hours during 0700 to 1500 hours shift, one to six hours during the 1500 to 2300 hours shift, and four to seven hours during the 2300 to 0700 hours shift. Review of Resident 12's Psychopharmaceutical Summary Sheet for July 2026 for the trazodone medication use showed Resident 12 slept zero to two hours during 0700 to 1500 hours shift, one to three hours during the 1500 to 2300 hours shift, and four to seven hours during the 2300 to 0700 hours shift. On 8/20/26 at 1107 hours, an interview and concurrent medical record review for Resident 12 was conducted with the ADON. The ADON stated she was responsible for completing the monthly behavior summary for the residents on psychotropic medications. When asked how she completed the monthly behavior summary for Resident 12 related to the use of the trazodone medication, the ADON stated she would review the resident's documented hours of sleep and would tally the range for each shift. The ADON verified Resident 12's documented hours of sleep in the MAR during the 1500 to 2300 hours shift was one to six hours; however, Resident 12's range of sleep in the monthly behavior summary during the 1500 to 2300 hours was one to three hours related to the use of the trazodone medication. On 8/21/26 at 1025 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON stated the ADON was responsible for completing the monthly behavior summary for the residents on psychotropic medications. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the formulation to have an advance directive was accepted or declined for three of 19 final sampled residents (Residents 13, 52, and 68). * The facility failed to follow up whether Residents 13, 52, and 68 would want or decline to formulate an advance directive. This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.Findings:Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives revised 12/19/22, showed:- On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive;- The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities;- Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions;- Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care; and- Any services that would be otherwise required, but are refused, will be documented in the resident's comprehensive care plan.1. Medical record review for Resident 13 was initiated on 8/18/26. Resident 13 was admitted to the facility on [DATE].Review of Resident 13's H&P examination dated 7/11/26, showed Resident 13 had the capacity to understand and make decisions.Review of Resident 13's Advance Directive Acknowledgement dated 7/10/26, showed Resident 13 was informed of the rights to formulate an advance directive. The form also showed the resident had not executed an advance directive and had executed a POLST. Review of Resident 13's Interdisciplinary Care Conference dated 7/11/26, under section CC16. Social Services Provided/Needed showed 1:1 room visit allowed resident to express feelings and concerns, POLST was full code/long term care artificial nutrition, provided/ information and advance health care directives form, and will refer to dentist, podiatry, optometrist. Further review of Resident 13's medical record did not show documented evidence whether Resident 13 would want or decline to formulate an advance directive after the resident was provided with the information regarding advance directive.2. Medical record review for Resident 52 was initiated on 8/18/26. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 8/7/26, showed Resident 52 had the capacity to understand and make decisions. Review of Resident 52's Advance Directive Acknowledgement dated 7/16/26, showed Resident 52 was informed of the rights to formulate an advance directive. The form also showed the resident had not executed an advance directive and had executed a POLST. Review of Resident 52's Interdisciplinary Care Conference dated 7/13/26, under section CC16. Social Services Provided/Needed showed 1:1 room visit allowed resident to express feelings and concerns, POLST was DNR/selective treatment/no artificial nutrition including feeding tubes, no advance health directives, and offered advance directives/provided information. Further review of Resident 52's medical record did not show documented evidence whether Resident 52 would want or decline to formulate an advance directive after the resident was provided with the information regarding advance directive.3. Medical record review for Resident 68 was initiated on 8/18/26. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's H&P examination dated 7/11/26, showed Resident 68 had the capacity to understand and make decisions. Review of Resident 68's Advance Directive Acknowledgement dated 8/12/26, showed Resident 68 was informed of the rights to formulate an advance directive. The form also showed the resident had not executed an advance directive and had executed a POLST. Review of Resident 68's Interdisciplinary Care Conference dated 8/10/26, under section CC16. Social Services Provided/Needed showed 1:1 room visit allowed resident to express feelings and concerns, POLST was full code/trial period of artificial nutrition, provided information about advance health directives, and offered dentist, podiatry, optometrist and ENT.Further review of Resident 68's medical record did not show documented evidence whether Resident 68 would want or decline to formulate an advance directive after the resident was provided with the information regarding advance directive. On 8/19/26 at 1025 hours, an interview and concurrent medical record review for Residents 13, 52 and 68 was conducted with the SSD. The SSD stated the advance directive information was discussed and provided to the resident and family member during the first family meeting and every quarterly during the interdisciplinary care conference. The SSD stated the resident could decline the formulation of advance directive or if the resident would want to formulate one, they would assist the resident. The SSD further stated if the resident wanted to formulate an advance directive or declined it, it would be recorded in the interdisciplinary care conference note. The SSD verified and acknowledged the findings for Residents 13, 52, and 68. On 8/21/26 at 1045 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 13, 52, and 68.

Based on interview and medical record review, the facility failed to provide the necessary care and services related to the resident's bowel elimination status for two of 19 final sampled residents (Residents 9 and 10). * The facility failed to assess and provide the necessary interventions when Residents 9 and 10 had no adequate bowel movements. These failures posed the risk for the residents to not receive the necessary care and services for bowel management. Findings: 1. Medical record for Resident 10 was initiated on 8/18/26. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's CNA ADLs documentation for August 2026 for the bowel movements showed Resident 10 only had four bowel movements between 8/1/26 to 8/21/26. Review of Resident 10's plan of care showed a care plan problem dated 7/2/26, to address Resident 10's risk for constipation related to immobility. The interventions included to monitor for complications related to constipation. On 8/21/26 at 1015 hours, an interview and concurrent medical record review was conducted with CNA 4. When asked about Resident 10, CNA 4 stated Resident 10 was nonverbal. When asked who would provide the reports about the residents to CNA 4, CNA 4 stated the nurses provided reports about what to monitor for the residents. When asked about Resident 10's last bowel movement was, CNA 4 stated she could only view back up to 8/20/26. CNA 4 verified Resident 10 did not have a bowel movement on 8/21/26 or on 8/20/26. On 8/21/26, at 1058 hours, an interview and concurrent medical record review was conducted with LVN 4. When asked about when Resident 10's last bowel movement was, LVN 4 stated Resident 10's last bowel movement was on 8/15/26. When asked about medications for Resident 10's bowel movements, LVN 4 stated Resident 10 was administered Senna (stool softener) 8.6 mg twice a day. LVN 4 stated Resident 10 also had orders for a Dulcolax (stool softener) suppository to be administered as needed every 24 hours for constipation. LVN 4 verified the suppository had not been administered for Resident 10's constipation. When asked about checking for Resident 10's bowel movement status prior to administering his Senna, LVN 4 acknowledged she did not check for Resident 10's bowel movement status prior to administering the Senna to ensure the medication's effectiveness. 2. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's CNA ADLs documentation for August 2026 for the bowel movements showed Resident 9's last bowel movement was on 8/15/26. On 8/20/26 at 1426 hours, an interview was conducted with CNA 5. When asked when Resident 9's last bowel movement was, CNA 5 stated Resident 9 did not have a bowel movement today. CNA 5 verbalized he was unable to view past the documentation to see when Resident 9's last bowel movement was. On 8/20/26 at 1429 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was observed accessing Resident 9's documented bowel movement status. LVN 5 verified Resident 9's last bowel movement was on 8/15/26. LVN 5 stated Resident 9's medications included DSS (docusate sodium - a stool softener) daily and a suppository as needed. When asked if LVN 5 had checked for Resident 9's bowel movement status prior to administering his DSS, LVN 5 stated no. LVN 5 stated she was not informed Resident 9 did not have bowel movements since 8/15/26, in other words was constipated.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one of two final sampled residents (Resident 3) reviewed for respiratory care. * The facility failed to administer oxygen to Resident 3 as per the physician's order. This failure had the potential for Resident 3 not to receive appropriate respiratory care, and potential to affect the resident's well-being.Findings: Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed oxygen is administered under orders of a physician, except in the case of an emergency. On 8/18/26 at 0929, 0941 and 1141 hours, Resident 3 was observed lying in bed, with a nasal cannula in place. The nasal cannula was connected to an oxygen concentrator which was set at a rate of one liter per minute of oxygen. On 8/18/26 at 1233 hours, an observation for Resident 3 and concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 3 was receiving oxygen at a rate of one liter per minute via nasal cannula. LVN 2 stated Resident 3 should receive oxygen at a rate of two liters per minute. LVN 2 stated Resident 3's oxygen saturation was checked this morning and then Resident 3 went to therapy using a portable oxygen tank. LVN 2 stated I am not sure who put her oxygen back on when she was placed back to bed, as he walked towards the nursing station. On 8/18/26 at 1236 hours, an observation for Resident 3 and concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 3 was receiving oxygen at a rate of one liter per minute via nasal cannula. RN 1 was observed changing the dial of the oxygen concentrator from the rate of one to two liters per minute. Medical record review for Resident 3 was initiated on 8/18/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 8/4/26, to administer oxygen at a rate of two liters per minute via nasal cannula as needed for oxygen saturation of less than 92% on room air or shortness of breath. Review of Resident 3's Weights and Vitals Summary for August 2026 showed Resident 3's oxygen saturation was monitored at varying times while the resident was on room air and while the resident was receiving oxygen via nasal cannula. The summary report showed Resident 3's oxygen saturation readings ranged from 92 to 99% while on room air and there were no oxygen saturation readings below 92% on room air. Review of Resident 3's MAR for August 2026 did not show Resident 3 was administered the ordered oxygen as needed for an oxygen saturation of less than 92% on room air, or when Resident 3 had shortness of breath. Further review of Resident 3's medical record did not show Resident 3's oxygen saturation reading was below 92%, no documentation in the MAR when Resident 3 was administered the oxygen as needed for an oxygen saturation of less than 92% on room air, or when Resident 3 had shortness of breath. On 8/20/26 at 1051 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no documented evidence to show Resident 3's oxygen saturation reading was below 92%, and no documentation in the MAR when Resident 3 was administered the oxygen as needed for an oxygen saturation of less than 92% on room air, or when Resident 3 had shortness of breath. On 8/21/26 at 1007 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated Resident 3's oxygen saturation readings documented in her medical record represent a snapshot of the resident's oxygen saturation at the time it was obtained, and the oxygen saturation reading could have been obtained after the oxygen was administered to Resident 3. The DON further stated when the licensed nurses would administer the resident's ordered oxygen as needed, the licensed nurse have to initial the MAR to indicate the oxygen was administered.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of three final sampled residents (Residents 2 and 68) reviewed for hemodialysis. * The facility failed to ensure Resident 2's fluid intake related to dialysis was monitored accurately. In addition, the facility failed to ensure Resident 2 had ongoing assessment and oversight before, during, and after the dialysis treatment. * The facility failed to ensure the emergency dialysis kit was available at bedside for Resident 68. These failures had the potential for the residents to have accurate assessment of the fluid status, complications associated with fluid overload, and delayed intervention in the event of a dialysis access emergency. Findings: 1. Review of the facility's P&P titled Hemodialysis revised 6/5/23, showed the following: - The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility, ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; - The license nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form; and - The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of the facility's P&P titled Fluid Restriction revised 5/18/26, showed the following: - It is the policy of the facility to ensure that fluid restriction will be followed in accordance with physician's orders; - The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes; and - Water will not be provided at bedside unless calculated into the daily total fluid restriction. 1. Medical record review for Resident 2 was initiated on 8/18/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed the following physician's orders dated: - dated 5/19/26, for hemodialysis on Tuesday, Thursday, and Saturday; and - dated 6/11/26, for water restriction of 1200 ml per day. The nursing department provides 300 ml, with a breakdown of 150 ml for the morning shift, 100 ml for the evening shift, and 50 ml for the night shift and dietary department provides 900 ml, with a breakdown of 420 ml for breakfast, 240 ml for lunch, and 240 ml for dinner. a. On 8/18/26 at 0840 and 0924 hours, during the initial tour of the facility, a green pitcher was observed at bedside, and a 1.5-liter bottle of water was observed on Resident 2's nightstand with approximately one-quarter of the bottle remaining. Review of Resident 2' MAR for August 2026, under monitoring for water restriction, only showed the checkmarks and initials, but did not show the actual fluid intake for Resident 2. On 8/20/26 at 0920 hours, a follow-up observation was conducted with Resident 2. A 1.5-liter bottle of water was observed on Resident 2's nightstand with approximately one-quarter of the bottle remaining. On 8/20/26 at 0953 hours, an observation for Resident 2 and concurrent interview was conducted with LVN 3. LVN 3 verified a 1.5-liter bottle of water was on the Resident 2's nightstand with approximately one-quarter of water remaining. LVN 3 stated Resident 2 was on dialysis, and on fluid restriction, and there should be no pitcher or water at bedside because the resident was on fluid restriction. LVN 3 further stated the nurses and CNAs would monitor Resident 2's intake, and the licensed nurses would document the resident's fluid intake from his meals and medication pass on a logbook. On 8/20/26 at 1004 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified Resident 2 was dialysis and had a daily fluid restriction of 1200 ml. When asked about Resident 2's dialysis records, RN 1 stated Resident 2 went to dialysis on Tuesday, Thursday, and Saturday, with the Dialysis Communication Record to document Resident 2's vital signs, and assessment of his dialysis access, before, during and after dialysis. When asked about the fluid intake monitoring process, RN 1 stated the licensed nurses would record Resident 2's fluid intake from meals and medication administration in the Intake and Output Record. Review of Resident 2's Intake and Output Record reviewed with RN 1 showed the 24-hour fluid intake totals were not calculated and documented for each day. In addition, when a 24-hour total was documented, the calculation was inaccurate. For example: - dated 7/13, 7/14, 7/15, and 7/17/26, showed the fluid intake of 50 ml for the NOC shift, 650 ml, for the AM shift, and 340 ml for the PM shift. The documented 24-hour total was 990 ml; however, the sum of the three shifts was 1,040 ml, resulting in a 50 ml discrepancy; - dated 7/16/26, showed the fluid intake of 50 ml for the NOC shift, 600 ml, for the AM shift, and 340 ml for the PM shift. The documented 24-hour total was 940 ml; however, the sum of the three shifts was 990 ml, resulting in a 50 ml discrepancy; - dated 7/25, 7/26, and 7/27/26, showed the fluid intake of 50 ml for the NOC shift, 600 ml, for the AM shift, and 340 ml for the PM shift. The documented 24-hour total was 890 ml; however, the sum of the three shifts was 990 ml, resulting in a 100 ml discrepancy; - dated 7/29/26, showed the fluid intake of 50 ml for the NOC shift, 600 ml, for the AM shift, and 340 ml for the PM shift. The documented 24-hour total was 960 ml; however, the sum of the three shifts was 990 ml, resulting in a 30 ml discrepancy; and - dated 7/28, 7/30 and 7/31/26, showed there were no 24-hour total recorded. RN 1 verified the above findings. b. Review of Resident 2's Dialysis Communication Record showed the dialysis communication records were missing for 6/18 and 8/13/26. Further review of Resident 2's medical record did not show documented evidence the information related to the resident's dialysis treatments was consistently communicated with the dialysis facility staff and documented in the Dialysis Communication Record on 6/18 and 8/13/26. On 8/21/26 at 1016 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated when Resident 2 comes back from dialysis, the receiving nurse would complete the Dialysis Communication Record, place it in a binder, then the medical records personnel would upload to Resident 2's electronic health record. The DON further stated the ADON was responsible for checking the Intake and Output Records but was not sure why the 24-hour totals were inaccurate or missing. 2. Medical record review for Resident 68 was initiated on 8/18/26. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's H&P examination dated 7/11/26, showed Resident 68 had the capacity to understand and make decisions. Review of Resident 68's Order Summary Report showed a physician's order dated 7/10/26, for hemodialysis days Monday, Wednesday, and Friday at the dialysis center and hemodialysis access site monitoring of Permacath in the right internal jugular vein every shift. On 8/18/26 at 0900 hours, during the initial tour of the facility, Resident 68 was observed awake and sitting on the bed. Resident 68 stated she would go to dialysis center every Monday, Wednesday and Friday. Resident 68 was observed with a Permacath on the right side of the neck. There was no dialysis emergency kit was observed in Resident 68's room. On 8/18/26 at 1235 hours, an observation for Resident 68 and concurrent interview was conducted with LVN 3. The dialysis emergency kit was still not observed in Resident 68's room. LVN 3 verified the findings for Resident 68. LVN 3 verified Resident 68's dialysis access was a Permacath in the right side of the resident's neck. LVN 3 stated the dialysis emergency kit should always be available in the resident's room for emergencies like bleeding in the dialysis access site. LVN 3 further stated the nurses would check the availability of the dialysis emergency kit every shift and it was usually pinned in the bulletin board inside the resident's room. On 8/21/26 at 1045 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to obtain a physician's order prior to the use of bed rail for one of two final sampled residents (Resident 60) reviewed for the use of bed rails. * The facility failed to obtain a physician's order prior to Resident 60's use of left bed rail. This failure had the potential to put the resident at risk for serious injuries.Findings: Review of the facility's P&P titled Proper Use of Bed Rails revised 5/18/26, showed upon receiving informed consent, the facility will obtain a physician's order for the use of specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. On 8/18/26 at 1122 hours, during the initial tour of the facility, Resident 60 was observed awake and lying in bed. A left bed rail was observed elevated. Resident 60 stated he knew it was for him to grab when turning on his left side and when getting out of bed. Resident 60 stated he did not know of any risks related to using the bed rails. Medical record review for Resident 60 was initiated on 8/18/26. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's H&P examination dated 8/5/26, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 60's Bed Rails - V2 dated 8/5/26, showed the following:- Resident 60 demonstrated difficulty with bed mobility or moving to a sitting position from the bed;- Resident 60 had difficulty with standing/sitting balance;- Resident 60 would benefit from bilateral grab bar for mobility/transfer purposes;- Bed rail/transfer bar was indicated for mobility/transfer purposes and Resident 60 demonstrated ability to use equipment as an enabler;- Position/side of bed rail: bilateral; and- Type of bed rails: left and right side (assist bar/grab bar). Further review of Resident 60's medical record failed to show the physician's order was obtained prior to Resident 60's use of the left bed rail. On 8/20/26 at 1015 hours, an observation of Resident 60 was conducted. Resident 60 was observed being assisted by the physical therapist in transferring from the wheelchair to the bed. Resident 60 was observed holding on the left bed rail during the transfer. On 8/20/26 at 1037 hours an interview was conducted with CNA 2. CNA 2 stated Resident 60 needed minimal assist with repositioning and getting out of bed. CNA 2 stated Resident 60 used the left bed rail as a grab bar when the resident turned in his left side or got out of bed. On 8/20/26 at 1044 hours an interview and concurrent medical record review for Resident 60 was conducted with LVN 3. LVN 3 verified Resident 60 was using the left bed rail when turning and getting out of bed and transferring to the wheelchair. If the resident needed the bed rail, the rehab staff would inform the nursing department, then the nurse would notify the physician to get an order and informed consent. LVN 3 verified there was no physician's order for Resident 60's use of the left bed rail. On 8/21/26 at 1045 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 60. Cross reference to F909, example #2.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident was free from the unnecessary medications for one of five final sampled residents (Resident 13) reviewed for unnecessary medications. * The facility failed to monitor Resident 13 for the signs and symptoms of bleeding related to the use of clopidogrel medication (a blood thinner used to prevent blood clots, heart attacks and strokes) as per the physician's order. This failure had the potential for the resident to receive unnecessary medications and develop significant adverse effects.Findings: According to the FDA approved Highlights of Prescribing Information for clopidogrel revised on 04/2012 showed the most commonly reported adverse reaction in adult patients are related to bleeding, including life-threatening and fatal bleeding. Medical record review for Resident 13 was initiated on 8/18/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 7/11/26, showed Resident 13 had the capacity to understand and make decisions. Review of Resident 13's Order Summary Report showed the following physician's orders:- dated 7/9/26, to monitor for any of the following: blood in the urine, blood in the stool, unusual bleeding after shaving, bleeding from the gums, bleeding from the nose, excessive bleeding from wounds, large hemorrhagic area, or petechia. If my initial N is noted, it means I've observed the signs and symptoms, hold the medication dose and notify the physician. If my initial Y is noted, it signifies the absence of the listed signs and symptoms, every shift for clopidogrel use; and- dated 7/15/26, to administer clopidogrel bisulfate 75 mg one tablet by mouth one time a day for CVA prophylaxis Review of Resident 13's MAR for July and August 2026 showed Resident 13 received the clopidogrel medication on the following dates and time:- from 7/10 to 7/31/26 at 0900 hours;- from 8/1 to 8/11/26 at 0900 hours; and- from 8/15 to 8/17/26 at 0900 hours. Further review of the MAR showed the monitoring of the signs and symptoms of bleeding related to the use of the clopidogrel medication for the dates above. However, the documentation did not indicate whether Resident 13 had signs and symptoms of bleeding. The boxes only showed a checked mark and did not indicate N or Y as per the physician's order. Further review of Resident 13's medical record failed to show any documentation whether the resident had or had no signs and symptoms of bleeding related to Resident 13's clopidogrel medication use. On 8/20/26 at 1533 hours, an interview and concurrent medical record review for Resident 13 was conducted with the ADON. The ADON verified the above findings for Resident 13. The ADON stated the nurses should properly assess the resident as per the physician's order to ensure the resident was not having any signs and symptoms of bleeding related to the use of the clopidogrel medication. On 8/21/26 at 1045 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of two medication carts (Medication Cart B) inspected to ensure proper storage of the medications. * The facility failed to ensure the medications administered internally were stored separately from the medications to be administered externally in Medication Cart B. This failure had the potential to have negative impact on the residents' well-being, and the potential for the medications to be contaminated, losing the stability and effectiveness of the medications.Findings: Review of the facility's P&P title Storage of Medications reviewed and revised 12/19/22, showed External Products: Disinfectants and drugs for external use are stored separately from the internal and injectable medications. Medications to be administered by mouth are stored separately from other formulations (i.e., eye drops, ear drops, injectables). On 8/19/26 at 1557 hours, a medication cart inspection for Medication Cart B was conducted with LVN 1. The following was observed:- one bottle of Alkums Antacid tablet (medication to reduce acid in the stomach) oral medications was stored with five tubes of Diclofenac Sodium topical gel (medication to treat pain) in the same compartment in the fourth drawer of Medication Cart B.-one box of Heparin 5000 units (blood thinner medications) injections vial stored with one box of Naloxone HCL (hydrochloride) nasal spray 4mg (medicine used to quickly reverse a life-threatening opioid overdose) in the same compartment in the fourth drawer of Medication Cart B. LVN 1 verified the above findings. LVN 1 stated the internal and external medications should not be stored in the same compartment because the medications were administered via different routes and could cause medication errors and contamination. On 8/20/26 at 0850 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON further stated the external medication and internal medications should be stored separately to prevent contamination and potential medication error.

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure 85 of 90 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus and recipes were not followed. * The facility failed to ensure 11 of 11 residents with Minced and Moist texture diets received the steamed rice as shown on the Diet Spreadsheet - Menu: Korean Summer Menu 2026 for Week 1 dated 2026. * The facility failed to ensure the puree recipes for the rice, meat, and vegetables were followed. * The facility failed to ensure Resident 9 was served milk in his lunch meal. * The facility failed to ensure Resident 60's meal ticket matched what was on their meal tray. These findings had the potential for the residents on special diets to not receive the adequate nutritional and caloric intake as recommended on the recipes and menus. Findings: 1. Review of the facility's P&P titled IDDSI Texture Modified Diet Explanations Based on IDDSI Framework – EC7, SB6, MM5, PU4 revised 9/2021 showed Minced and Moist (MM5) is used in the dietary management of dysphagia with food texture described as soft, tender, moist foods with no separate thin liquids. Food should be no greater than 1/8-inch by 1/2-inch pieces. Grains: Soft, cooked noodles, rice, and other grains (no greater than 1/8-inch by 1/2-inch and well-moistened with thick sauce or gravy are allowed. Serve drained of excess liquid. Review of the facility's document titled Dining Manager – Steamed [NAME] Combined with Thick Broth (MMS) showed food must be moist without any separate water-thin gravy, broth or sauce pooling onto the serving plate. If food cannot be processed soft and minced no larger than four mm wide by 15 mm long, serve as pureed. Review of the facility's document titled Diet Spreadsheet - Menu: Korean Summer Menu 2026 for Week 1 dated 2026, showed for Minced and Moist texture diets, the menu included steamed white rice combined with thick broth, pureed fish cake soup, pureed kimchi, minced and moist steamed egg batter, pureed yuchae namul (a traditional Korean side dish), minced and moist or puree citrus angel food cake, and choice of beverage. On 8/19/26 at 1255 hours, during tray line, an observation and concurrent interview was conducted with the DSS and RD. An observation of Residents 66 and 87's meal ticket showed the residents were on Minced and Moist diet texture. Further observation showed Residents 66 and 87 received pureed rice. The DSS and RD verified the findings and stated the menu showed the steamed white rice should have been combined with thick broth and stated it did not show to use pureed rice. The DSS also verified all 11 residents with Minced and Moist diet texture received pureed rice. On 8/20/26 at 1545 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS verified the facility document titled Dining Manager – Steamed [NAME] Combined with Thick Broth (MMS) showed if the food cannot be processed soft and minced no larger than four mm wide by 15 mm long, serve as pureed. The DSS verified the rice was not measured; however, were served as pureed. 2. Review of the facility's P&P titled IDDSI Texture Modified Diet Explanations Based on IDDSI Framework – EC7, SB6, MM5, PU4 revised 9/2021 showed Puree (PU4) modification is designed for people who have severe chewing and/or swallowing problems. Properly pureed foods eliminate the chewing phase. Pureed diet menus follow the foods on the regular menu as closely as possible and differ primarily in consistency. Review of the facility's P&P titled Standardized Recipes revised 8/2018 showed standardized recipes will be used for all products prepared and will note appropriate seasonings in order to assure acceptance from the residents. Standardized recipes will have adjustments for yields needed. Recipes note how to prepare the food items in order to preserve vitamins, taste, and appearance. Review of the facility's document titled Pureed Potatoes, Pasta, Rice, and Other Grains revised 11/2021 showed to yield 15 serving showed to include 3 and ¾ (three-fourths) cups of hot broth or hot 2% milk with the directions to first remove portions required from regular prepared recipe and drain. Place in food processor and process until smooth. The Step 2, showed to slowly add hot broth or hot milk and margarine. If needed add thickener and process until smooth in consistency. Review of the facility's document titled Pureed Fish/Meet/Poultry – 2 oz revised 10/2021 showed to yield 15 servings include 2 (two) and 1/4 (one quarter) cups of hot reserved cooking liquid or broth. Review of the facility's document titled Pureed Vegetables (undated) showed to yield 15 servings use 3 (three) and 1/2 (one half) cup reserve liquid. On 8/19/26 at 1030 hours, during the puree diet preparation, an observations was conducted with [NAME] 1 and the DSS with the RD present. The following were observed: - for puree rice, [NAME] 1 was observed adding the steamed rice and hot water together and blended. [NAME] 1 stated he used a total of two cups of hot water. [NAME] 1 was not observed using a measuring cup to measure the liquid, hot water was used instead of hot broth or hot 2% milk as per the recipe for puree rice, and margarine was not added; - for pureed meat, [NAME] 1 stated adding a total of one cup of beef broth and blend; however, [NAME] 1 was not observed measuring the amount of beef broth added; and - for pureed vegetables, [NAME] 1 stated he used a total of one cup vegetable broth; however, [NAME] 1 was not observed measuring the vegetable broth. On 8/19/26 at 1115 hours, an interview and facility document review of the Puree Recipes were conducted with [NAME] 1 and the DSS with the RD present. [NAME] 1, the DSS, and RD verified the recipe for pureed rice, meat, and vegetables were not followed. [NAME] 1 stated he used hot water and did not add margarine for the Puree [NAME] recipe. [NAME] 1 also verified he did not measure the cups of liquids added to the pureed rice, meat and vegetable recipes. [NAME] 1, the DSS, and RD stated the pureed recipes should be followed as directed on the recipes. 3. On 8/19/26 at 1250 hours, during tray line, an observation and concurrent interview was conducted the DSS and RD. Resident 60's lunch tray was observed with two portions of chicken, two scoops of sweet potato and two bread rolls. Review of Resident 60's meal ticket on the lunch tray showed resident was on a regular CCHO diet with double portion protein. The DSS and RD verified the above findings and stated the resident should only have double portion protein and not double the portion of the sweet potato and bread roll. The RD stated Resident 60 could have double portion protein, but should not have double the portion of carbohydrates for a CCHO diet. On 8/20/26 at 1435 hours, an interview was conducted with the Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services. The Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services were informed and acknowledged all of the above findings. 4. On 8/18/26 at 1107 hours, a telephone interview Resident 9's responsible party was conducted. Resident 9's responsible party stated she was informed by the facility Resident 9 had a weight loss of six pounds. On 8/18/26 at 1200 hours, a lunch observation was initiated. On 8/18/26 at 1334 hours, an observation and concurrent interview was conducted with Resident 9 and CNA 3. Resident 9's meal tray was observed with bread with cut up vegetables, juice and a nutritional shake. Review of Resident 9's diet card showed Resident 9 was also to be served milk. Resident 9's meal tray was observed without the milk. When asked about not having the milk on his meal tray, Resident 9 verbalized he loves milk. CNA 3 verified Resident 9's meal tray was missing the milk. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE].

Based on observations, interviews, facility document review, and facility P&P review, the facility failed to ensure the food served was appetizing and palatable for three of 85 residents (Residents 7, 52, and 68) who received food prepared in the facility kitchen were not satisfied with the facility food. * The facility failed to ensure Residents 7, 52, and 68 who received food prepared in the facility kitchen were satisfied with the facility food. In addition, the facility failed to ensure the asparagus served during lunch on 8/19/26, was palatable. These failures posed the risk for the residents to not receive appetizing and palatable food prepared in the kitchen and negatively affect the residents' nutritional status. Findings: Review of the facility's P&P titled Standardized Recipes revised 8/2018 showed the recipes note on how to prepare the food items in order to preserve vitamins, taste, and appearance. Review of the facility's document titled Diet Spreadsheet, Menu: Summer American Menu 2026 showed the lunch for the American menu on Wednesday 8/19/26, included panko mustard chicken, rosemary sweet potatoes, fresh asparagus, bread or roll with margarine, citrus angel food cake, and a choice of milk or beverage. a. On 8/18/26 at 0900 hours, during the initial tour of the facility, Resident 68 stated sometimes food is cold. On 8/18/26 at 0942 hours, during the initial tour of the facility, Resident 52 stated she was not happy with the food provided. On 8/18/26 at 1000 hours, during the initial tour of the facility, Resident 7 stated the food had no taste. b. On 8/19/26 at 1405 hours, a concurrent interview and test tray of the regular menu for the Korean and American meal trays were conducted with the DSS, RD, and five surveyors present. The DSS, RD, and five surveyors verified the asparagus on the American meal tray was mushy and the color was pale green. The DSS and RD stated the facility uses frozen asparagus. The RD verified and stated, just by looking at the asparagus, the texture looked mushy. The DSS also acknowledged the findings. On 8/20/26 at 1435 hours, an interview with the Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services was conducted. The Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services were informed and acknowledged the above findings.

Based on observation and interview, the facility failed to ensure the facility's garbage and refuse was properly disposed. * The facility failed to ensure the area behind the waste dumpsters were free from debris. This failure had the potential to cause unsafe sanitary conditions and potential harbor pests and rodents.Findings: According to the USDA Food Code 2022, Section 5-501.11 Storing Refuse, Recyclables, and Returnables showed refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code 2022, Section 5-501.115 Maintaining Refuse Areas and Enclosures showed a storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items and clean. According to the USDA Food Code 2022, Section 5-501.116 Cleaning Receptacles:(B) Soiled receptacles and waste handling units for refuse, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. On 8/18/26 at 1004 hours, an observation and concurrent interview was conducted with the Maintenance Director. Debris including dried leaves, five cardboard boxes, four unused shower chairs, and two cabinet doors were observed behind the waste dumpsters. The Maintenance Director verified findings and stated the area should be kept clean to prevent the potential for the rodents and pests to harbor amongst the debris. On 8/20/26 at 1435 hours, an interview with the Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services was conducted. The Administrator, DON, AIT, DSS, and [NAME] President of Dietary Services were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate and complete for one of 19 final sampled residents (Residents 78). * The facility failed to ensure the follow up regarding Resident 78's advance directive was documented in a timely manner. This failure had the potential for the resident to not receive the care and services according the resident's care needs and preferences. Findings: Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed documentation can be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation shall be timely and in chronological order. Medical record review for Resident 78 was initiated on 8/18/26. Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's H&P examination dated 4/10/26, showed Resident 78 had the capacity to understand and make decisions. Review of Resident 78's Advance Directive Acknowledgement dated 4/21/25, showed Resident 78 was informed of the rights to formulate an advance directive. The form also showed the resident had not executed an advance directive and had executed a POLST. Review of Resident 78's Social Service Assessment - Quarterly note dated 6/30/26, did not show documented evidence Resident 78 was offered again to formulate an advance directive or addressed the formulation of the advance directive. Further review of Resident 78's medical record showed no documented evidence Resident 78 was provided a follow up regarding formulation of advance directive. On 8/19/26 at 1025 hours, an interview and concurrent medical record review for Resident 78 was conducted with the SSD. The SSD stated the advance directive information was discussed and provided to the resident and family member during the first family meeting and every quarterly during the interdisciplinary care conference. The SSD stated the resident could decline the formulation of advance directive or if the resident would want to formulate one, they would assist the resident/family member. The SSD further stated if the resident/family member wanted to formulate or declined an advance directive, it would be recorded in the interdisciplinary care conference note or social service assessment note. The SSD verified Resident 78 had not formulated an advance directive. The SSD was informed and acknowledged the findings. The SSD was observed doing a telephone call to Resident 78's family member. On 8/19/26 at 1330 hours, a follow-up interview was conducted with the SSD. The SSD stated the SSC was able to speak with Resident 78's family member on 6/30/26, during the quarterly care plan meeting. The SSD showed the surveyor the SSC note; however, the note was just entered today (8/19/26), 57 minutes ago by the SSC in the Social Services Progress Note. Review of Resident 78's Social Services Progress Note dated 8/19/26 at 1233 hours, showed the SSC spoke with Resident 78's family member during the care plan meeting regarding the advance health directive. Resident 78's family member was offered to formulate the advance directive but the family member stated he would consider it when he would visit the resident. On 8/21/26 at 1045 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure a facility staff received education about Covid-19 vaccine and offered the Covid-19 vaccine for one of one facility staff (LVN 2) reviewed for Covid-19 vaccination. * The facility failed to maintain the documentation to show LVN 2 was provided the required Covid-19 vaccine education and offered the vaccine or information on obtaining the vaccine. This failure increased the risk for LVN 2 to remain unvaccinated, susceptible to Covid-19 infection and potentially facilitating increased risk of exposure to and transmission of SARS-CoV-2 to the residents which could result in serious illness, hospitalization, and/or death.Findings: According to CDC's Covid-19 Vaccination for Long-Term Care Residents dated 6/11/25, people who live or work in LTC settings can help protect themselves and others by receiving an updated Covid-19 vaccine and older adults and people with certain health conditions are more likely to become very ill from Covid-19. Review of the facility's P&P titled Coronavirus Prevention and Response revised 12/19/22, showed the facility should offer resources and counseling to healthcare personnel, residents and visitors on the importance of receiving the Covid 19 vaccine. On 8/20/26 at 1412 hours, an interview and concurrent facility document review was conducted with the IP. When asked if the facility offered the Covid-19 vaccine to the facility staff, the IP stated facility offered Covid-19 vaccine to the facility staff, but he has not given any Covid-19 vaccine in the facility, and the facility staff have taken the Covid-19 vaccine outside the facility. The IP further stated he kept a binder to keep all the documentation to show Covid-19 was offered to the facility staff. The IP was unable to show documented evidence LVN 2 was provided the required Covid-19 vaccine education and offered the vaccine or information on obtaining the vaccine. Review of the facility's document titled Covid Isolation Tracking for August 2026 showed the following:- Resident 45 in Room G tested positive for Covid-19 on 8/19/26;- Resident 97 in Room E tested positive for Covid-19 on 8/21/26;- Resident 66 in Room D tested positive for Covid-19 on 8/21/26; and- Resident 79 in Room F tested positive for Covid-19 on 8/21/26. However, review of the facility's staffing schedule showed LVN 2 was assigned to provide care for the residents in rooms including Rooms D, E, F, and G, on 8/18 to 8/20/26 at 0700 to 1500 hour shift. The IP verified the above findings. On 08/21/2026 at 1028 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review the facility failed to ensure the residents' bed inspection and entrapment assessments were conducted and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of the side rails for two of 19 final sampled residents (Residents 60 and 79) reviewed for the use of side rails. * The facility failed to conduct a regular inspection of all the bed frames, mattresses, and side rails as part of the regular maintenance program. * The facility failed to ensure the entrapment assessment was completed and the measurement was obtained when identifying areas of possible entrapment with the use of bed rail for Residents 60 and 79. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/06, the seven areas in the bed system where there is potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. According to FDA's A Guide for Modifying Bed Systems and Using Accessories to Reduce the Risk of Entrapment dated 6/21/06, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. Bed system includes the bed frame, mattress, bed rails and other compatible accessories. The bed safety approach is to inventory and evaluate bed systems, rather than simply determine whether a side rail exists. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the facility's P&P titled Proper Use of Bed Rails revised 5/18/26, showed the following: - Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include but are not limited to side rails, safety rails, grab bars and assist bars; - The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail, or in the bed rail itself; - The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes ensuring the bed dimensions are appropriate for the resident by inspecting and regularly, inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; - Conduct routine preventative maintenance of beds and bedrails to ensure they meet current safety standards and are not in need of repair; and - The Maintenance Director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses and bed rails. 1. On 8/18/26 at 0849 hours, 8/19/26 at 1104 hours, and 8/21/26 at 0922 hours, Resident 79 was observed lying in bed with the right grab bar elevated. On 8/20/26 at 0945 hours, an interview for Resident 79 was conducted with CNA 1. CNA 1 stated Resident 79 used the side rails when repositioning in bed. Medical record review for Resident 79 was initiated on 8/18/26. Resident 79 was admitted to the facility on [DATE]. Review of Resident 79's Rehab Screen – V 1 dated 4/22/26, showed the resident/family requested a grab bar in bed. The resident would benefit from the use of grab bar to the right side of the bed to promote increased independence with bed mobility tasks as well as the ability to reposition self. Resident 79 was alert and oriented, and able to demonstrate ability to safely use grab bar using right upper extremity. Review of Resident 79's Order Summary Report showed a physician's order dated 5/22/26, for a grab bar on the right side of the bed to assist in bed mobility and repositioning. Review of Resident 79's plan of care showed a care plan problem dated 5/22/26, to address Resident 79's preference to use a grab bar on the right side of the bed. The interventions included to ensure the grab bar was securely installed and maintained according to the facility safety standards, and to monitor for signs of entrapment. On 8/20/26 at 1041 hours, an interview and concurrent medical record review for Resident 79 was conducted with RN 1. RN 1 verified Resident 79 had a grab bar on the right side of the bed. RN 1 stated when a resident preferred to have a side rail, the rehabilitation staff would screen or evaluate the resident if the resident would benefit from using a side rail, then the rehabilitation staff would inform the nursing department, and the maintenance department. RN 1 further stated the nursing department would inform the physician for an order for the side rail, and the informed consent, and the maintenance department would install the side rail. When asked about the entrapment assessment, RN 1 stated she was not aware of the entrapment assessment but the ADON was responsible for the side rails usually. On 8/20/26 at 0912 hours, an interview and concurrent facility document review for Resident 79 was conducted with the Maintenance Director. The Maintenance Director stated he was responsible for the monthly bed inspection in the facility, including checking the side rails, bed remote control, brakes, wheels, mattresses, headboards and foot boards. When asked about side rails, the Maintenance Director stated he was verbally informed by the rehabilitation staff after their assessment of the resident, to install the side rails, and what size of side rails the resident needed, such as half-side rails or full side rails. The Maintenance Director stated the DON also helped with determining what size of side rails the resident needed. When asked about the entrapment assessment, the Maintenance Director stated after installing the side rails, he used his measuring device to make sure the rails were compliant with the seven zones of entrapment. When asked about documentation of the entrapment assessment, the Maintenance Director stated he used the Bed System Measurement Device Test Results Worksheet to document his entrapment assessment for the bed rails. a. Review of the maintenance binder failed to show documentation of the facility's monthly bed inspection as part of the maintenance program. When asked about documentation of the monthly bed inspection, the Maintenance Director was unable to show documented evidence of his monthly bed inspection. b. Review of the facility's Bed Rails Log Sheet for August 2026 did not show Resident 79 was on the list of residents with the bed rails. c. Review of the facility's Bed System Measurement Device Test Results failed to show the entrapment assessment was completed for Resident 79 related to the use of right grab bar. The Maintenance Director verified the above findings. The Maintenance Director stated he only conducted an entrapment assessment only for side rails. The Maintenance Director further stated he installed Resident 79's right grab bar, but he did not conduct an entrapment assessment because a grab bar is different from side rails. On 8/21/26 at 1023 hours, an interview and concurrent medical record review for Resident 79 was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 8/18/26 at 1122 hours, during the initial tour of the facility, Resident 60 was observed awake and lying in bed. A left bed rail was observed elevated. Resident 60 stated he knew it was for him to grab onto when he was turning in his left side and when getting out of bed. Resident 60 stated he did not know of any risks related to using the bed rail. Medical record review for Resident 60 was initiated on 8/18/26. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's H&P examination dated 8/5/26, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 60's Bed Rails – V2 dated 8/5/26, showed: - Resident 60 demonstrated difficulty with bed mobility or moving to a sitting position from the bed; - Resident 60 had difficulty with standing/sitting balance; - Resident 60 would benefit from bilateral grab bar for mobility/transfer purposes; - Bed rail/transfer bar was indicated for mobility/transfer purposes and Resident 60 demonstrated ability to use equipment as an enabler; - Position/side of bed rail: bilateral; and - Type of bed rails: left and right side (assist bar/grab bar). On 8/20/26 at 1015 hours, an observation of Resident 60 was conducted. Resident 60 was observed being assisted by a Physical Therapist in transferring from the wheelchair to the bed. Resident 60 was observed holding onto the left bed rail during transfer. On 8/20/26 at 1037 hours an interview for Resident 60 was conducted with CNA 2. CNA 2 stated Resident 60 needed minimal assist with repositioning and getting out of bed. CNA 2 stated Resident 60 used the left bed rail as a grab bar when the resident turned in his left side or got out of bed. On 8/20/26 at 1044 hours an interview and concurrent medical record review for Resident 60 was conducted with LVN 3. LVN 3 stated Resident 60 needed moderate to maximum assistance with mobility. LVN 3 verified Resident 60 was using the left bed rail when turning and getting out of bed, and transferring into the wheelchair. LVN 3 stated the rehabilitation staff would evaluate the resident to determine the need for a bed rail and type of bed rail. If the resident needed the bed rail, the rehabilitation staff would inform the nursing department, then the licensed nurse would notify the physician to get an order and informed consent. LVN 3 further stated the bed rails were installed by the maintenance department. On 8/20/26 at 0912 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. Review of the facility's binder for the Bed System Measurement Device Test Results failed to show the entrapment assessment was completed for Resident 60 related to the use of left bed rail. The Maintenance Director stated he installed the left bed rail for Resident 60 but did not do the entrapment assessment and measurement of the bed zones because the left bed rail was only used by Resident 60 as a grab bar. On 8/21/26 at 1045 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 60. Cross reference to F700.

Based on interview and medical record review, the facility failed to ensure a person-centered care plan problem was developed for one of 19 final sampled residents (Resident 9). * The facility failed to ensure the person-center care plan problem was developed when Resident 9's responsible party refused the treatments for Resident 9. In addition, there were no care plan problem developed when Resident 9's responsible party had restricted and supervised visitation. This failure posed the risk for Resident 9's needs not met and for the staff to inadequately provide care for Resident 9.Findings: On 8/7/26, CDPH L&C Department received a complaint regarding Resident 9 from Responsible Party 1. The allegations included restrictions to visiting Resident 9 and the facility's allegation of Responsible Party 1 going in and out of other resident's rooms to talk to people. Review of the facility's document dated 8/5/26, showed a letter from the facility to Responsible Party 1. The letter showed in part, due to the concerns outlined above, we are implementing the following measures to ensure the safety of our residents and staff effective immediately. The letter further showed the visitation hours and restricted access. On 8/20/26 at 1507 hours, an interview was conducted with the Administrator. The Administrator stated Resident 9's responsible party had restrictions in-placed related to visiting hours for Resident 9. The Administrator stated the visitation should be during the daytime when enough staff were in the facility to supervise Resident 9's responsible party's visits. The Administrator stated Resident 9's responsible party would refuse treatments recommended for Resident 9, such as liberalizing Resident 9's diet as an intervention for Resident 9's weight loss. The Administrator stated Resident 9's responsible party was observed going in and out of other resident rooms, talking to other residents' family members, and trying to act as the family members' liaison. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included mood disorder. Review of Resident 9's Facesheet dated 8/26/26, showed Responsible Party 1 was Resident 9's responsible party and emergency contact. Review of Resident 9's plan of care failed to show a care plan problem was developed to address Resident 9's responsible party refusing the treatments for Resident 9 and the restricted and supervised visits for when Responsible Party 1 would visit Resident 9. On 8/21/26 at 1530 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON and Administrator. The DON and Administrator verified there were no care plan problems developed for Resident 9's responsible party refusing the treatments and restricted/supervised visitation.

Based on observation, interview, and facility documents review, the facility failed to maintain a home-like environment for one nonsampled resident (Resident 61) and in Rooms B and C. * The facility failed to ensure the air conditioner vent inside Resident 61's room was clean. In addition, the facility failed to ensure Resident 61's fan next to the resident's head of bed was secured. * The facility failed to ensure the paint was not peeling in Room B's ceiling and in the hallway outside Room C. These failures posed the risk for the residents to not have a homelike environment and for unsafe environmental conditions for residents.Findings: On 8/18/2026 at 1014 hours, during an initial tour of the facility the following were observed:- Room B ceiling was observed with paint peeling;- the paint was observed peeling in the hallway outside Room C; and- the air conditioner vent located near Resident 61's bed was observed with black and gray colored dust. In addition, Resident 61's fan, measuring approximately three to four feet in diameter, was observed unsecured on top of Resident 61's nightstand next to Resident 61's head of the bed. On 8/19/26 at 0916 hours, resident room observations and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the above findings. On 08/21/2026 at 1044 hours, an interview was conducted with Resident 61. When asked about the air conditioner vent, Resident 61 stated she was not aware the air conditioner vent was dusty and dirty because she could not see that far. Resident 61 stated she only knew it was kind of hot inside the room in the afternoons. Resident 61 found out the air conditioner vent was observed with black and gray colored dust, Resident 61 stated that's the reason why she was feeling more nasal congestion. Medical record review for Resident 61 was initiated on 8/19/26. Resident 61 was admitted to the facility on [DATE]. Resident 61's diagnoses included cancer, pneumonia, and pulmonary fibrosis.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or resident's representative were notified of changes of care and services for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1 and/or Resident 1's representative was notified and provided with information when Lispro (a fast-acting insulin used to control high blood sugar) was discontinued and Jardiance (a medication used to help control blood sugar level) was initiated. This failure had the potential to place the resident and/or the resident's representative at risk of not receiving adequate information needed to make informed decisions regarding the resident's care.Findings: Review of the facility's P&P titled Resident Rights revised 4/6/26, showed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. In the case of a resident who has not been adjudged incompetent by the State court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by State law. The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language he or she can understand of his or her total health status, including but not limited to, his or her medical condition. The right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility must inform the resident, consult with the resident's physician and notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification included circumstances that require a need to alter treatment. This may include new treatment, and discontinuation of current treatment. Medical record review for Resident 1 was initiated on 7/23/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/16/26, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS Summary Score was 12, indicating the resident had moderate cognitive impairment. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 5/15/26, to administer Lispro insulin subcutaneously before meals and at bedtime per sliding scale for blood sugar level as follows: 151 to 200 mg/dL = 2 units; 201 to 250 mg/dL = 4 units; 251 to 300 mg/dL = 6 units; 301 to 350 mg/dL = 8 units; 351 to 400 mg/dL = 10 units; 401 to 450 mg/dL = 12 units; and if blood sugar is greater than 400 mg/dL give 12 units and report to the physician. This order was discontinued on 7/13/26; and- dated 7/13/26, to administer Jardiance 10 mg tablet by mouth daily in the morning. Review of Resident 1's Nutrition Progress note dated 7/13/26 at 1450 hours, showed an order was received from Physician 1 to discontinue the Lispro insulin sliding scale and ordered to start the Jardiance medication. Further review of Resident 1's medical records failed to show Resident 1 and the resident's representative was informed of the change in treatment when Lispro insulin was discontinued and Jardiance oral medication was started. On 7/23/26 at 1019 hours, an interview and concurrent record review for Resident 1 was conducted with the ADON. The ADON stated the Lispro insulin was discontinued and the Jardiance medication was started because the resident will be going to an assisted living facility. The ADON verified Resident 1's medical record failed to show the resident and resident's representative was informed of the changes to discontinue the Lispro insulin and the new order for the Jardiance oral medication. On 7/23/26 at 1334 hours, an interview was conducted with Resident 1. Resident 1 stated he was not informed by the physician, or the facility when his Lispro insulin was discontinued and was started on the Jardiance medication. On 7/23/26 at 1442 hours, an interview was conducted with the DON. The DON stated the resident's discharge plan was to go to lower level of care. The assisted living cannot give the insulin medication. The DON further stated the expectation for the licensed nurses were to inform the resident and resident's representative of any changes in medication order and to document in the resident's medical records. On 7/24/26 at 0948 hours, a telephone interview was conducted with Physician 1. Physician 1 stated he did not inform Resident 1 or Resident 1's representative prior to discontinuing the Lispro insulin and starting Resident 1 on the Jardiance medication because he did not think he needed to because he was the resident's physician. On 7/24/26 at 1645 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed and acknowledged the above findings.

Based on interview, clinical record review and facility document and P&P review, the facility failed to be administered in a manner which used its resources effectively and efficiently in order to attain the highest practicable physical, mental and psychosocial well being of each resident related to prevention of neglect, pain management, and prevention of pressure ulcers. This involved six residents from two of the facility's two nurses' stations; two from Station 2 and four from Station 1. Findings: Immediate Jeopardy was identified on 5/12/11 at 1015 hours, regarding the facility's failure to thoroughly investigated injuries of unknown origin, failure to assess and prevent pressure ulcers and failure to assess residents for pain. The Administrator was made aware of the Immediate Jeopardy on 5/12/11 at 1030 hours. On 5/12/11 at 1950 hours, the facility's final plan of correction taken to abate the Immediate Jeopardy was reviewed with the DON and the Administrator. The corrections the facility took were immediate skin and pain assessments on all residents, and staff inservicing on skin and pain management and incident reporting. The facility provided documented evidence staff, including nursing staff, rehabilitation therapists, respiratory therapists, maintenance and housekeeping departments, received inservices, via telephone or as they came on duty, prior to providing care to residents. The inservices included information related to prevention of the development of pressure ulcers, assessing pain for cognitively impaired residents and residents speaking in a foreign language, and investigations of injuries of unknown origin. In addition on 5/13/11, random interviews were done with staff to assess their knowledge of prevention of pressure ulcers, assessment of the cognitively impaired and foreign speaking residents and investigations of injuries of unknown origin. As of 5/13/11, all residents were assessed for related skin issues, and pain assessments. On 5/14/11 at 1135 hours, the Administrator, the DON and the Regional Consultant were informed Immediate Jeopardy was abated. 1. The facility failed to prevent neglect for four of 17 sampled residents (Residents 4, 14, 6, & 1) and one nonsampled resident (Resident C). Resident C was admitted to the facility on [DATE], with bilateral Stage III pressure ulcers (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough (dead tissue) may be present.) to the heels. The facility staff failed to provide treatment and services to help promote healing of the pressure ulcers. LVN 4 and RN 1 could not explain why the resident's low air loss mattress (a special alternating air mattress used in the treatment of pressure ulcers) and waffle boots (vinyl inflatable boots that suspend the heels) were not in use. Resident C also experienced pain in her heel, but the licensed nursing staff failed to assess Resident C for her pain and treat the pain. RN 1 stated Resident C no longer has pain. Resident 4 was listed as high risk for fractures due to [MEDICAL CONDITION] (softening of the bone) in November, 2010, and was completely dependent on staff members to transfer in and out of bed. The facility documented in the MDS Resident 4 needs extensive assistance with transfers (two or more persons). The facility did not provide any instructions to the CNAs responsible for transferring Resident 4 on how to safely transfer the resident. On 4/30/11, while at the facility, Resident 4 sustained two fractured legs. In addition, Resident 4 was sent to a physician's appointment to have her cast replaced on 5/11/11. Resident 4 was not given any pain medication prior to the appointment. A staff member stated the resident did not want any pain medication, but Resident 4 is listed as being cognitively impaired. The facility did not anticipate any pain Resident 4 might have while being transported to and from the physician's office, while visiting with the physician, or while having her cast changed. Resident 14 is listed as being aphasic (not able to speak). Resident 14 was observed pointing to her teeth repeatedly and moaning. The facility noted Resident 14 had a toothache on 5/8/11, gave her a pain pill, but did not arrange for the resident to see a dentist or follow up with the physician. Resident 14 was observed crying due to mouth pain on 5/12/11. On 5/12/11, the facility made arrangements for Resident 14 to see the dentist. She had an abscessed tooth. Resident 6, who is aphasic (nonverbal), has a mask face (no expressions), severe dementia, and does not understand English. Resident 6 was observed moaning during a wound care treatment, during repositioning, and during passive range of motion exercises. The facility's staff conducting the procedures, continued the treatments despite the resident's indication of pain. This has the potential for increasing Resident 6's pain and unnecessary suffering. The facility failed to monitor Resident 1 for chest pain. Resident 1 had a low heart rate, was sent to the emergency room (ER) and assessed for chest pain on 5/10/11. The physician from the ER gave written instructions for the resident to return to the ER if symptoms worsen, and to increase fluids. The resident returned to the facility on the same day; however, the facility staff was not aware of the resident's condition, and did not start monitoring the resident for chest pain (chest discomfort or pain is a key symptom of a [MEDICAL CONDITION]). In addition, Resident 1 had multiple pressure ulcers. During wound care treatment, the licensed nurse did not assess the resident for pain prior to dressing changes. This has the potential to compromise the resident's health by not monitoring early warning signs of a life-threatening condition as a [MEDICAL CONDITION]. Resident 1 was admitted with multiple pressure ulcers. The repositioning schedule was not implemented, and the heels were not elevated at all times, as ordered by the physician. Resident 1 developed a new pressure ulcer while in the facility that deteriorated to Stage III (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough (dead tissue) may be present). Resident 1 was at risk for further pressure ulcers or deterioration of current pressure ulcers; his care plan was not individualized for the different pressure ulcers on his body. Resident 1 has a GT (a soft rubber tube inserted through the abdomen into the stomach to infuse enteral nutrition). During dressing change, when RN 1 removed the old dressing, redness and a black substance was noted on the gauze. The resident had developed an unnoted infection of the skin around the GT stoma (opening). Treatment with topical antibiotics and dressing is necessary to treat the infection. (Cross-Reference F224 and F322). 2. The facility failed to ensure six of 17 sampled residents (Residents 6, 1, 4, 14, 12 and 11) and one nonsampled resident (Resident C) received the necessary care and services to maintain the highest practicable physical and mental well-being. Resident 6 who is aphasic (nonverbal), has a mask face (no expressions), severe dementia, and is foreign language speaking. Resident 6 was observed moaning during wound care treatment, during repositioning, and during passive range of motion exercises. The facility staff conducting the procedures continued the treatments despite the resident's indication of pain. This caused increased pain to Resident 6 and unnecessary suffering. The facility failed to monitor Resident 1 for chest pain. Resident 1 had a low heart rate, was sent to the emergency department, where he was assessed for chest pain on 5/10/11. The physician from the emergency department gave written instructions for the resident to return to the emergency department if symptoms worsened, and to increase fluids. The resident returned to the facility on the same day; however, the facility staff were not aware of the resident's condition, and did not monitor the resident for chest pain (chest discomfort or pain is a key symptom of a [MEDICAL CONDITION]). This has the potential to compromise the resident's health by not monitoring early warning signs of a life-threatening condition as a [MEDICAL CONDITION]. In addition, Resident 1 had multiple pressure ulcers. During wound care treatment, the licensed nurse did not assess the resident for pain prior to dressing changes. This resulted in the resident suffering unnecessary pain during the treatment of his pressure ulcers. Resident 11 had a recent insertion of a permanent pacemaker due to a low heart rate. The facility failed to obtain the pacemaker parameters (the setting for the pacemaker to initiate a heart beat if the heart rate goes below a certain rate) to ensure the pacemaker was functioning properly. This could result in the nursing staff not recognizing if the pacemaker is malfunctioning. Resident 4 was sent to a physician's appointment to have her cast replaced on 5/11/11. Resident 4 was not given any pain medication prior to the appointment. A staff member stated the resident did not want any pain medication, but Resident 4 is listed as being cognitively impaired. The facility did not anticipate the pain Resident 4 might have while being transported to and from the physician's office, or while having her cast changed. This resulted in the resident suffering unnecessary pain. Resident 14 is listed as being aphasic (not able to speak). Resident 14 was observed pointing to her teeth repeatedly, and moaning. The facility noted Resident 14 had a toothache on 5/8/11, gave her a pain pill, but did not arrange for the resident to see a dentist or follow up with the physician. Resident 14 was observed crying due to mouth pain on 5/12/11. On the morning of 5/12/11, arrangements were made for Resident 14 to see the dentist. She had an abscessed tooth. This resulted in Resident 14 suffering pain for an extended period of time. Resident 12 was receiving hospice services. The hospice agency did not coordinate the visits with the facility staff. The staff did not know when the hospice agency would be providing care to the resident. This poses the potential for the resident not receiving the necessary care and services. Resident C, who has pressure ulcers and receives routine treatment for these wounds, was not assessed for pain. This poses the risk of the resident suffering needless pain during treatments. (Cross-Reference F309). 3. The facility failed to ensure pressure ulcer care and treatment for two of 17 sampled residents (Residents 1 and 6) and one nonsampled (Resident C) was provided. Resident 1 was admitted with multiple pressure ulcers. The repositioning schedule was not implemented, and the heels were not elevated at all times, as ordered by the physician. Resident 1 was at risk for further pressure ulcers or deterioration of current pressure ulcers; his care plan was not individualized for the different pressure ulcers on his body. As a result, Resident 1 developed a new pressure ulcer while in the facility that deteriorated to Stage III (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough (dead tissue) may be present). Resident 6 developed a Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister) pressure ulcer after admission. The facility failed to monitor the use of Waffle boots (an inflatable vinyl boot to keep pressure off the heels). As a result, Resident 6 developed a Stage II pressure ulcer. (Cross-Reference to F314). 4. The facility failed to ensure residents are free from accident hazards for two of 17 sampled residents (Residents 4 and 3). Resident 4 is assessed as a high risk for fractures due to [MEDICAL CONDITION] (softening of the bones). Resident 4 is dependant on the facility staff for assistance with all her ADLs, including transferring in and out of bed. The MDS showed Resident 4 needs the assistance of two or more people to transfer, but the facility did not give instructions to the staff to use two or more people to transfer her. Resident 4 sustained two fractures of the left lower leg on 4/30/11, while at the facility, when a CNA transferred Resident 4 by herself. The facility failed to ensure nursing care for Resident 3 included continuing supervision. Resident 3 was assessed as a high risk for aspiration due to difficulty in swallowing. On 5/10/11 at 1220 hours, Resident 3 was observed independently eating lunch in the dining room, without supervision. Resident 3 suddenly started coughing, gasping for air, and became distressed. Although staff suspected Resident 3 was choking on food, no immediate attempt was made to stop the resident from eating and drinking; instead LVN 2 held her glass of liquids to her mouth. No immediate attempt was made to clear Resident 3's air way. A chest x-ray taken on 5/10/11, showed slight bilateral lung infiltrates. (Cross-Reference to F323).

Based on interview and clinical record review, the facility failed to prevent neglect for four of 17 sampled residents (Residents 4, 14, 6, & 1) and one nonsampled resident (Resident C). Resident C was admitted to the facility on [DATE], with bilateral Stage III pressure ulcers (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough (dead tissue) may be present.) to the heels. The facility staff failed to provide treatment and services to help promote healing of the pressure ulcers. LVN 4 and RN 1 could not explain why the resident's low air loss mattress (a special alternating air mattress used in the treatment of [REDACTED]. Resident C also experienced pain in her heel, but the licensed nursing staff failed to assess Resident C for her pain and treat the pain. RN 1 stated Resident C no longer has pain. Resident 4 was listed as high risk for fractures due to [MEDICAL CONDITION] (softening of the bone) in November, 2010, and was completely dependent on staff members to transfer in and out of bed. The facility documented in the MDS Resident 4 needs extensive assistance with transfers (two or more persons). The facility did not provide any instructions to the CNAs responsible for transferring Resident 4 on how to safely transfer the resident. On 4/30/11, while at the facility, Resident 4 sustained two fractured legs. In addition, Resident 4 was sent to a physician's appointment to have her cast replaced on 5/11/11. Resident 4 was not given any pain medication prior to the appointment. A staff member stated the resident did not want any pain medication, but Resident 4 is listed as being cognitively impaired. The facility did not anticipate any pain Resident 4 might have while being transported to and from the physician's office, while visiting with the physician, or while having her cast changed. Resident 14 is listed as being aphasic (not able to speak). Resident 14 was observed pointing to her teeth repeatedly and moaning. The facility noted Resident 14 had a toothache on 5/8/11, gave her a pain pill, but did not arrange for the resident to see a dentist or follow up with the physician. Resident 14 was observed crying due to mouth pain on 5/12/11. On 5/12/11, the facility made arrangements for Resident 14 to see the dentist. She had an abscessed tooth. Resident 6, who is aphasic (nonverbal), has a mask face (no expressions), severe dementia, and does not understand English. Resident 6 was observed moaning during a wound care treatment, during repositioning, and during passive range of motion exercises. The facility's staff conducting the procedures, continued the treatments despite the resident's indication of pain. This has the potential for increasing Resident 6's pain and unnecessary suffering. The facility failed to monitor Resident 1 for chest pain. Resident 1 had a low heart rate, was sent to the emergency room (ER) and assessed for chest pain on 5/10/11. The physician from the ER gave written instructions for the resident to return to the ER if symptoms worsen, and to increase fluids. The resident returned to the facility on the same day; however, the facility staff was not aware of the resident's condition, and did not start monitoring the resident for chest pain (chest discomfort or pain is a key symptom of a [MEDICAL CONDITION]). In addition, Resident 1 had multiple pressure ulcers. During wound care treatment, the licensed nurse did not assess the resident for pain prior to dressing changes. This has the potential to compromise the resident's health by not monitoring early warning signs of a life-threatening condition as a [MEDICAL CONDITION]. Resident 1 was admitted with multiple pressure ulcers. The repositioning schedule was not implemented, and the heels were not elevated at all times, as ordered by the physician. Resident 1 developed a new pressure ulcer while in the facility that deteriorated to Stage III (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough (dead tissue) may be present). Resident 1 was at risk for further pressure ulcers or deterioration of current pressure ulcers; his care plan was not individualized for the different pressure ulcers on his body. Immediate Jeopardy was identified on 5/12/11 at 1015 hours, regarding the facility's failure to prevent negligence by their failure to assess and prevent pressure ulcers and failure to assess residents for pain. The Administrator was made aware of the Immediate Jeopardy on 5/12/11 at 1030 hours. On 5/12/11 at 1950 hours, the facility's final plan of correction taken to abate the Immediate Jeopardy was reviewed with the DON and the Administrator. The corrections the facility took were immediate skin and pain assessments on all residents, and staff inservicing on skin and pain management and incident reporting. The facility provided documented evidence staff, including nursing staff, rehabilitation therapists, respiratory therapists, maintenance and housekeeping departments, received inservices, via telephone or as they came on duty, prior to providing care to residents. The inservices included information related to prevention of the development of pressure ulcers, assessing pain for cognitively impaired residents and residents speaking in a foreign language, and investigations of injuries of unknown origin. In addition on 5/13/11, random interviews were done with staff to assess their knowledge of prevention of pressure ulcers, assessment of the cognitively impaired and foreign speaking residents and investigations of injuries of unknown origin. As of 5/13/11, all residents were assessed for related skin issues, and pain assessments. On 5/14/11 at 1135 hours, the Administrator, the DON and the Regional Consultant were informed the Immediate Jeopardy was abated. Findings: 1a. During initial tour rounds on 5/9/11 at 1345 hours, accompanied by LVN 3, Resident C was observed lying in her bed on a low air loss mattress. A [DEVICE] Assisted Closure (V.A.C.- a device with mechanical forces to the wound to create an environment that promotes wound healing) device was connected to Resident C's right heel. LVN 3 stated Resident C was admitted to the facility with bilateral heel pressure ulcers. During an observation on 5/12/11 at 0835 hours, Resident C was observed lying in her bed. Her low air loss mattress was off and her bilateral waffle boots were on the floor on the right side of her bed. During interviews on 5/12/11 at 0835 hours, LVN 4 and RN 1 stated they were unaware of the reason Resident C's low air loss mattress was turned off or why her waffle boots were not in place. Later the same day at 0900 hours, Resident C was observed lying in bed with her right heel pressed against the foot cradle. RN 1 stated Resident C's heel should not be against the foot cradle, and repositioned her foot. Review of Resident C's physician's orders [REDACTED]. b. Review of Resident C's physician's orders [REDACTED]. A physician's orders [REDACTED]. xeroform in a [MEDICATION NAME] blend) every day. A physician's orders [REDACTED]. Review of Resident C's Pressure Ulcer Status Record dated 5/9/11, shows her right heel as a Stage III pressure ulcer measuring 3 cm by 2 cm by 0.2 cm, with a small amount of drainage. Review of Resident C's Pressure Ulcer Status Record dated 5/9/11, shows her left heel as a Stage III pressure ulcer measuring 1.5 cm by 1 cm by 0.2 cm, with a small amount of drainage. Review of Resident C's Pain assessment dated [DATE], shows she denies pain in both lower extremities. Review of Resident C's Pain Assessment Flowsheet for dates 5/1/11 - 5/11/11, shows Resident C complained of pain at a score 6 (on a scale 1 - 10, 10 being the worst) in her right or left leg 13 times during the evenings and was administered pain medication. No documentation was available to show Resident C was assessed or administered pain medication prior to her wound treatments. Review of Resident C's Pressure Ulcer Records for her Stage III right and left heel pressure ulcers showed for dates 4/25/11, 5/2/11, and 5/9/11, Resident C was no experiencing pain. During an interview on 5/12/11 at 0900 hours, RN 1 stated Resident C does not have pain any more in her heels since she had surgery. During an interview on 5/12/11 at 0910 hours, Resident C was asked by another resident's visitor in Resident C's language, if she is experiencing any pain. Resident C raised up her right leg, pointed to her right heel and said she was having pain in her heel. 2a. According to the facility's undated P&P "Protecting of Residents: Reducing the threat of Abuse and Neglect," each resident has the right to be free from mistreatment, neglect and misappropriation of property. Clinical record review for Resident 4 was initiated on 5/9/11. Review of the physician's orders [REDACTED]. Review of Resident 4's MDS dated [DATE], showed Resident 4 was assessed as needing extensive assistance with transferring, requiring two persons or more to transfer. An interview with CNA 4 was initiated on 5/12/11 at 1130 hours. CNA 4 was asked about the care she provides for Resident 4. CNA 4 stated she usually works at the other nurses' station and had not worked with this resident for about a month. CNA 4 was asked how she knows what care to provide for Resident 4, the CNA stated she asks another CNA. An interview with CNA 5 was initiated on 5/12/11 at 1345 hours. CNA 5 was asked about the care she provides for Resident 4. CNA 5 stated the resident can not walk or transfer in or out of bed. Resident 4 is fully dependant on the staff for care. CNA 5 stated she lifts Resident 4 out of bed to transfer her once a day. CNA 5 was asked how many people assist her to transfer the resident. When asked where information is kept for the CNA staff to know the care needed by each resident, CNA 5 stated there is a Special Needs book at the nurses' station. Review of the Special Needs book showed Resident 4 was not listed in the book as needing any special assistance for transferring. Review of the Investigation Report for Resident 4 dated 5/3/11, showed on 4/30/11, Resident 4 was discovered to have swelling and pain of the left lower leg. Resident 4 was transferred to the acute care hospital and was diagnosed as having a fractured fibula and tibia of the left leg. An interview with Resident 4's family member was initiated on 5/11/11 at 1030 hours. The family member stated he was upset Resident 4 had sustained the fractures. The family member stated Resident 4 only gets out of bed once a day. He stated he witnessed one nurse lifting the resident out of bed on many occasions. The family member stated he felt it was not safe to do so, but thought the facility knows best. b. Further review of the clinical record for Resident 4 showed Resident 4 has altered thought processes, compromised memory and recall ability and impaired decision making. Resident 4's dementia is manifested by disorientation, unawareness to time or place, and Resident 4 is unable to recognize staff, faces or significant others. An interview with Resident 4's family member was initiated on 5/12/11 at 0925 hours. The family member stated Resident 4 was scheduled to go to a physician's appointment on 5/11/11, to have her leg cast changed after two recent fractures, which occurred on 4/30/11. The family member stated the facility arranged transportation to the physician's office and he accompanied Resident 4 to the appointment. Resident 4 was transported in the wheelchair. The medical transport stopped to pick up another person in a trailer park. The trailer park had speed bumps every few feet. Every time the van went over a speed bump, Resident 4 would yell in pain. The other occupant of the van was dropped off at the laundromat, and it took over an hour and a half to get to the physician's office. The family member stated there were a lot of speed bumps along the way. When Resident 4 got to the physician's office she screamed when the physician changed the cast. Review of the Controlled or Antibiotic Drug Record dated 5/3/11, showed Resident 4 was not given any pain medication prior to leaving for the physician's appointment on 5/11/11. The form showed Resident 4 was last administered [MEDICATION NAME] (a narcotic pain medication) on 5/9/11. An interview with RN 3 was initiated on 5/12/11 at 1030 hours. RN 3 was asked why Resident 4 was not given any pain medication prior to the physician's appointment. RN 3 stated she asked Resident 4 if she was in pain prior to leaving for the appointment, and the resident said no. RN 3 was asked if Resident 4 was not in pain at that moment, did she anticipate the resident might have pain while having her cast changed or during the transportation to and from the physician's office. RN 3 stated she was not aware Resident 4 was having the cast changed. 3. Clinical record review for Resident 14 was initiated on 5/12/11. Review of the Face Sheet showed Resident 14's [DIAGNOSES REDACTED]. Review of the care plan problem dated 1/21/11, to address Pain showed Resident 14 had potential for generalized pain as evidenced by facial grimacing. Review of the PRN Medication Administrative Record dated May, 2011, showed Resident 14 received a [MEDICATION NAME] (a narcotic pain medication) on 5/8/11, for a toothache. On 5/7/11, and 5/9/11, Resident 14 also received a [MEDICATION NAME]. No reason for the medication is documented. According to the PRN Medication Administrative Record, Resident 14 did not have any pain medication administered to her after 5/9/11. Review of the Nurses' Notes for May, 2011, showed two entries for the month of May. Neither entry mentioned Resident 14's dental problems. The entry dated 5/10/11, showed no mention of Resident 14's toothache. There is no documentation to show the physician was informed of the resident's toothache and no new interventions were done. An observation of Resident 14 was made on 5/11/11 at 1420 hours. Resident 14 was not able to answer questions, but when asked how she was feeling, she repeatedly pointed to her teeth and moaned. On 5/12/11 at 0820 hours, Resident 14 was observed pointing to her teeth and moaning when asked how she felt. On 5/12/11 at 1040 hours, Resident 14 was seated in the wheelchair in front of the nurses' station. Resident 14 was crying. Two nurses were trying to calm the resident. RN 2 was asked why Resident 14 was crying. RN 2 stated she had an abscessed tooth. The dentist had just visited. The tooth needed to be pulled, but Resident 14 is on blood thinners and the tooth cannot be pulled until the blood thinner medication has been held for a few days to prevent Resident 14 from bleeding excessively. RN 2 stated she would give Resident 14 pain medication. Review of the Dental Services report dated 5/12/11, showed the dentist examined the resident and the resident had complaints of pain. The #14 tooth needed to be extracted. Review of the physician's orders [REDACTED]. A telephone interview with the dental office manager was initiated on 5/17/11 at 1530 hours. The office manager was asked when the facility contacted the dentist to schedule an appointment for Resident 14. The office manager stated the facility called the doctor on the morning of 5/12/11, to schedule the dental appointment for Resident 14. 4. On 5/9/11 at 1400 hours, during initial tour rounds to the facility accompanied by LVN 1, Resident 6 was observed lying in bed, nonverbal, unable to provide any information. She was able to make eye contact with no facial expression. Resident 6 was observed to be moaning, the sound was audible from the hallway. The LVN accompanying the surveyor stated she has joint contractures, and a wound inside her gluteal folds (the crease where the buttock and leg meet) and anus. Clinical record review for Resident 6 was initiated on 5/9/11. Resident 6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of history and physical dated 7/22/10, showed the resident has "masked face," is nonverbal, not following commands, severe dementia, and contractures of the extremities. Review of the MDS dated [DATE], showed Resident 6 is alert, with short and long term memory impairment and severe cognitive skills for decision making, absence of speech (spoken words). Resident 6 is completely dependent on staff for all care needs. Resident 6's assessment for pain showed no signs of non-verbal sounds (moaning), vocal complaints of pain, facial expressions, protective body movements or postures were observed or documented. Review of the Nurse's Notes dated 3/14/11 at 1100 hours, skin assessment was done after CNA 1 reported a drop of fresh blood of the floor when she was taking Resident 6 to the bathroom via a shower chair. An area of open skin was noted on the inferior gluteal fold measuring approximately 1.5 cm by 0.5 cm. During an interview on 5/13/11 at 1055 hours with CNA 1, she stated on 3/14/11, Resident 6 was transferred from her bed to the shower chair using a gait belt. She saw fresh blood on the floor, and reported to the treatment nurse. On 5/10/11 at 1445 hours, RN 1 was observed changing the dressing from Resident 6's wound located in the inferior gluteal folds. Resident 6 was observed moaning before the treatment began. RN 1 removed the dressing from the buttocks area prior to the observation. RN 1 proceeded to open the residents gluteal folds and she started cleansing the skin with normal saline. The RN picked up [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing), cut a ribbon measuring approximately 1 cm by 5 cm, and insert the ribbon inside the wound cavity to pack it. The RN stated the wound is difficult to heal due to the proximity with the resident's anus, and contamination with feces. When asked if the resident had been premedicated for pain, and why the resident was constantly moaning during the whole procedure, the RN stated she did not premedicate the resident because she has routine pain medication. She stated Resident 6 did not have facial grimacing; if she had pain she would have stopped the treatment. On 5/11/11 at 0900 hours, Resident 6 was observed moaning, audible from the hallway. Behind the privacy curtain, RNA 1 was found stretching the resident's left arm. The RNA stated Resident 6 has severe contractures to all extremities. When asked if she had assessed Resident 6's level of pain or premedicated, RNA 1 stated not really, unless the resident is in pain, if they say ouch, grimace, or feel uncomfortable during the procedure. When asked when the resident moans, she stated every time when I do the exercises. On 5/11/11 at 1115 hours, Resident 6 was observed moaning, audible from the hallway. Behind the privacy curtain, RN 1 and RN 2 were changing the resident's dressing, located in the inferior gluteal folds. RN 2 was able to speak the resident's foreign language. She stated Resident 6 is cognitively impaired and is unable to verbalize if she is in pain. The RN further stated Resident 6 makes "this sound" whenever they are positioning, changing her diapers, or working with her. Review of a physician's orders [REDACTED]. Review of the MARs for the months of April and May, 2011, showed Resident 6 did not receive Tylenol or [MEDICATION NAME] medication for pain as needed. Review of a Consultation Report form dated 5/10/11, showed a pharmacist's recommendation to discontinue [MEDICATION NAME] for lack of use within the previous 60 days. On 5/11/11 at 1130 hours, during an interview with the DON, he stated the residents need specific orders from the physician, and the licensed nurses use their own judgement for pain management. If the resident is cognitively impaired, the nurses should use the residents' expressions, such as grimacing or moaning, and a communication board to determine the level of pain. On 5/12/11 at 1400 hours, during an interview with LVN 2, he stated Resident 6 had been reassessed for pain, and her pain level was ranging from 7 out of 10 on a pain rating scale. The LVN stated the staff was medicating the resident with Tylenol and [MEDICATION NAME] as ordered, when she was moaning, and premedicating her before painful procedures. On 5/12/11 at 1400 and 1700 hours, Resident 6 was observed lying in bed, calm and quiet. On 5/12/11 at 1400 hours, LVN 2 stated Resident 6 was relieved from moaning after the pain medication interventions were started. 5a. Initial tour round observation was conducted with LVN 1 on 5/9/11 at 1345 hours. Observation of Resident 1 showed the resident was lying in bed on his back, awake, and unable to communicate. LVN 1 stated the resident had developed a pressure ulcer to the left heel while in the facility. Clinical record review was initiated on 5/9/11. Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 1 is alert, with short and long term memory impairment and severe cognitive impairment for decision making, and completely dependent on staff for all care needs, unclear speech (slurred or mumbled words). Resident 1's assessment for pain showed no signs of non-verbal sounds (moaning), vocal complaints of pain, facial expressions, protective body movements or postures were observed or documented. On 5/11/11 at 1335 hours, observation of the treatment of [REDACTED]. A communication board (book with pictures) was observed at the resident's bedside; however, it was not used prior to the treatment as a tool to assess if the resident was in pain. RN 1 came in and proceeded to remove the left boot and the soiled dressing from his left foot, without assessing the resident. Review of the Pressure Ulcer Status Record form dated 5/5/11, showed a healing left lateral heel Stage III pressure ulcer measured 0.3 cm by 1 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known; non-verbal signs was not marked. Review of the Pressure Ulcer Status Record form dated 5/5/11 and 5/14/11, showed a left heel Stage III pressure ulcer measured 1 cm by 2.5 cm by 0.2 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known; non-verbal signs was not marked. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11 showed a right heel Stage III pressure ulcer measured 5 cm by 5 cm by 0.2 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known. Non-verbal signs was not marked. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11, showed a right hip Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present) measured 6.5 cm by 5 cm by 1 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known. Non-verbal signs was not marked. During an interview with RN 1 on 5/11/11 at 1500 hours, she was asked if they conduct pain assessment prior to the pressure ulcer treatments. She stated Resident 1 has no pain, only when he goes out to the wound care clinic, they administer [MEDICATION NAME] (local anesthetic). When asked why she does not use the communication book, she stated the resident is unable to communicate. Review of the Nurse's Notes dated 5/11/11 at 0845 hours, showed the licensed nurse called the physician, who ordered Tylenol (pain medication) 650 mg via GT every 4 hours, and before dressing changes. however, review of a physician's orders [REDACTED]. During a family interview on 5/13/11 at 1700 hours, the family member stated Resident 1 shakes his head when he has pain; he has constant headaches. The family member stated Resident 1 complains of pain only when they change his pressure ulcer dressings. b. Review of the MDS dated [DATE], showed Resident 1 is completely dependent on staff for all care needs; he requires extensive assistance for turning/repositioning in bed with the assistance of two persons. Observation of Resident 1 on 5/11/11 at 0735 hours, showed a [DEVICE] Assisted Closure (V.A.C.- a device with mechanical forces to the wound to create an environment that promotes wound healing) was in place. Further review of the Pressure Ulcer Status Record form for the right heel failed to show documentation of the use of a wound vac. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11, showed the right hip had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) measuring 6.5 cm by 5 cm by 1 cm deep. On 5/11/11 at 0735 hours, a wound V.A.C. was observed in place, but further review of the Pressure Ulcer Status Record form failed to show documentation regarding the use of the wound V.A.C. Review of the care plan showed a care plan problem dated 4/30/11, to address the risk for further pressure ulcers or deterioration of current pressure ulcers: right hip Stage IV, right heel Stage III, left heel Stage III, left lateral heel Stage III and scrotal swelling. The approaches showed turn and reposition the resident every two hours, three times per each shift: back, left side and maintain pressure free to both heels while in bed. Place pressure-reducing mattress on the bed, needs two persons to assist with repositioning to avoid skin friction/shearing. Needs daily observation of skin with routine care. Needs full skin evaluation weekly with shower. The care plan was not individualized. Resident 1 had multiple pressure ulcers, in different sites of his body, and there were no specific interventions for each, in order to monitor healing, measurable objectives for each of the pressure ulcers. Interventions for the use of Waffle boots was not addressed in the resident's care plan. Review of the care plan showed no care plan problem had been developed on admission to address pain related to the multiple pressure ulcers. Review of the physician's orders [REDACTED]. On 5/10/11 at 0640, 1000, 1130 hours, on 5/11/11 at 0750, and 1200 hours, and on 5/13/11 at 0745, 1000, and 1400 hours, Resident 1 was observed lying in his bed, alert, and positioned on his back. The resident had Waffle boots on. There was one pillow placed under the resident's lower legs; however, both of the resident's heels were resting on the mattress and were not offloaded (floating). On 5/10/11 at 0945 hours, both Waffle boots were observed on the resident's feet. RN 1 was present and preparing to provide treatment to the resident's left heel pressure ulcer. When asked if the resident's pressure ulcers developed in the facility, the RN stated, yes, he got one here; a Stage III to his left heel that started as a blister. In addition, RN 1 stated it is her responsibility to educate the CNAs on correct positioning of the residents to prevent the development of pressure ulcers. Review of a physician's orders [REDACTED]. An interview was conducted with CNA 3 on 5/11/10 at 0945 hours. The CNA stated Resident 1 is unable to move at all by himself and is unable to talk. She stated she turns the resident every two hours, and floats his heels. During an interview with the DON on 5/12/11 at 1100 hours, the concern regarding Resident 1's skin integrity problems, lack of individualized care plan interventions for the multiple pressure ulcers, not repositioning, and not consistently elevating Resident 1's heels was discussed. The DON was unable to give an explanation as to why the CNAs are not taking steps to prevent deterioration of Resident 1's skin integrity. c. On 5/10/11 at 1100 hours, LVN 1 was asked the whereabouts of Resident 1. The LVN stated he had gone out to a wound care center to treat his pressure ulcers. Review of the acute care hospital discharge instructions dated 5/10/11, showed on the way to the wound care center, the family member requested Resident 1 be evaluated for a low heart rate. He was taken to the acute care hospital. The emergency department physician documentation showed the resident has dementia, but nods to chest pain and shakes his head to shortness of breath and/or headache. Re-questioning later, the resident was nodding yes to all rule out symptom questions. On 5/13/11 at 0845 hours, during an interview with LVN 1, he stated he was not aware the chief complaint at the ER was chest pain. He was unable to find documentation to show the facility was monitoring Resident 1 for signs and symptoms of chest pain.

Based on observation, interview and clinical record review, the facility failed to ensure six of 17 sampled residents (Residents 6, 1, 4, 14, 12 and 11) and one nonsampled resident (Resident C) received the necessary care and services to maintain the highest practicable physical and mental well-being. Resident 6 who is aphasic (nonverbal), has a mask face (no expressions), severe dementia, and is foreign language speaking. Resident 6 was observed moaning during wound care treatment, during repositioning, and during passive range of motion exercises. The facility staff conducting the procedures continued the treatments despite the resident's indication of pain. This caused increased pain to Resident 6 and unnecessary suffering. The facility failed to monitor Resident 1 for chest pain. Resident 1 had a low heart rate, was sent to the emergency department, where he was assessed for chest pain on 5/10/11. The physician from the emergency department gave written instructions for the resident to return to the emergency department if symptoms worsened, and to increase fluids. The resident returned to the facility on the same day; however, the facility staff were not aware of the resident's condition, and did not monitor the resident for chest pain (chest discomfort or pain is a key symptom of a [MEDICAL CONDITION]). This has the potential to compromise the resident's health by not monitoring early warning signs of a life-threatening condition as a [MEDICAL CONDITION]. In addition, Resident 1 had multiple pressure ulcers. During wound care treatment, the licensed nurse did not assess the resident for pain prior to dressing changes. This resulted in the resident suffering unnecessary pain during the treatment of [REDACTED]. Resident 11 had a recent insertion of a permanent pacemaker due to a low heart rate. The facility failed to obtain the pacemaker parameters (the setting for the pacemaker to initiate a heart beat if the heart rate goes below a certain rate) to ensure the pacemaker was functioning properly. This could result in the nursing staff not recognizing if the pacemaker is malfunctioning. Resident 4 was sent to a physician's appointment to have her cast replaced on 5/11/11. Resident 4 was not given any pain medication prior to the appointment. A staff member stated the resident did not want any pain medication, but Resident 4 is listed as being cognitively impaired. The facility did not anticipate the pain Resident 4 might have while being transported to and from the physician's office, or while having her cast changed. This resulted in the resident suffering unnecessary pain. Resident 14 is listed as being aphasic (not able to speak). Resident 14 was observed pointing to her teeth repeatedly, and moaning. The facility noted Resident 14 had a toothache on 5/8/11, gave her a pain pill, but did not arrange for the resident to see a dentist or follow up with the physician. Resident 14 was observed crying due to mouth pain on 5/12/11. On the morning of 5/12/11, arrangements were made for Resident 14 to see the dentist. She had an abscessed tooth. This resulted in Resident 14 suffering pain for an extended period of time. Resident 12 was receiving hospice services. The hospice agency did not coordinate the visits with the facility staff. The staff did not know when the hospice agency would be providing care to the resident. This poses the potential for the resident not receiving the necessary care and services. Resident C, who has pressure ulcers and receives routine treatment for [REDACTED]. This poses the risk of the resident suffering needless pain during treatments. Findings: Immediate Jeopardy was identified on 5/12/11 at 1015 hours, regarding the facility's failure to thoroughly investigated injuries of unknown origin, failure to assess and prevent pressure ulcers and failure to assess residents for pain. The Administrator was made aware of the Immediate Jeopardy on 5/12/11 at 1030 hours. On 5/12/11 at 1950 hours, the facility's final plan of correction taken to abate the Immediate Jeopardy was reviewed with the DON and the Administrator. The corrections the facility took were immediate skin and pain assessments on all residents, and staff inservicing on skin and pain management and incident reporting. The facility provided documented evidence staff, including nursing staff, rehabilitation therapists, respiratory therapists, maintenance and housekeeping departments, received inservices, via telephone or as they came on duty, prior to providing care to residents. The inservices included information related to prevention of the development of pressure ulcers, assessing pain for cognitively impaired residents and residents speaking in a foreign language, and investigations of injuries of unknown origin. In addition on 5/13/11, random interviews were done with staff to assess their knowledge of prevention of pressure ulcers, assessment of the cognitively impaired and foreign speaking residents and investigations of injuries of unknown origin. As of 5/13/11, all residents were assessed for related skin issues, and pain assessments. On 5/14/11 at 1135 hours, the Administrator, the DON and the Regional Consultant were informed the Immediate Jeopardy was abated. 1. Review of the facility's CMS-672 form titled "Resident Census and Conditions of Residents" dated 5/10/11, and signed by the DON, showed 27 of 85 residents are on a pain management program. Clinical record review for Resident C was initiated on 5/12/11. Resident C was readmitted to the facility on [DATE] with bilateral heel pressure sores. Resident C's dominant language is non-English speaking. Review of Resident C's physician's orders dated 2/21/11, showed to administer [MEDICATION NAME] (a pain medication) 5/325 mg every three hours as needed for moderate pain. A physician's order dated 4/27/11, showed to cleanse Resident C's left heel wound with normal saline, pat dry, and to apply Santyl ointment (topical ointment that promotes debridement of necrotic tissue), and apply an [MEDICATION NAME] AG (a dressing for moderate to high drainage wounds which are infected or at risk of infection), and a [MEDICATION NAME] gauze dressing (a sterile, non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with xeroform in a [MEDICATION NAME] blend) every day. A physician's order dated 4/27/11, showed to cleanse Resident C's right heel wound with normal saline, pat dry, apply a [DEVICE], instill 0.5% silver [MEDICATION NAME], instill silver [MEDICATION NAME] for 20 seconds, hold 20 second vacuum for 30 minutes, and change the dressing every three days and as needed. Review of Resident C's Pressure Ulcer Status Record dated 5/9/11, shows her right heel as a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) measuring 3 cm by 2 cm by 0.2 cm, with a small amount of drainage. Review of Resident C's Pressure Ulcer Status Record dated 5/9/11, shows her left heel as a Stage III pressure ulcer measuring 1.5 cm by 1 cm by 0.2 cm, with a small amount of drainage. Review of Resident C's Pain assessment dated [DATE], shows she denies pain in both lower extremities. Review of Resident C's Pain Assessment Flowsheet for dates 5/1/11 - 5/11/11, shows Resident C complained of pain at a level 6 (on a scale 1 - 10, 10 being the worst) in her right or left leg 13 times during the evenings and was administered pain medication. No documentation was available to show Resident C was assessed or administered pain medication prior to her wound treatments. Review of Resident C's Pressure Ulcer Records for her Stage III right and left heel pressure ulcers showed for dates 4/25/11, 5/2/11, and 5/9/11, Resident C was not experiencing pain. During an interview on 5/12/11 at 0900 hours, RN 1 stated Resident C does not have pain any more in her heels since she had surgery. During an interview on 5/12/11 at 0910 hours, Resident C was asked by another resident's visitor in Resident C's language, if she was experiencing any pain. Resident C raised up her right leg, pointed to her right heel and said she was having pain in her heel. 2. Review of the facility's P&P titled "Permanent Pacemaker" revised date 1/03, shows all residents who have a pacemaker must have documentation in their clinical record of the type of pacemaker, date of implant, manufacturer's number, serial number and model number. During an observation on 5/10/11 at 0800 hours, Resident 11 was sitting on the edge of her bed, eating breakfast. She had a sling in place to her left arm. Resident 11's family member who was present, stated the sling was on her left arm for her recent pacemaker (device that is implanted in the chest wall to regulate heart rate) insertion. Clinical record review for Resident 11 was initiated on 5/12/11. Resident 11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 11's hospital Discharge Summary dated 4/25/11, showed she had a permanent pacemaker inserted for a low heart rate in the 30s and 40s (normal heart rate 60-100 beats per minute). Review of Resident 11's physician's orders dated 4/25/11, shows an order to monitor the pacemaker site for discoloration, pain, swelling and redness. No physician's order was available for an application of a sling to Resident 11's left arm. No care plan was available for the application of a sling to Resident 11's left arm. No documentation was available to show Resident 11's pacemaker parameters or a date for the next scheduled pacemaker check. During an interview on 5/12/11 at 1435 hours, RN 3 was unable to locate pacemaker parameters in Resident 11's clinical record, or the next scheduled pacemaker check. 3. Review of the facility's P&P titled "Vital Signs" (undated) showed nursing staff will initiate a plan of care to address the resident's individualized needs for pain management. Encourage the residents to tell about their pain. If they are unable to tell, look at the signs that they may be experiencing pain. Do you see facial grimaces, muscle flinching, moaning, poor appetite, agitation, more confused, delirious, immobile, contracted, depressed, unable to sleep, exhausted, angry, or crying? Use the smiley face pain scale posted in their room. It is everyone's responsibility to assess pain and re-assess pain relief after medications or alternative measures have been taken. Let your nurse know your resident is having pain and ask for suggestions on how to help; turning, positioning, medications, and distractions. On 5/9/11 at 1400 hours, during initial tour rounds of the facility, accompanied by LVN 1, Resident 6 was observed lying in bed, nonverbal, unable to provide any information. She was able to make eye contact, with no facial expression. Resident 6 was observed to be moaning; the sound was audible from the hallway. The LVN accompanying the surveyor stated Resident 6 has joint contractures, and a wound inside her gluteal folds (the crease where the buttock and leg meet) and anus. Clinical record review for Resident 6 was initiated on 5/9/11. Resident 6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of history and physical from the acute care hospital dated 7/22/10, showed the resident has masked face, is nonverbal, not following commands, has severe dementia, and severe contractures of the extremities. Review of the MDS dated [DATE], showed Resident 6 is alert, with short and long term memory impairment and severe cognitive skills for decision making, absence of speech (spoken words). Resident 6 is completely dependent on staff for all care needs. Resident 6's assessment for pain showed no signs of non-verbal sounds (moaning), vocal complaints of pain, facial expressions, protective body movements or postures were observed or documented. Review of the Nurse's Notes dated 3/14/11 at 1100 hours, skin assessment was done after CNA 1 reported a drop of fresh blood of the floor when she was taking Resident 6 to the bathroom via a shower chair. An open area was noted on the inferior gluteal fold measuring approximately 1.5 cm x 0.5 cm. During an interview on 5/13/11 at 1055 hours, with CNA 1, she stated on 3/14/11, Resident 6 was transferred from her bed to the shower chair using a gait belt. She saw fresh blood on the floor and reported it to the treatment nurse. On 5/10/11 at 1445 hours, RN 1 was observed changing the dressing from Resident 6's wound located in the inferior gluteal folds. Resident 6 was observed moaning before the treatment began. RN 1 removed the dressing from the buttocks area prior to the observation. RN 1 proceeded to open the resident's gluteal folds. She started cleansing the skin with normal saline. The RN picked up [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing), cut a ribbon measuring approximately 1 cm by 5 cm, and inserted the ribbon inside the wound cavity to pack it. The RN stated the wound is difficult to heal due to the proximity with the resident's anus, and contamination with feces. When asked if the resident had been premedicated for pain, and why the resident was constantly moaning during the whole procedure, the RN stated she did not premedicate the resident because she has routine pain medication. She stated Resident 6 did not have a facial grimace; if she had pain she would have stopped the treatment. RN 1 stated Resident 6 "moans sometimes." On 5/11/11 at 0900 hours, Resident 6 was observed moaning, audible from the hallway. Behind the privacy curtain, RNA 1 was found stretching the resident's left arm. The RNA stated Resident 6 has severe contractures to all extremities. When asked if she had assessed Resident 6's level of pain or premedicated, she stated, not really, unless the resident is in pain, if they say ouch!, grimaces, or feels uncomfortable during the procedure. When asked when the resident moans, she stated, every time when I do the exercises. On 5/11/11 at 1115 hours, Resident 6 was observed moaning, audible from the hallway. Behind the privacy curtain RN 1 and RN 2 were changing the resident's dressing, located in the inferior gluteal folds. RN 2 was able to speak the resident's foreign language. She stated Resident 6 is cognitively impaired and unable to verbalize if she is in pain. The RN further stated Resident 6 makes "this sound" whenever they are positioning, changing her diaper, or working with her. Review of a care plan problem dated 7/25/10, to address the potential for alteration in comfort evidenced by facial grimacing, at risk for pain due to contractures and decreased mobility, showed approaches to assess location, frequency, duration and intensity of pain. Report increased pain trend to the physician, provide non-pharmacological interventions such as relaxation techniques, deep breathing exercises, guided imagery, proper positioning for comfort, administer medications as ordered, educate resident and family about comfort measures, disease process during care, assess every shift for pain. Review of a physician's order dated 7/25/10, showed an order for [REDACTED]. Review of the MAR for the months of April and May, 2011, showed Resident 6 did not receive Tylenol or [MEDICATION NAME] medication for pain as needed. Review of a Consultation Report form dated 5/10/11, showed a pharmacist's recommendation to discontinue the [MEDICATION NAME] for the lack of use within the previous 60 days. On 5/11/11 at 1130 hours, during an interview with the DON, he stated the residents need specific orders from the physician, and the licensed nurse's own judgement for pain management. If the resident is cognitively impaired, the licensed nurses should use the resident's expressions, such as grimacing or moaning, and a communication board to determine the level of pain. The DON was unable to state if Resident 6 received any non-medication intervention for pain. On 5/12/11 at 1400 hours, in an interview with LVN 2, he stated Resident 6 has been reassessed for pain and her pain level ranged from 7 out of 10 on a pain rating scale. The LVN stated the staff is medicating the resident with Tylenol and [MEDICATION NAME] as ordered, when she is moaning, and premedicating her before painful procedures. On 5/12/11 at 1400 and 1700 hours, Resident 6 was observed lying in bed, awake, calm and quiet. LVN 2 stated Resident 6 was relieved from moaning after the pain medication interventions started. 4a. According to The National Pressure Ulcer Advisory panel (NPUAP), assess all individuals for pain related to a pressure ulcer or its treatment, assess for pressure-ulcer-related pain in adults using a validated scale, an assessment for pain should includes an assessment of body language and nonverbal cues (e.g., change in activity, loss of appetite, guarding, grimacing and moaning), position the individual off the pressure ulcer whenever possible, minimize pressure ulcer pain by handling all wounds gently. Administer pain medication regularly, in the appropriate dose, encourage repositioning. Initial tour round observation was conducted with LVN 1 on 5/9/11 at 1345 hours. Observation of Resident 1 showed the resident was lying in bed on his back, awake, and unable to communicate. Clinical record review was initiated on 5/9/11. Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 1 is alert, with short and long term memory impairment and severe cognitive impairment for decision making, and completely dependent on staff for all care needs, unclear speech (slurred or mumbled words). Resident 1's assessment for pain showed no signs of nonverbal sounds (moaning), vocal complaints of pain, facial expressions, protective body movements or postures were observed or documented. No care plan problem to address the potential for alteration in comfort, and pain due Resident 1's multiples pressure ulcers was found in the clinical record. Review of a care plan problem dated 4/30/11, to address communication impaired related to language barrier, showed approaches to provide a communication board, staff to anticipate needs and meet daily. On 5/11/11 at 1335 hours, the treatment of [REDACTED]. A communication board (book with pictures) was observed at the resident's bedside; however, it was not used prior to the treatment as a tool to assess if the resident was in pain. RN 1 came in and proceeded to remove the left boot and the soiled dressing from his left foot, without assessing the resident. Review of the Pressure Ulcer Status Record form dated 5/5/11, showed a healing left lateral heel Stage III pressure ulcer measured 0.3 cm by 1 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known; non-verbal signs was not marked. Review of the Pressure Ulcer Status Record form dated 5/5/11 and 5/14/11, showed a left heel Stage III pressure ulcer measured 1 cm by 2.5 cm by 0.2 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known; non-verbal signs was not marked. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11 showed a right heel Stage III pressure ulcer measured 5 cm by 5 cm by 0.2 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known. Non-verbal signs was not marked. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11, showed a right hip Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present) measured 6.5 cm by 5 cm by 1 cm. Documentation showed the resident was not experiencing pain; however, he was unable to make it known. Non-verbal signs was not marked. During an interview with RN 1 on 5/11/11 at 1500 hours, she was asked if they conduct pain assessment prior to the pressure ulcer treatments. She stated Resident 1 has no pain, only when he goes out to the wound care clinic, they administer [MEDICATION NAME] (local anesthetic). When asked why she does not use the communication book, she stated the resident is unable to communicate. Review of the Nurse's Notes dated 5/11/11 at 0845 hours, showed the licensed nurse called the physician, who ordered Tylenol (pain medication) 650 mg via GT every 4 hours, and before dressing changes. however, review of a physician's order dated 3/22/11, showed an order for [REDACTED]. During a family interview on 5/13/11 at 1700 hours, the family member stated Resident 1 shakes his head when he has pain; he has constant headaches. The family member stated Resident 1 complains of pain only when they change his pressure ulcer dressings. b. On 5/10/11 at 1100 hours, LVN 1 was asked the whereabouts of Resident 1. The LVN stated he had gone out to a wound care center to treat his pressure ulcers. A Nurse's Notes dated 5/10/11 at 1730 hours, showed the resident came back from the appointment, new order received to have a repeat BMP (basic metabolic panel, a blood test) in the morning. Review of the acute care hospital discharge instructions dated 5/10/11, showed on the way to the wound care center, the family member requested Resident 1 be evaluated for a low heart rate. He was taken to the acute care hospital. The emergency department physician documentation showed the resident has dementia, but nods to chest pain and shakes his head to shortness of breath and/or headache. Re-questioning later, the resident was nodding yes to all rule out symptom questions. Troponin (a test for a protein to detect heart disorders, including [MEDICAL CONDITION] infarction, or a [MEDICAL CONDITION]) was elevated. The results were reviewed with the family member and the family member agreed to the plan to rehydrate the resident and recheck the laboratory tests at home. The physician sent instructions to return to the emergency department immediately for any worsening of symptoms. On 5/13/11 at 0845 hours, during an interview with LVN 1, he stated he was not aware the chief complaint at the ER was chest pain. He was unable to find documentation to show the facility was monitoring Resident 1 for signs and symptoms of chest pain. In addition, LVN 1 confirmed there was no follow up with the resident's physician regarding Resident 1's hydration status. There was no care plan problem developed to address Resident 1's chest pain. On 5/13/11 at 1000 hours, during an interview with the DON, he stated the family member took the resident to the emergency department because his heart rate was low, but he was not aware what happened to Resident 1 while he was in the emergency department. 5. Clinical record review for Resident 4 was initiated on 5/9/11. Review of the [MEDICAL CONDITION] care plan problem dated 5/2/11, showed Resident 4 had altered thought processes, compromised memory and recall ability and impaired decision making. Resident 4's dementia is manifested by disorientation, unawareness to time or place, and Resident 4 is unable to recognize staff, faces or significant others. Review of the Impaired Cognition care plan problem dated 5/2/11, showed Resident 4 has impaired cognition with short and long term memory problems. An interview with Resident 4's family member was initiated on 5/12/11 at 0925 hours. The family member stated Resident 4 was scheduled to go to a physician's appointment on 5/11/11, to have her leg cast changed after two recent fractures, which occurred on 4/30/11. The family member stated the facility arranged transportation to the physician's office and he accompanied Resident 4 to the appointment. The medical transport stopped to pick up another person in a trailer park. The trailer park had speed bumps every few feet. Every time the van would go over a speed bump, Resident 4 would yell in pain. It took over an hour and a half to get to the physician's office. The family member stated there were a lot of speed bumps along the way. When Resident 4 finally got to the physician's office, she screamed when the physician changed her cast. Review of the Controlled or Antibiotic Drug Record showed Resident 4 was not given any pain medication prior to leaving for the physician's appointment on 5/11/11. Resident 4 was documented as last having [MEDICATION NAME] (a narcotic pain medication) on 5/9/11. An interview with RN 3 was initiated on 5/12/11 at 1030 hours. RN 3 was asked why Resident 4 was not given any pain medication prior to the physician's appointment. RN 3 stated she asked Resident 4 if she was in pain prior to leaving for the appointment. Resident 4 said, no. RN 3 was asked if Resident 4 was not in pain at that moment, did she anticipate Resident 4 might have pain while having her cast changed or during the transportation to and from the physician's office. RN 3 stated she was not aware Resident 4 was having the cast changed. 6. Clinical record review for Resident 14 was initiated on 5/12/11. Review of the Pain care plan problem dated 1/21/11, showed Resident 14 has potential for generalized pain as evidenced by facial grimacing. The goal for the pain problem is the resident will be free of pain. Review of the PRN Medication Administrative Record dated May, 2011, showed Resident 14 received a [MEDICATION NAME] (a pain medication) on 5/8/11. The reason is listed as a toothache. On 5/7/11, and 5/9/11, Resident 14 also received [MEDICATION NAME]. No reason for the pain medication is documented. According to the record, Resident 14 did not have any pain medication administered to her after 5/9/11. Review of the Nurse's Notes for May, 2011, showed two entries for the month of May. Neither entry mention Resident 14's dental problem. The entry dated 5/10/11, showed no mention of Resident 14's toothache. There is no documentation to show the physician was informed about the resident's toothache, and no new interventions were done. An observation of Resident 14 was made on 5/11/11 at 1420 hours. Resident 14 was not able to answer questions, but when asked how she was feeling, she repeatedly pointed to her teeth and moaned. On 5/12/11 at 0820 hours, Resident 14 was observed pointing to her teeth and moaning when asked how she felt. On 5/12/11 at 1040 hours, Resident 12 was seated in the wheelchair in front of the nurses' station. Resident 14 was crying. Two nurses were trying to calm the resident. RN 2 was asked why Resident 14 is crying. RN 2 stated she had an abscessed tooth. The dentist had just visited. The tooth needed to be pulled, but Resident 14 is on blood thinners and the tooth can not be pulled until the blood thinner medication has been held for a few days to prevent Resident 14 from bleeding excessively. RN 2 stated she would give Resident 14 pain medication. Review of the Dental Services report dated 5/12/11, showed the dentist examined the resident and the resident had complaints of pain. The #14 tooth needed to be extracted. A telephone interview with the dental office manager was initiated on 5/17/11 at 1530 hours. The office manager was asked when the facility contacted the dentist to schedule an appointment for Resident 14. The office manager stated the facility called the doctor on the morning of 5/12/11, to schedule the dental appointment for Resident 14. The dental office manager stated the dentist went to the facility within an hour of the call. Review of the physician's orders dated 5/12/11, showed an order to hold the resident's blood thinner medication, to start the resident of an antibiotic and to schedule a tooth extraction. 7. Clinical record review for Resident 12 was initiated on 5/11/11. Review of the hospice care plan problem dated 3/28/11, showed Resident 12 was admitted to hospice care on 3/28/11. The frequency of visits showed the nurse will visit the resident two times a week. The CHHA (Certified Hospice Health Aide) will visit two times a week and the Medical Social Worker is scheduled to visit one time a month. Review of the hospice Patient Calendar dated 3/28/11, showed the schedule for the nurse and CHHA visits for the next three weeks, but no further visits are scheduled. From 4/18/11 to 5/12/11, there are no scheduled visits listed. An interview with CNA 2 was initiated on 5/12/11 at 1415 hours. CNA 2 was asked if she knows when the hospice staff will be visiting next. She stated she is not sure. CNA 2 was asked if she is not sure when they are visiting, how does she know what kind of care to provide the resident. CNA 2 stated, if the resident needs a shower she will wait and let the hospice CHHA do it.

Based on observation, interview and clinical record review, the facility failed to ensure nursing assessments were complete and an order for [REDACTED]. This had the potential for staff not identifying the resident's worsening [MEDICAL CONDITION] and a subsequent delay in treatment. In addition, this had the potential to exacerbate the resident's condition by not implementing the physician's orders [REDACTED]. Findings: Review of the facility's P&P titled Fluid Restriction dated 3/2011, showed nursing and dietary services will determine the amounts of fluids to be provided by each department. The specific beverage and fluid amount to be served at meals will be written on each residents' tray card. On 7/6/11, clinical record review for Resident 23 was initiated. The Initial Data Collection Tool/Nursing Service assessment form dated 6/29/11, showed Resident 23 had 2+ [MEDICAL CONDITION] to both legs. The Weekly Summary assessment form dated 7/2/11, showed a section on the form related to [MEDICAL CONDITION] assessment, degree and location. However, this section of the assessment form was blank. The Weekly Summary assessment form dated 7/5/11, showed Resident 23 had no [MEDICAL CONDITION]. However, on 7/6/11, the physician documented Resident 23 had 3+ [MEDICAL CONDITION] to his extremities. On 7/6/11, the physician ordered a fluid restriction of 1500 ml daily and [MEDICATION NAME] (a diuretic medication, used to eliminate excess fluids from the body) 20 mg twice daily. On 7/7/11 at 0755 hours, during an interview with Resident 23, the resident stated he wanted to drink Ensure (a supplement shake). The resident pointed to his water pitcher and stated he did not want to drink water because the "doctor said." The resident pointed to his abdomen and then to his pitcher of water. On 7/7/11 at 0800, Resident 23's dietary tray card was observed on his breakfast tray. The tray card showed the resident was on a 1500 ml fluid restriction. However, the tray card did not show the specific beverage amounts provided by dietary. On 7/7/11 at 0815 hours, a ? full water pitcher was observed at Resident 23's bedside along with a cup which was half full of water. On 7/7/11 at 0945 hours, a pitcher of water 2/3 full was observed at Resident 23's bedside along with a full cup of water with a straw in it. On 7/7/11 at 1315 hours, a pitcher of water ? full was observed at Resident 23's bedside along with a cup of Ensure. On 7/7/11 at 1440 hours, during an interview with CNA 2, the CNA stated Resident 23 has a pitcher of water at his bedside. CNA 2 stated she filled it up in the morning and the resident drinks from it. CNA 2 stated Resident 23 also received fluids on his meal trays. Additional record review found a care plan problem dated 6/29/11, to address the resident's nutritional status, [DIAGNOSES REDACTED]. However, there were no interventions to address how the fluids would be divided between dietary and nursing to ensure they did not exceed the 1500 ml of fluid in a day.

Based on observation, interview and clinical record review, the facility failed to provide appropriate treatment and services to prevent complications for one of 17 sampled residents (Resident 1). Resident 1 has a GT (a soft rubber tube inserted through the abdomen into the stomach to infuse enteral nutrition). During dressing change, when RN 1 removed the old dressing, redness and a black substance was noted on the gauze. The resident had developed an unnoted infection of the skin around the GT stoma (opening). Treatment with topical antibiotics and dressing is necessary to treat the infection. Findings: According to Wound Ostomy and Continence Nurses Society (WOCN). It is recommended to asses for appropriateness of the tube, constipation, compliance with a bowel program, assess the tube, assess skin around the tube daily for maceration (softening of the tissue) from excess moisture, denudation (removal of the protective layer of skin) from acidity of [MEDICAL CONDITION] fluid leakage, fungus from wet dressings, infection, pressure ulcers from stabilizers, and the stoma (the opening) for leakage (assess color and amount), tube displacement, tube stabilization, and positioning during feeding. Review of the facility's P&P titled "Wound Care" (undated) showed medical treatments must be documented on a treatment record in the resident's clinical record. The nurse is responsible for administration and recording all treatments according to the physician's orders [REDACTED]. Changes in a wound, refusal of a treatment, anything unusual, or other pertinent information will be documented. Initial tour round observation was conducted with LVN 1 on 5/9/11 at 1330 hours. Observation of Resident 1 showed the resident was awake, unable to communicate. He was receiving nutrition through a GT. Two 4 cm by 4 cm gauze pads secured with tape were observed around the GT stoma. Clinical record review was initiated on 5/9/11. Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], showed the resident is completely dependent on staff for all care needs. Review of a care plan problem revised on 5/4/11, to address GT feedings related to dysphagia, and at risk for aspiration, weight loss and dehydration showed goals the GT site will be maintained clean without signs and symptoms of irritation or infection for three months, and approaches for care of the GT site daily or as ordered. On 5/11/11 at 1335 hours, RN 1 was observed providing skin treatment around the GT site. The LVN stated the reason for the treatment was for GT maintenance. Observation of the GT stoma showed surrounding redness, moderate amount of [MEDICAL CONDITION] contents was leaking from the stoma, the old dressing was soiled with a blackish substance. When the RN was asked what the blackish substance is, she stated she did not know. When asked if there is a physician's orders [REDACTED]. RN 1 was unable to provide documentation to show daily assessment of the GT stoma site. Review of the physician's orders [REDACTED]. Follow up review showed a physician's orders [REDACTED].

Based on interview, observation and clinical record review, the facility failed to ensure the facility is as free from accident hazards as possible for two of 17 sampled residents (Residents 4 and 3). Resident 4 is assessed as a high risk for fractures due to osteoporosis (softening of the bones). Resident 4 is dependant on the facility staff for assistance with all her ADLs, including transferring in and out of bed. The MDS showed Resident 4 needs the assistance of two or more people to transfer, but the facility did not give instructions to the staff to use two or more people to transfer her. Resident 4 sustained two fractures of the left lower leg on 4/30/11, while at the facility, when a CNA transferred Resident 4 by herself. The facility failed to ensure nursing care for Resident 3 included continuing supervision. Resident 3 was assessed as a high risk for aspiration due to difficulty in swallowing. On 5/10/11 at 1220 hours, Resident 3 was observed independently eating lunch in the dining room, without supervision. Resident 3 suddenly started coughing, gasping for air, and became distressed. Although staff suspected Resident 3 was choking on food, no immediate attempt was made to stop the resident from eating and drinking; instead LVN 2 held her glass of liquids to her mouth. No immediate attempt was made to clear Resident 3's air way. A chest x-ray taken on 5/10/11, showed slight bilateral lung infiltrates. A television set was found to be a potential hazard as it was observed to be unsecured, a janitor's closet with hazardous chemicals was unlocked, and a Wanderguard system (a system that alerts the staff when a resident wearing a wrist or ankle band signaling device approaches a Wanderguard monitored door) was disconnected from an electrical outlet. Findings: 1. Clinical record review for Resident 4 was initiated on 5/9/11. According to the facility's P&P Resident Care Plans dated 12/08, the resident's care plan should be a brief written portrait of the resident and an individualized guide of the nursing care needed. The care plan should describe what is actually going to be done for, to, or with the resident in order to achieve the goals in the care plan. Review of Resident 4's MDS dated [DATE], showed Resident 4 was assessed as needing extensive assistance with transfers, requiring two persons or more to transfer. Review of the Risk for Spontaneous Fractures related to Osteoporosis care plan problem dated 11/10/10, showed a goal to prevent fractures for Resident 4. The approach plan is to provide a safe and hazard free environment, calcium supplements as ordered, diet as ordered, observe for joint and bone pain and to handle gently when moving, turning and repositioning of the resident. The care plan does not describe how to reposition, turn or move the resident, or how many people are needed to do so. Review of the Impaired Mobility care plan problem dated 11/20/10, showed Resident 4 is totally dependant in bed mobility, walking, toileting, bathing and personal hygiene. The approach plan is to assist with positioning, transfers and ambulation as necessary or as requested by the resident. No specific instructions are available to describe what level of assistance is needed with transfers, positioning or ambulation, such as the need for a mechanical lift, one or two persons needed for transfer, or if the resident can pivot, needs to be lifted or can assist with the transfer process. Review of the Investigation Report dated 5/3/11, showed on 4/30/11 at 0430 hours, Resident 4 was found to have swelling of the left leg. The resident was having facial grimacing and thought to be in pain. The skin was intact, but had redness. The resident was transferred to the acute care hospital. Review of the acute care hospital x-ray report dated 4/30/11, showed Resident 4 sustained a fracture to the left tibia and left fibula (the two lower leg bones). There is a questionable fracture of the left calcaneous (heel bone). An interview with Resident 4's family member was initiated on 5/11/11 at 1030 hours. The family member stated he was upset Resident 4 sustained the fractures. The family member stated Resident 4 only gets out of bed once a day. He stated he had witnessed one nurse lifting the resident out of bed on many occasions. The family member felt it was not safe to do so, but thought the facility knows best. An interview with the DON was initiated on 5/11/11 at 1550 hours. The DON was asked about Resident 4's fractures. The DON stated he was not sure what happened to the resident. According to the investigation, Resident 4 was not witnessed as having any falls or trauma to the legs. If he had to speculate, he thinks the resident's legs could have gotten twisted during transferring, but he really was not sure. An interview with CNA 5 was initiated on 5/12/11 at 1345 hours. CNA 5 was asked about the fractures of Resident 4. CNA 5 stated she was the CNA caring for the resident on 4/29/11 from 0700 to 1500 hours. CNA 5 stated she got the resident out of bed that day by herself and transferred her back to bed unassisted. CNA 5 stated she did not see any redness of the left leg and the resident did not appear to be in pain. CNA 5 was asked about the care she provided for Resident 4. CNA 5 stated the resident could not walk or transfer in or out of bed. Resident 4 is fully dependent on the staff for care. CNA 5 would lift Resident 4 out of bed to transfer her once a day. CNA 5 was asked how many people assisted her to transfer the resident. CNA 5 stated she usually transferred the resident by herself. CNA 5 was asked, if a resident needs special assistance with transferring, such as two or more people to assist with transfers, or the need for a mechanical lift, where would that information be kept. CNA 5 stated there is a Special Needs book at the nurses' station. Review of the Special Needs book showed Resident 4 is not listed in the book as needing any special assistance for transfers. 2. Review of the facility's P&P titled "Aspiration Precautions" dated 6/06, showed the residents at risk for aspiration may be identified on assessment or evaluation by the physician, licensed nurse, or speech language pathologist. the assessment may reveal conditions that could support the need for aspiration precautions: coughing and or choking, resident complaining of difficulty swallowing, reduced cognitive level of function. When identified at risk, the resident is placed on aspiration precautions. 1. The physician is notified when the resident is placed on aspiration precautions, and an order is received. 2. Residents placed on aspiration precautions are supervised during all intakes by mouth. 3. The resident and family are notified, and appropriate education provided. 4. The care plan is updated with documentation of interventions. 5. The Speech Therapist is notified if not already involved, and recommendations or plans are followed. 6. The resident is encouraged to take, or is fed, small bites of food and sips of water. 7. Emergency procedures are followed on any resident who, as a result of aspiration, presents with an obstructed airway or absent breathing. Initial tour round observation was conducted with LVN 1 on 5/9/11 at 1350 hours. Observation of Resident 3 showed the resident was lying in bed alert. A suction machine was observed at the bedside. The LVN stated Resident 3 sometimes uses it because she has increased oral secretions. Clinical record review for Resident 3 was initiated on 5/9/11. Resident 3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 3 is alert, with short and long term memory impairment and moderate cognitive skills for decision making, absence of speech (spoken words). Resident 3 requires extensive assistance to eat, has a mechanically altered diet, and a therapeutic diet. According to the MDS assessment, Resident 3 does not have swallowing disorder. Review of the Clinical Swallowing Evaluation from the acute care hospital dated 1/14/11, showed Resident 3 presented with moderate to severe oropharyngeal dysphasia, with residue left in her mouth post swallow, multiple swallows required to clear bolus (chewed food ball). Review of Resident 3's transfer sheet from the acute care hospital dated 1/15/11, showed aspiration precautions. A physician's order dated 3/3/11, showed an order for [REDACTED]. There was no physician's order to show the resident is on aspiration precautions. Review of a care plan problem dated 1/15/11, to address aspiration precautions showed approaches to follow the diet as ordered, provide encouragement and cuing during meals, puree diet and nectar thick liquids. However, the care plan did not address how the staff is to monitor her tolerance to the food and liquids, swallowing strategies used during meals, and the signs and symptoms of aspiration (choking). On 5/10/11 at 1205 hours, during the lunch observation, Resident 3 was sitting at a dining room table with 10 other residents. She was alert, calm and quiet, prior to receiving her tray. Her lunch was served and she started eating at 1220 hours. She was eating independently, without close supervision by the staff. Resident 3 suddenly started coughing, gasping for air, and became distressed. No immediate attempt was made to stop the resident from eating and drinking; instead LVN 2 held the resident's glass of nectar thick liquids to her mouth. The resident started gulping and struggling to swallow the liquid. Her mouth became full and she started drooling. LVN 3 kept feeding her, than he grabbed a straw and put it in her glass of nectar thick liquid. Finally, they took the resident back to her room. No immediate attempt was made to clear Resident 3's airway. Review of the Nurse's Notes dated 5/10/11 at 1410 hours, showed the resident's vital signs were recorded as follows: blood pressure 131/61 mmHg (normal reading is in the range of 120/80), pulse 82 (normal range is 60 to 100 beats per minute), respirations 16 (normal range is 15 to 20 per minute), and oxygen saturation 95%. The documentation showed chest congestion, and wheezing. The physician ordered suction as needed for increase of oral secretions, and chest x-ray. Review of Resident 3's chest x-ray results dated 5/10/11, showed slight bilateral lower lobe infiltrates. During an interview on 5/10/11 at 1445 hours, LVN 1 stated Resident 3 was trying to drink from the glass, she was coughing, but she was not turning blue. When asked what the staff should have done to prevent the resident from aspiration, LVN 1 stated the staff should have stopped her from drinking and eating immediately. The LVN stated he listened to the resident's lungs in the morning and her lungs were clear. LVN 1 stated the resident is still coughing, and they are suctioning now. During an interview on 5/10/11 at 1520 hours with the speech therapist (ST), she stated the resident needs smaller bites, caregiver supervision, education, and specific instructions on how to feed the resident. When asked why Resident 3 did not have the specific swallowing strategies before choking, the ST stated she was not working with the resident before, now she developed the strategies and it is in the resident's clinical record. When asked what happened to Resident 3 in the dining room this morning, the ST stated Resident 3 had a "big phlegm in her throat." Review of the "Dysphagia" form (undated) showed to eat in the upright position, no straws, small bites and sips, cue the resident to swallow and double swallow, check for pocketing, provide supervision for all meals, and stop feeding if the resident coughs on food or liquid. During an interview on 5/13/11 at 1015 hours, with RNA 1, she stated, when a resident is on aspiration precautions, during meals the staff should sit the resident up, feed with small bites and sips of liquid, double swallow, and make sure the resident swallows, and clears the throat before taking another bite. RNA 1 stated Resident 3 needs a trained caregiver during meals. 3. During the initial tour rounds on 5/9/11 at 1345 hours, accompanied by LVN 1, an unsecured television set was observed in Room E on top of a chest of drawers. The LVN stated the TV set is 27 inches and it is approximately 4 feet off the floor. The LVN tilted the television set and stated it is not secured. Resident 13 was lying down in a low bed by the chest of drawers. 4. During environmental tour rounds on 5/12/11 at 1200 hours, accompanied by Maintenance Assistant 1, the Wanderguard alarm was found disconnected on the exit door leading to the facility's east parking lot. The Maintenance Assistant stated the housekeeping requested it be disconnected because one of the residents was wearing a Wanderguard bracelet and liked to sit by the exit door. Every time the resident sits by the door, the Wanderguard won't stop going off. During an interview on 5/12/11 at 1200 hours, with LVN 1, he stated he never requested for the Wanderguard alarm to be disconnect. During an interview on 5/12/11 at 1205 hours, with housekeeping, he denied asking to disconnect the Wanderguard alarm. 5. During initial tour rounds on 5/9/11 at 1345 hours, accompanied by LVN 3, Resident 7 was sitting in a wheelchair, in her room. A Wanderguard was observed on Resident 7's right ankle. LVN 3 stated a Wanderguard was placed on Resident 7 earlier today, because she has attempted to leave the facility. During observations on 5/9/11 at 1345 hours and 1500 hours and 5/10/11 at 0630 hours, 0930 hours and 1200 hours, Resident 7 remained unattended lying in bed or sitting in her wheelchair, and made no attempts to exit her room. Clinical record review for Resident 7 was initiated on 5/10/11. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Risk of Elopement Review dated 4/25/11, shows no history of elopement while at home, leaving the facility without the need of supervision, or leaving the facility without informing the staff. In addition, Resident 7 had not expressed the desire to go home, packed belongings to go home or stayed near an exit door. Resident 7's Summary Review showed she was not at risk for elopement. Review of Resident 7's MAR showed a physician's order dated 5/9/11, to monitor the number of attempts every shift of her attempt to leave the facility. Review of Resident 7's Nurse's Notes dated 5/9/11, showed she was attempting to leave the facility numerous times, unattended and a physician's order was obtained to apply a Wanderguard bracelet. Review of Resident 7's care plan problem dated 5/9/11, to address a potential for injury related to a history of wandering showed an approach plan to check the resident's Wanderguard bracelet. No documentation was available to show Resident 7 was assessed prior to applying a Wanderguard. In addition, no documentation was available to show Resident 7 was monitored to ensure the Wanderguard is in place or to ensure the Wanderguard is functioning properly. During an interview on 5/10/11 at 1420 hours, LVN 3 stated Resident 7 was not assessed prior to placing the Wanderguard bracelet on. During an interview on 5/11/11 at 0835 hours, the DON stated an elopement assessment is needed on a resident prior to applying a Wanderguard. He stated the licensed nurses document on the MAR, the number of attempts the resident tries to exit the facility. When the DON was asked if the resident is monitored for the placement of the Wanderguard, he stated "no." When the DON was asked how the Wanderguard is checked to ensure it is functioning properly, he stated, once a month the maintenance staff bring the resident with the Wanderguard to the door to check if the alarm goes off. 6. During initial tour rounds on 5/9/11 at 1345 hours, accompanied by LVN 3, a storage closet next to Room 3 was unlocked. Inside the closet was a clear spray bottle with a white substance and a gallon of floor cleaner. LVN 3 stated the storage room should be locked. 7. During tour rounds on 5/11/11 at 0735 hours, accompanied by LVN 4, Resident B's bed was elevated approximately two feet above the ground, and a floor mat was on the left side of the bed. LVN 4 stated Resident B was admitted to the facility with a neck fracture and passed out at home and fell . He stated Resident B requests her bed to be elevated that high and she should have floor mats on both sides of the bed. Clinical record review for Resident B was initiated on 5/11/11. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. No documentation was available to show Resident B requested her bed to be elevated off the floor. During an interview on 5/11/11 at 1115 hours, Resident B stated she only raises the head of her bed. She stated she did not request for her bed to be elevated off the floor. Resident B stated the staff raise the bed and do not lower it. During an observation on 5/13/11 at 1515 hours, accompanied by the DSD, Resident B's bed was elevated off the floor. The DSD stated Resident B likes the bed that high.

Based on observation, interview and clinical record review, the facility failed to ensure pressure ulcer care and treatment for two of 17 sampled residents (Residents 1 and 6) and one nonsampled (Resident C) was provided. Resident 1 was admitted with multiple pressure ulcers. The repositioning schedule was not implemented, and the heels were not elevated at all times, as ordered by the physician. Resident 1 developed a new pressure ulcer while in the facility that deteriorated to Stage III (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough (dead tissue) may be present). Resident 1 was at risk for further pressure ulcers or deterioration of current pressure ulcers; his care plan was not individualized for the different pressure ulcers on his body. Resident 6 developed a Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister) pressure ulcer after admission. The facility failed to monitor the use of Waffle boots (an inflatable vinyl boot to keep pressure off the heels). As a result, Resident 6 developed a Stage II pressure ulcer. Findings: According to the National Pressure Ulcer Advisory Panel (NPUAP), support surfaces alone neither prevent nor heel pressure ulcers. They are to be used as part of a total program of prevention and treatment. If the pressure ulcers are not healing, re-evaluate the individual and his pressure ulcers, intensify prevention strategies as indicated. Consider changing the support surface to improve pressure redistribution. 1. Initial tour round observations were conducted with LVN 1 on 5/9/11 beginning at 1330 hours. At 1345 hours, Resident 1 was visited. The LVN stated Resident 1 has four pressure ulcers: to his left, and right heels, and to his right hip. LVN 1 stated the resident developed the Stage III pressure ulcer to the left heel while in the facility. Resident 1 was awake, unable to communicate and was observed to be positioned on his back with the head of the bed elevated. The heels were resting on the mattress. Clinical record review for Resident 1 was initiated on 5/9/11. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed the resident is completely dependent on staff for all care needs; he requires extensive assistance for turning/repositioning in bed with the assistance of two persons. Review of the Pressure Ulcer Status Record form dated 5/5/11, showed the left lateral heel had a healing Stage III pressure ulcer measuring 0.3 cm by 1 cm, depth superficial. Review of the Pressure Ulcer Status Record form dated 5/5/11, showed the left heel had a Stage III pressure ulcer measuring 2 cm by 2.5 cm by 0.2 cm deep. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11, showed the right heel had a Stage III pressure ulcer measuring 5 cm by 5 cm by 0.2 cm deep. Observation of Resident 1 on 5/11/11 at 0735 hours, showed a [DEVICE] Assisted Closure (V.A.C.- a device with mechanical forces to the wound to create an environment that promotes wound healing) was in place. Further review of the Pressure Ulcer Status Record form for the right heel failed to show documentation of the use of a wound vac. Review of the Pressure Ulcer Status Record form dated 5/6/11 and 5/14/11, showed the right hip had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) measuring 6.5 cm by 5 cm by 1 cm deep. On 5/11/11 at 0735 hours, a wound vac was observed in place, but further review of the Pressure Ulcer Status Record form failed to show documentation regarding the use of the wound vac. Review of the care plan showed a care plan problem dated 4/30/11, to address the risk for further pressure ulcers or deterioration of current pressure ulcers: right hip Stage IV, right heel Stage III, left heel Stage III, left lateral heel Stage III and scrotal swelling. The approaches showed turn and reposition the resident every two hours, three times per each shift: back, left side and maintain pressure free to both heels while in bed. Place pressure-reducing mattress on the bed, needs two persons to assist with repositioning to avoid skin friction/shearing. Needs daily observation of skin with routine care. Needs full skin evaluation weekly with shower. The care plan was not individualized. Resident 1 had multiple pressure ulcers, in different sites of his body, and there were no specific interventions for each, in order to monitor healing, measurable objectives for each of the pressure ulcers. Interventions for the use of Waffle boots was not addressed in the resident's care plan. Review of the care plan showed no care plan problem had been developed on admission to address pain related to the multiple pressure ulcers. Review of the physician's orders [REDACTED]. On 5/10/11 at 0640, 1000, 1130 hours, on 5/11/11 at 0750, and 1200 hours, and on 5/13/11 at 0745, 1000, and 1400 hours, Resident 1 was observed lying in his bed, alert, and positioned on his back. The resident had Waffle boots on. There was one pillow placed under the resident's lower legs; however, both of the resident's heels were resting on the mattress and were not offloaded (floating). On 5/10/11 at 0945 hours, both Waffle boots were observed on the resident's feet. RN 1 was present and preparing to provide treatment to the resident's left heel pressure ulcer. When asked if the resident's pressure ulcers developed in the facility, the RN stated, yes, he got one here; a Stage III to his left heel that started as a blister. In addition, RN 1 stated it is her responsibility to educate the CNAs on correct positioning of the residents to prevent the development of pressure ulcers. Review of a physician's orders [REDACTED]. An interview was conducted with CNA 3 on 5/11/10 at 0945 hours. The CNA stated Resident 1 is unable to move at all by himself and is unable to talk. She stated she turns the resident every two hours, and floats his heels. During an interview with the DON on 5/12/11 at 1100 hours, the concern regarding Resident 1's skin integrity problems, lack of individualized care plan interventions for the multiple pressure ulcers, not repositioning, and not consistently elevating Resident 1's heels was discussed. The DON was unable to give an explanation as to why the CNAs are not taking steps to prevent deterioration of Resident 1's skin integrity. 2. Review of the facility's P&P titled "Heel Protectors" (undated) showed inspect the skin, secure with ankle straps, be sure straps are not too tight; you should be able to insert two fingers under the strap. Remove the protectors at least once each shift to expose the skin to air. Repeat skin care before applying protectors and when removed. If redness does not disappear, report to the charge nurse. In addition to the heel protectors, position the resident's feet to relieve pressure on the heels and ankles. Clinical record review for Resident 6 was initiated on 5/9/11. Resident 6 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 6 is alert, with short and long term memory impairment and severe cognitive impairment for decision making, and has absence of speech (spoken words). Resident 6 is completely dependent on staff for all care needs. Review of the Nurse's Notes dated 5/9/11 at 1300 hours, showed a skin assessment was done, and Resident 6's right foot had a clear fluid blister approximately 1 cm by 1 cm, intact. Boots were reapplied, and ensured the straps were loose. On 5/10/11 at 1450 hours, RN 1 was observed checking Resident 6's feet. RN 1 removed a pair of foam boots and found Resident 6 had developed a clear fluid blister on her right anterior foot measuring approximately 1 cm by 1 cm. Another blister was observed to the sole of the foot, measuring 1 cm by 1 cm, filled with reddish/purplish fluid. The RN stated she did not know how the resident developed the new pressure ulcers. When asked why the new pressure ulcer was not assessed when it was a Stage I (intact skin with non-blanchable redness of a localized area, usually over a bony prominence), she had no answer. Boots were reapplied, and ensured the straps were loose. Review of a physician's orders [REDACTED]. 3. During initial tour rounds on 5/9/11 at 1345 hours, accompanied by LVN 3, Resident C was observed lying in her bed on a low air loss mattress (a special air flow mattress to help reduce pressure). A wound V.A.C. device was connected to Resident C's right heel. LVN 3 stated Resident C was admitted to the facility with bilateral heel pressure ulcers. During an observation on 5/12/11 at 0835 hours, Resident C was observed lying in her bed. Her low air loss mattress was off and her bilateral waffle boots (vinyl inflatable boots that suspend the heels) were on the floor on the right side of her bed. During interviews on 5/12/11 at 0835 hours, LVN 4 and RN 1 stated they were unaware of the reason Resident C's low air loss mattress was turned off or why her waffle boots were not in place. LVN 4 turned Resident C's low air loss mattress on. Later the same day at 0900 hours, Resident C was observed lying in bed with her right heel pressed against the foot cradle. RN 1 stated Resident C's heel should not be against the foot cradle, and repositioned her foot. Clinical record review for Resident C was initiated on 5/12/11. Resident C was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident C's physician's orders [REDACTED]. A physician's orders [REDACTED]. with xeroform in a [MEDICATION NAME] blend) every day. A physician's orders [REDACTED]. Review of Resident C's Pressure Ulcer Status Record dated 5/9/11, shows her right heel as a Stage III pressure ulcer measuring 3 cm by 2 cm by 0.2 cm, with a small amount of drainage. Review of Resident C's Pressure Ulcer Status Record dated 5/9/11, shows her left heel as a Stage III pressure ulcer measuring 1.5 cm by 1 cm by 0.2 cm, with a small amount of drainage. Review of Resident C's care plan problem dated 2/21/11, to address her Stage III heel pressure ulcer, shows an approach plan for a pressure relieving mattress on the bed. Review of Resident C's Treatment Administration Record for May, 2011, show to have Waffle boots on both feet at all times. 4. During an observation on 5/14/11 at 0950 hours, Resident 1 was lying in his bed on a low air loss mattress. Hooked on to the foot of Resident 1's bed was the low air loss mattress' power source with a connection site for the plastic ribbed tubings to allow air flow from the power source to the air mattress. White tape and blue tape were observed circling around the tubings, holding them together near the connection site. During an interview on 5/14/11 at 0950 hours, LVN 1 stated he was unaware of the reason the tubings had two different kinds of tape around them. During an interview on 5/14/11 at 1000 hours, Maintenance Assistant 1 stated he was unaware of the reason Resident 1's low air loss mattress tubings were taped together. During an interview on 5/14/11 at 1010 hours, the DON stated he was unaware Resident 1's air mattress tubings were taped. He stated he was unable to ensure the low air loss mattress was functioning properly with the tape.