Every finding on record at The Wolfe Living Center at Summit Ridge

Based on record review and interview, the facility failed to ensure a resident's assessment was accurately coded for 1 (#1) of 3 sampled residents reviewed for accuracy of resident assessments. The administrator identified 41 residents resided in the facility. Findings: A policy titled MDS 3.0 Completion, dated 10/01/24, read in part, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. A Quarterly MDS, ARD of 04/18/25, showed Resident #1 had diagnoses of Alzheimer's, dementia, and severely impaired cognition. The assessment showed section E0900 (Section of the MDS for wandering) was coded as 0 for wandering in the seven day look-back period. A Progress note, dated 04/18/25 at 6:00 a.m., showed Resident #1 had wandered/paced three times that shift. An Elopement Risk Assessment, dated 04/18/25 at 2:49 p.m., showed Resident #1 was at risk for elopement. The assessment showed the resident wandered aimlessly or was non-goal-directed. On 04/20/25 at 3:03 p.m., ADON #1 reviewed Resident #1's MDS and progress note for the ARD of 4/18/25. They stated section E0900 was not accurately coded because the resident Went out the door.

Based on record review and interview, the facilty failed to review and revise the care plan for 1 (#1) of 3 sampled residents whose care plans were reviewed for elopement. The administrator identified 41 residents resided in the facility. Findings: A policy titled Comprehensive Care Plans, dated 03/24/25, read in part, Resident specific interventions that reflect the residents' needs.The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. An incident report for elopement for Resident #1, dated 04/15/25, read in part, Call received from maintenance staff the resident was in the back of the building ambulating across the parking lot. Maintenance staff stayed with resident until nursing staff reached [them] and assisted [them] back into the facility without incident. A head to toe assessment was performed with no noted injuries or distress. Video was reviewed, resident was shown leaving through the ambulance door on East Wing without door alarm sounding.INTERVENTIONS: 15 minute visual checks on resident and hourly checks on door alarms initiated immediately. A Care Plan, initiated 12/01/24, with a target date of 02/19/25, showed a risk for elopement problem listed. The care plan did not show the incident or any interventions added or changed for the incident on 04/15/25. On 04/30/25 at 1:49 p.m., ADON #1 stated care plans were to be updated with any changes needed and with anything new or changed. ADON #1 looked through Resident #1's care plan and progress notes and stated there was not a new update on the care plan for the elopement attempt and did not locate the same incident from 04/15/25 on the care plan. ADON #1 stated they did not add the every fifteen minute resident checks or the hourly door checks.

Based on record review and interview, the facility failed to ensure a resident's POA was included in their clinical record for 1 (#13) of 16 sampled residents reviewed for advance directives. The administrator identified 38 residents resided in the facility. Findings: Resident #13 had diagnoses which included cognitive communication deficit and atrial fibrillation. Resident #13's Advance Directives Acknowledgement form, dated 08/21/23, read in part, I do have an Advance Directive/ Living Will/ Durable Power of Attorney for medical or health care decisions. Resident #13's clinical record did not contain a copy of their POA. A Residents' Rights Regarding Treatment and Advance Directives policy, dated 03/24/25, read in part, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives .Advance Directive is a written instruction, such as a living will or durable power of attorney .On admission, the facility will determine if the resident has executed an advance directive .should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. On 03/26/25 at 10:58 a.m., the SSD stated Resident #13 had a POA. They stated the facility did not have a copy, and the resident's family was contacted that day and would bring a copy up to the facility. The social service director stated in the admission paperwork, they would review advance directives with the resident/family. They stated they would ask if they had a POA, and if they did, they would get a copy of the POA. They stated a POA was effective in the event a resident was unable to make health care decisions for themselves, they could appoint someone to make decisions on their behalf. The social service director stated they believed Resident #13's family member was POA for medical and financial.

Based on record review and interview, the facility failed to ensure advance beneficiary notices were provided for 2 (#140 and #141) of 3 sampled residents who were reviewed for beneficiary notices. The Beneficiary Notice - Residents discharged within the Last Six Months form, showed 12 residents who were discharged to home with skilled days remaining in the last six months. Findings: A facility policy titled [NAME] Living Center-Advanced Beneficiary Notices, dated 02/17/22, read in part, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .If services are being terminated and the beneficiary wants to continue receiving care that is no longer considered medically reasonable and necessary, the facility shall issue an ABN prior to furnishing non-covered care. 1. The Beneficiary Notice - Resident Discharge Within the Last Six Months form, showed Resident # 140 was discharged from skilled services, had skilled days remaining, and discharged home. Resident #140's EHR showed they were admitted on part A Medicare services on 01/28/25 and discharged from part A services to home on 02/27/25. The SNF Beneficiary Protection Notification Review form, showed Resident #140 was discharged from skilled services on 02/27/25 and the resident or resident representative had not been provided an ABN. 2. The form Beneficiary Notice - Resident Discharge Within the Last Six Months form, showed Resident # 141 was discharged from skilled services, had skilled days remaining, and discharged home. Resident #141's EHR showed they were admitted on part A Medicare services on 01/27/25 and discharged from part A services to home on 02/03/25. The SNF Beneficiary Protection Notification Review form, showed Resident #141 was discharged from skilled services on 02/03/25 and the resident or resident representative had not been provided an ABN. On 03/26/25 at 10:17 a.m., the MDS coordinator stated Resident #140 and Resident #141 ABN's were not signed. The MDS coordinator stated if they were not signed by a resident or resident representative, it did not indicate the residents received an ABN notice. On 03/26/25 at 12:59 p.m., the BOM stated they were responsible for completing the ABNs . They were asked why Resident #140 and Resident #141 did not receive the ABN's. They stated, I put them on my desk and never got to them. On 03/31/25 at 8:17 a.m., the BOM was asked what dates did Resident #140 start skilled part A Medicare services. They stated Resident #140's part A Medicare services started on 01/28/25 and part A ended on 02/27/25. The BOM stated Resident #141 started Medicare part A on 01/27/25 and services ended 02/03/25.

Based on record review and interview, the facility failed to implement their abuse policy by not: a. conducting a complete and thorough investigation; b. establishing coordination with the QAPI program; c. reporting to the OSDH within 2 hours of the allegation of abuse; and d. assess the residents for any sign of injury for 2 (#1 and #23) of 2 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/22, read in part, The facility will develop an implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property; b. Established policies and procedures to investigate any such allegations; and c. Include training for new existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI program .an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . 4. Identifying and interviewing, all involve persons, including the alleged victim, alleged, perpetrator, witnesses, and others who might have knowledge of the allegation . 6. Providing complete and thorough documentation of the investigation . 1. Reporting of all alleged violations to Administrator, state agency, adult protective services, and to all other required agencies within Specified timeframe: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury . B. Examining the alleged victim for for any sign of injury, including a physical examination or psychosocial assessment if needed. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, dysphagia, and cognitive communication deficit. The facility's QAPI binder was reviewed 08/01/24 through 03/26/25. The QAPI binder showed the QAPI committee met monthly and did not QAPI any abuse allegations. Resident #1's annual assessment, dated 12/08/24, showed Resident #1's BIMS score was 03 and they were dependent on staff for showers and baths. An OSDH form 283, combined initial and final report, dated 08/26/24, showed an allegation of abuse was made on 08/26/24 alleging CNA #3 pushed Resident #1 aggressively to the shower. The report showed after the shower, CNA #3 reported to nurse they had scratches on their arm inflicted by Resident #1. The report showed Resident #1 had no history of aggression or violence and Resident #1 stated CNA #3 made them feel uncomfortable. A facsimile confirmation, dated 08/27/24 at 10:45 a.m., showed OSDH received form 283, combined initial and final report, the following business day. The report was not reported within two hours. There was no documentation in Resident #1's electronic health record: a. a complete and thorough investigation was conducted; b. abuse allegation was coordinated with the QAPI program; c. the abuse allegation was reported to OSDH within two hours; and d. the resident was assessed for physical and psychosocial harm. On 03/26/25 at 2:13 p.m., CNA #4 was asked about the abuse allegation on 08/26/24. CNA #4 stated CNA #3 came out of the shower room with scratches on their arms and face and CNA #3 stated they were not going to do that shower because they were not going to be scratched by Resident #1. CNA # 4 stated they heard screaming, but Resident #1 screamed in the shower as a base line. CNA #4 stated they reported to the DON immediately and the incident occurred on 08/26/24 around 8:30 p.m. On 03/26/25 at 2:29 p.m., the administrator stated they never QAPI abuse allegations. The administrator stated, If its our staff member and its substantiated they are terminated. If its unsubstantiated after the investigation, I would do a one on one and bring them back to work and no in-service was conducted after this event. On 03/26/25 at 3:05 p.m., the DON was asked about the incident on 08/26/24. The DON stated they witnessed CNA #3 push Resident #1 rough in a wheelchair, but thought it was due to the resident's weight. The DON stated after the shower Resident #1 scratched CNA #3 because the CNA was not being patient with Resident #1 in the shower. The DON was asked what the policy was when an abuse allegation was made. The DON stated we suspend the employee immediately and we do an investigation. The DON stated they did not do safe surveys with other residents. The DON was asked when an abuse allegation was made, when should it be reported to OSDH. The DON stated they could not recall. The DON was asked if they QAPI the abuse allegations. The DON stated they had never did QAPI on abuse even at other facilities. The DON stated did not do in service training and probably should have. The DON stated the physician notification should be in an internal report and the incident was not reported in two hours to OSDH. They DON stated the incident was reported within twenty four hours due to resident not being harmed. The DON stated documentation the resident was assessed after the incident should be in the resident's electronic health record. On 03/26/25 at 3:36 p.m., the administrator stated the DON did not conduct an investigation after the incident, complete safe surveys with other residents, and document the physician was notified after the incident in the residents electronic health record. On 03/27/25 at 8:23 a.m., ADON #2 was asked what should happen after an allegation of abuse was made. ADON #2 stated a state reportable should be completed, the administrator, doctor, and family notified, a full assessment of the resident head to toe for seventy two hours every shift for thee days, and they should assess physical and emotional possible outcome. ADON #2 was asked what Resident #1's full head to toe assessment documented. ADON #2 stated there was no assessment completed after the event with the exception of a weekly skin assessment that was completed on 08/29/24. ADON #2 was asked where it was documented the physician was notified. ADON #2 stated it was not documented the physician was notified. ADON #2 was asked about the investigation after the incident. ADON #2 stated there was no documentation an investigation was conducted. ADON #2 was asked when was the report of abuse was made to the OSDH. ADON #2 stated it was reported on 08/27/24 at 10:44 a.m. and they spoke with NP who stated they were notified after the fact. On 03/27/25 at 8:44 a.m., the NP was asked if they were notified after the abuse allegation on 08/26/24. They stated they were not notified at the of the time of the event, but thought it was a week later. 2. On 03/27/25 at 1:31 p.m., Resident #23 was admitted on [DATE] with diagnoses of cerebral infarction, hyperlipidemia, abnormal posture, and muscle wasting disease. Resident #23 admission assessment, dated 01/22/25, showed Resident #23's BIMS score was 13 indicating their cognition was mildly impaired and they required assistance to transfer from bed to chair. An OSDH 283 form, dated 02/19/25, showed Resident #23 alleged CNA #2 was rough during a shower and hit and sprayed water in their face. The form showed interviews were conducted with four other residents with one resident of CNA #2 being rough. The form showed employees were interviewed and was stated that that CNA #2 was noted to have an angry effect at time and CNA #2 was terminated. On 03/27/25 at 1:48 p.m., CNA #5 was asked about the incident. They stated the resident stated CNA #2 came into change their room and was mad resident asked to go to the restroom and alleged CNA #2 was rough and slung them to a chair during a transfer and almost hit their head. On 03/27/25 at 2:04 p.m., SSD was asked about the event involving Resident #23. The SSD stated CNA #2 was alleged to be rough during a transfer and almost hit the resident's head on a table. The SSD stated the CNA was suspended then terminated. The SSD was asked about the QAPI program and abuse. The SSD stated they were on the QAPI committee and they never QAPI any abuse. 03/27/25 1:15 p.m., the administrator stated they had never completed QAPI on any abuse, but recently saw it in their policy they should.

Based on record review and interview, the facility failed ensure an allegation of abuse was reported immediately to the state agency, but no later than two hours after the allegation was made for 1 (#1) of 2 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/22, read in part, 1. Reporting of all alleged violations to Administrator, state agency, adult protective services, and to all other required agencies within Specified timeframe: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, dysphagia, and cognitive communication deficit. Resident #1's annual assessment, dated 12/08/24, showed Resident #1's BIMS score was 03 and they were dependent on staff for showers and baths. An OSDH form 283, combined initial and final report, dated 08/26/24, showed an allegation of abuse was made on 08/26/24 alleging CNA #3 pushed Resident #1 aggressively to the shower. The report showed after the shower, CNA #3 reported to nurse they had scratches on their arm inflicted by Resident #1. The report showed Resident #1 had no history of aggression or violence and Resident #1 stated CNA #3 made them feel uncomfortable. A facsimile confirmation, dated 08/27/24 at 10:45 a.m., showed OSDH received form 283, combined initial and final report, the following business day. The report was not reported within two hours. On 03/26/25 at 2:13 p.m., CNA #4 was asked about the abuse allegation on 08/26/24. CNA #4 stated CNA #3 came out of the shower room with scratches on their arms and face and CNA #3 stated they were not going to do that shower because they were not going to be scratched by Resident #1. CNA # 4 stated they heard screaming, but Resident #1 screamed in the shower as a base line. CNA #4 stated they reported to the DON immediately and the incident occurred on 08/26/24 around 8:30 p.m. On 03/26/25 at 3:05 p.m., the DON was asked about the incident on 08/26/24. The DON stated they witnessed CNA #3 push Resident #1 rough in a wheelchair, but thought it was due to the resident's weight. The DON stated after the shower Resident #1 scratched CNA #3 because the CNA was not being patient with Resident #1 in the shower. The DON was asked what the policy was when an abuse allegation was made. The DON stated the incident was not reported in two hours to the OSDH and was reported within 24 hours due to resident not being harmed. On 03/27/25 at 8:23 a.m., ADON #2 was asked what should happen after an allegation of abuse was made. ADON #2 stated a state reportable should be completed, the administrator, doctor, and family notified, a full assessment of the resident head to toe for seventy two hours every shift for thee days, and they should assess physical and emotional possible outcome. ADON #2 was asked when was the report of abuse was made to the OSDH. ADON #2 stated it was reported on 08/27/24 at 10:44 a.m. which was the following morning after the allegation.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 (#1) of 2 sampled residents reviewed for abuse and neglect. The administrator identified 38 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/22, read in part, The facility will develop an implement written policies and procedures that: . 4. Identifying and interviewing, all involve persons, including the alleged victim, alleged, perpetrator, witnesses, and others who might have knowledge of the allegation . 6. Providing complete and thorough documentation of the investigation. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, dysphagia, and cognitive communication deficit. Resident #1's annual assessment, dated 12/08/24, showed, Resident #1's BIMS score was 03 and they were dependent for showers and baths. An OSDH form 283, combined initial and final report, dated 08/26/24, showed an allegation of abuse was made on 08/26/24 alleging CNA #3 pushed Resident #1 aggressively to the shower. The report showed after the shower, CNA #3 reported to nurse they had scratches on their arm inflicted by Resident #1. The report showed Resident #1 had no history of aggression or violence and Resident #1 stated CNA #3 made them feel uncomfortable. On 03/26/25 at 2:13 p.m., CNA #4 was asked about the abuse allegation on 08/26/24. CNA #4 stated CNA #3 came out of the shower room with scratches on their arms and face and CNA #3 stated they were not going to do that shower because they were not going to be scratched by Resident #1. CNA # 4 stated they heard screaming, but Resident #1 screamed in the shower as a base line. CNA #4 stated they reported to the DON immediately and the incident occurred on 08/26/24 around 8:30 p.m. On 03/26/25 at 3:05 p.m., the DON was asked about the incident on 08/26/24. The DON stated they witnessed CNA #3 push Resident #1 rough in a wheelchair, but thought it was due to the resident's weight. The DON stated after the shower Resident #1 scratched CNA #3 because the CNA was not being patient with Resident #1 in the shower. The DON was asked what the policy was when an abuse allegation was made. The DON stated we suspend the employee immediately and we do an investigation. The DON stated they did not do safe surveys with other residents. There was no documentation in Resident #1's electronic health a complete and thorough investigation was conducted. On 03/26/25 at 3:36 p.m., the administrator was asked to provide documentation of an investigation on the abuse allegation. They stated the DON did not complete safe surveys or conduct an investigation after the incident and they should of completed safe surveys with other residents. On 03/27/25 at 8:23 a.m., the ADON #2 was asked about the investigation after the incident. ADON #2 stated there was no documentation an investigation was conducted.

Based on observation, record review and interview the facility failed to ensure residents received their baths/showers as scheduled for 1 (#25) of 1 sampled resident reviewed for activities of daily living. The administrator identified 38 residents resided in the facility. Findings: On 03/25/25 at 10:44 a.m., Resident #25 was observed with a medium length beard, hair combed, dressed in a long sleeve shirt, with long pants, and no odors present. A Bathing a Resident policy, dated 01/2022, read in part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Resident #25 had diagnoses which included stage 4 chronic kidney disease and bilateral primary osteoarthritis of knee. An admission resident assessment, dated 03/12/25, showed Resident #25's cognition was intact (BIMS 15), and they required supervision or touching assistance for the task of shower/bathe self. The assessment showed it was very important to Resident #25 to choose between a tub bath, shower, bed bath, or sponge bath. An undated shower schedule showed Resident #25 was to receive a shower during the evening shift on Saturdays, Tuesdays, and Thursdays. Bathing records for March 2025 showed Resident #25 was to receive bathing assistance every Sunday, Tuesday, and Thursday on the 2-10 p.m. shift. The record showed a not applicable for bathing on the 16th and 30th. There was no bath/shower documented for Saturdays during the month. There were baths/showers documented for Sunday on the 2nd, 9th and 23rd. On 03/25/25 at 10:23 a.m., Resident #25 stated they required assistance for a shower and were having trouble getting bathed at the facility. They stated they had made two separate requests and the staff failed to show up both times. They stated they believed the last time they received a bath or shower was more than a week ago. On 03/31/25 at 2:11 p.m., CNA #4 stated the facility had an assignment sheet that told them what days residents received bathing assistance. On 03/31/25 at 2:12 p.m., CNA #4 stated they had shower skin assessment sheets on paper they would fill out. They stated if a resident refused, they would have the resident sign the sheet. They stated they also charted in the electronic record. They stated if a resident refused, it would also be charted electronically as refused. On 03/31/25 at 2:14 p.m., CNA #4 stated they were told never to chart not applicable because you either gave a bath/shower, or you did not. They stated they had only provided bathing assistance once for Resident #25 which they refused. They stated they had not been assigned their shower since. On 03/31/25 at 2:15 p.m., CNA #4 stated Resident #25 was scheduled to receive bathing assistance on the evening shift on Saturday, Tuesday, and Thursday. On 03/31/25 at 2:41 p.m., CNA #6 stated there was a bathing schedule located in a binder at the front. They stated staff were assigned residents to assist with bathing and would ensure the proper number of staff were present for safe transfers. On 03/31/25 at 2:42 p.m., CNA #6 stated they would chart bathing assistance was provided electronically and they also had bathing sheets where they would document whether a resident refused and what services were provided such as washed hair. On 03/31/25 at 2:43 p.m., CNA #6 stated if a resident refused bathing assistance, they would re-approach later and if they still refused they would ask the nurse to try, if they still refused, they would ask them to sign refused on the shower sheet. CNA #6 stated they did not know the reason staff would document not applicable because they could chart refused or not available if the resident was not in the facility. On 03/31/25 at 2:44 p.m., CNA #6 stated they had only assisted Resident #25 once with bathing. They stated the resident could complete all areas of bathing themselves except their back side. On 03/31/25 at 2:45 p.m., CNA #6 stated they did not know if Resident #25 ever refused a bath/shower. On 03/31/25 at 2:47 p.m., ADON #2 stated if staff were unfamiliar with residents, they could reference the clinical record to identify what bathing assistance they required. They stated there were bathing assignment sheets for staff. ADON #2 stated staff documented a bath/shower was provided in the clinical record. They stated if a resident refused bathing assistance, staff would offer again three different times by different staff members. On 03/31/25 at 2:49 p.m., ADON #2 stated staff should not be documenting not applicable for bathing. On 03/31/25 at 2:50 p.m., ADON #2 stated Resident #25 required limited physical help for transfers and supervision oversight for bathing. They stated the resident was scheduled to receive bathing assistance every Sunday, Tuesday, and Thursday on the evening shift.

Based on observation, record review and interview, the facility failed to ensure wound care was provided as ordered for 1 (#4) of 2 sampled residents reviewed for non pressure wounds. ADON #1 identified six residents with non pressure wounds resided in the facility. Findings: On 03/26/25 at 1:30 p.m., Resident #4 was observed in the horse shoe activity. The resident was observed to have ace wrap dressings to their bilateral lower legs and shoes and socks to their bilateral feet. A clean dressing change policy, dated 01/2022, read in part, It is the policy of this facility to provide wound care in a manner to decrease potential for infection .Physician's orders will specify type of dressing and frequency of changes. Resident #4 had diagnoses which included a full thickness venous ulcer. Resident #4's current wound care order, dated 03/05/25 with a start date of 03/12/25, showed a wound care order for the left posterior lower leg venous wound: cleanse with wound cleanser, pat dry with gauze, apply collagen powder, super absorbent pad, wrap with four layer wrap once weekly and prn every day shift on Wednesday. A wound care progress note, dated 03/12/25, showed Resident #4 had a full thickness venous ulcer of the left posterior lower leg which measured 2 cm length x 3 cm width x 0.1 cm depth. The note showed wound orders: cleanse wound with wound cleanser, apply collagen, apply Medihoney to eschar area, cover with super absorbent dressing and four layer compression dressing. The note showed the wound care was to be provided weekly and as needed. The note showed Added Medihoney to current treatment plan and was signed by the wound care physician. There was no documentation the medihoney wound care was implemented. A wound care progress note, dated 03/19/25, showed Resident #4 had a full thickness venous ulcer of the left posterior lower leg with post debridement measurements: 1.6 cm length x 1.5 cm width x 0.1 cm depth. The note showed wound orders: cleanse wound with wound cleanser, apply alginate, cover with super absorbent dressing and four layer compression dressing. The note showed the wound care was to be provided weekly and as needed. The note was signed by the wound care physician. There was no documentation the alginate wound care was implemented. On 03/26/25 at 9:03 a.m., Resident #4 was able to answer yes/no questions. They stated they had a wound on their foot and they were not sure if it was getting better. On 03/27/25 at 1:25 p.m., LPN #2 stated staff put a four layer dressing to Resident #4's left leg and wound care was provided weekly. They stated ADON #1 completed weekly wound care rounds with the wound care physician. They stated the floor nurses would provide prn dressing changes. LPN #2 stated the resident's wound was measured weekly by the wound care physician. They stated the resident had a lot of swelling that affected wound healing. They stated staff encouraged the resident to elevate their legs. LPN #2 stated the wound care physician ordered wound care for the resident and ADON #1 put the wound care orders into the electronic record. On 03/27/25 at 1:29 p.m., LPN #2 stated the wound care order on the wound progress note dated 03/12/25 showed wound cleanser, apply collagen, apply Medihoney to eschar area, use maxorb super absorbent dressing and a four layer compression weekly and prn for saturation. On 03/27/25 at 1:31 p.m., LPN #2 was unable to locate the Medihoney being implemented for the wound care physician's order on 03/12/25. On 03/27/25 at 1:36 p.m., LPN #2 stated the wound care order on the wound progress note dated 03/19/25 showed cleanse left posterior lower leg wound with wound cleanser, apply alginate, cover with super absorbent dressing, compression four layer dressing once weekly and prn for soiling or saturation. They stated alginate and collagen were not the same thing. LPN #2 was unable to show the alginate dressing was implemented. On 03/27/25 at 1:38 p.m., ADON #1 stated Resident #4's venous wound to the left leg was improving. On 03/27/25 at 1:39 p.m., ADON #1 stated wound care was provided once weekly with a four layer compression wrap and prn. They stated they completed the dressing change when they rounded with the wound care physician. On 03/27/25 at 1:43 p.m., ADON #1 stated they along with the charge nurses were responsible for ensuring wound care orders were implemented. They stated they usually put the orders in and notified the charge nurses with any new orders. ADON #1 reviewed the 03/12/25 wound care note and stated the note said added medihoney, but the physician verbally told them to do calcium alginate. ADON #1 acknowledged the wound care on the wound care note showed apply collagen, apply Medihoney to eschar area, apply super absorbent dressing and four layer compression change once weekly and prn. On 03/27/25 at 1:48 p.m., ADON #1 stated they did not believe the Medihoney was ever implemented. They reviewed the wound care note dated 03/19/25 and stated the orders were to cleanse the wound with wound cleanser, apply alginate, super absorbent dressing, and four layer compression once weekly and prn. On 03/27/25 at 1:50 p.m., ADON #1 stated alginate and collagen were not the same thing. They stated Resident #4's wound care order was dated 03/12/25 and showed cleanse with wound cleanser, pat dry, apply collagen powder, super absorbent dressing, and wrap with four layer compression dressing once weekly and prn.

Based on record review and interview, the facility failed to ensure side effect of monitoring was in place for a resident who was prescribed anticoagulant therapy for 1 (#22) of 5 residents sampled for unnecessary medication. The ADON identified three residents were prescribed anticoagulant medication. Findings: An undated facility policy titled Medication Monitoring, read in part, This facility takes a collaborative, systematic approach to medication management, including the monitoring of medication's for efficacy and adverse consequences .'Adverse Consequence' refers to unwanted, unintended, or dangerous effects that a drug may have, such as impairment or decline in an individual mental or physical condition or functional or psychosocial status. Resident #22 was admitted on [DATE] with diagnoses which included schizoaffective bi-polar type and cognitive communication deficit. Resident #22's annual assessment, dated 01/17/24, showed their BIMS score was 15 and they were prescribed an anticoagulant medication. Resident #22's physician orders, dated 10/25/21, showed Resident #22 was prescribed Eliquis tablet 5 mg two times a day for anticoagulant therapy. The physician orders did not document side effect monitoring for anticoagulant therapy. Resident #22's TAR, dated 03/01/25 through 03/31/25, showed Resident #22 was receiving an anticoagulant medication two times a day. The TAR did not document side effect monitoring for anticoagulant therapy. On 03/31/25 at 1:15 p.m., ADON #2 was asked what was the facility's policy for monitoring side effects for residents who were prescribed anticoagulants. ADON #2 there should be side effect monitoring on the TAR. ADON #2 asked what anticoagulant medication was Resident #22 prescribed. ADON #2 stated Resident #22 was prescribed Eliquis 5 mg two times a day. ADON #2 was asked where was side effect monitoring for Resident #22. ADON #2 stated there was no side effect monitoring for anticoagulant therapy in Resident #22 physician orders or on the TAR.

Based on observation, record review, and interview, the facility failed to utilize a gait belt when assisting a resident in a geriatric chair for one (#2) of one sampled resident observed being positioned during the lunch meal service. The Administrator identified 39 residents resided in the facility. Findings: A Use of Gait Belt policy, dated 01/2022, read in part, .It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety .Each nursing department employee will be given a gait belt during orientation .All employees will receive education on the proper use of gait belt during orientation and annually . A Turning and Repositioning policy, dated 01/22, read in part, .Repositioning techniques in bed .To minimize friction and shear, use sheets or lift equipment to avoid pulling or dragging . Resident #2 had diagnoses which included dementia and cognitive communication deficit. A quarterly assessment, dated 10/27/23, documented Resident #2 had severe cognitive impairment, and they required substantial/maximal assistance for the task of sit to stand, lying to sitting on side of bed, chair/bed-to-chair transfer and toilet transfer. It documented the resident required partial/moderate assistance for the task of roll to left and right, and sit to lying. On 11/20/23 at 12:03 p.m., LPN #1 was observed putting their arm under the left arm of Resident #2 while CNA #2 placed their arm under the right arm of Resident #2 who was seated in a geriatric chair located in the assisted dining room. Both LPN #1 and CNA #2 grabbed the upper portion of the back of Resident #2's pants and hoisted the resident up in the geriatric chair. No gait belt was used during the repositioning of Resident #2. On 11/20/23 at 12:20 p.m., LPN #1 was asked the policy for assisting a resident with sitting up further in the geriatric chair. They stated, Are we supposed to use a gait belt, let me think. LPN #1 was observed pointing to the gait belt they had around their body. CNA #1 stated they always did a two person assist under the arm. LPN #1 stated at a bare minimum it should be a two person assist. On 11/20/23 at 12:21 p.m., LPN #1 stated they used gait belts when they were getting anyone out of the chair, or getting them to stand up. On 11/21/23 at 8:54 a.m., the DON stated staff should use gait belts when getting a resident up and when trying to reposition a resident. On 11/21/23 at 8:56 a.m., the DON stated each employee was given a gait belt and provided education on gait belts. They stated the gait belt should be available at all times, and was used to help residents ambulate or transfer for safety. They stated if a resident was being assisted to move by two staff members in a geriatric chair, staff should use a gait belt.

Based on observation and interview, it was determined the facility failed to ensure the removal of expired medications and supplies from the medication storage room and medication cart. This had the potential to affect all 39 residents who resided in the facility. Findings: On 10/12/22 at 9:45 a.m., the medication room was observed. Expired medications and supplies were found in the facility's medication room refrigerator and medication storage room for the following. 1. 9- [MEDICATION(S)] suppositories with an expiration date of 09/2022. 2. 7- [CONDITION(S)] vaccines with an expiration date of 03/01/22. 3. 1- Box [NAME] 20cc syringes with an expiration date of 11/01/21. 4. 14- BD Safety-Lok 3ml syringes with an expiration date of 06/29/21. 5. 10- [NAME] Prevent Syringes with Safety [MEDICATION(S)] Needle 3cc/23gauge with an expiration date of 03/31/22. 6. 2- Entra-Flo Gastrostomy Feeding Tubes with an expiration date of 08/06/22. 7. 2- Boxes adhesive remover wipes with an expiration date of 02/16/21. 8. 1- Box Inter-dry moisture wicking fabric with antimicrobial silver With an expiration date of 05/2022. On 10/12/22 at 3:24 p.m., RN #1 was asked if expired medications and supplies should have been removed from the medication room. They stated Yes. On 10/13/22 at 8:45 a.m., the medication cart was observed with CMA #1. 1. 1- Bottle of [NAME] 81mg aspirin [MEDICATION(S)] coated with expiration date of 09/2022. On 10/13/22 at 8:54 a.m., CMA #1 was asked if expired medication should have been removed from the cart. They stated Yes.

A past noncompliance Immediate Jeopardy situation was determined to exist effective 12/01/20 related to failure to implement weekly wound and skin assessments for a resident who was non weight bearing (left foot) and implement interventions to prevent pressure ulcers for a resident who was at risk for pressure ulcers. Res #3 was admitted with a left trimalleollar fracture with surgical repair and was non weight bearing for 12 weeks. On 12/01/20 the facility identified a wound on Res #3's right heel. There was no wound assessments or measurements conducted until 12/14/20. Res #4 had no pressure reducing interventions implemented prior to aquiring a Stage IV pressure ulcer. On 04/29/22 at 2:15 p.m., the Oklahoma State Department of Health verified the existence of a past noncompliance IJ. The past noncompliance IJ was removed effective 02/02/22 after the facility initiated weekly wound and skin assessments on residents who have or were at risk for pressure ulcers, and implemented pressure ulcer prevention interventions. Based on record review, observation, and interview the facility failed a. to complete weekly wound and skin assessments for one (#3) of three sampled residents reviewed for wound care and, b. to develop a care plan and implement interventions to prevent pressure ulcers for one ( #4) of three samped residents reviewed for wound care. The DON identified three residents with pressure wounds, and one resident with a surgical wound. Findings: A Policy and Procedure titled Documentation of Wound treatments, undated, read in parts, .Wound assessment? are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .Wound treatments are documented at the time of each treatment. If no treatment is due an indication of the status of the dressing shall be documented each shift (i.e., clean, dry, intact) . A Policy and Procedure titled, Skin Assessment, undated, read in part, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . 1. Res #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A document titled, Skin Only Evaluation, dated 11/11/20, read in part: .Skin issue #1 .surgical wound .left calf 17x0.1x.0 .wound exudate none .peri wound condition normal .dressing saturation none . Skin Issue #4 .Pressure Ulcer/Injury .right wrist .2.5 x 3.25 x0 .wound bed granulation .wound exudate serous drainage .Dressing saturation .< 25% . Skin Issue #5 .laceration .left shin .1.5 x 0.3 x 0.5 .wound bed granulation .wound exudate serous . Skin Issue #6 .laceration .Left shin 1 x 0.4 x 0.5 .wound bed granulation .wound exudate none . Skin issue #7 .Laceration .medial ankle 1x0.3x0.5 .wound exudate none . Skin Issue #8 .Laceration .left calf 1x0.5 x 0 .wound exudate none . Skin issue #9 .Other skin issue .Dry scaly patches .right foot no measurements . Skin Issue #10 .Other skin issue .dry scaly patch .right distal shin 3.5x4x0 . Skin Issue #11 .Other skin issue .Dry scaly patches .right distal shin 2x1.5x0 . A Braden skin assessment, dated 11/12/20, documented Res #3 was not at risk for pressure ulcers. Res #3's Care Plan, dated 11/15/20, read in part, .Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Date initiated .12/15/20 .Pressure relieving mattress to .bed at all times . A five day assessment, dated 11/17/20, read in part, .no pressure ulcer/injury, a scar over bony prominence, or a non removable dressing/device. At risk for pressure ulcers, no unhealed pressure ulcers, identified surgical wound. Pressure relieving device for chair, and bed . Identified Res #3 was cognitively intact and needed extensive assist of two staff for transfers and extensive assist of one staff for hygiene and bathing. Resident was non-weight bearing for 12 weeks due to surgical repair on his left ankle. A Physician Order, dated 11/23/20, read in part, .Adjust and or remove boot as needed. Wear boot as much as possible and remove for bathing only A Nurse Progress Note, dated 11/24/20 at 9:03 a.m., read in part, .New order faxed over from [doctor] to wear boot to LLE as much as possible . A Skin Only Evaluation, dated 11/27/20, read in part, .excoriation lower back buttocks and scrotum . There was no documentation of the multiple skin issues that were identified on the admission skin evaluation. A nurse Progress Note, dated 12/01/20, read in part, .NO to right heel . A nurse Progress Note, dated 12/01/20, read in part .Clean right heel with NS pat dry, apply nickel thick santyl to eschar. Apply skin prep to peri wound and cover with dynoderm cover with sterile gauze, secure with tape on 6-2 and PRN . No wound care assessment was completed at the time the wound was identified. A nurse Progress Note, dated 12/06/20, read in part, .During wound care treatment residents right heel was noted to have a moderate amount of seropurulent drainage with dark tissue observed in wound bed, a foul odor was also noted . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 800-160 .Give one tablet by mouth two times a day for Right heel infection for 7 days until finished . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse right heel with NSS, pat dry, Apply nickel thick Santyl, and calcium alginate to open area. Cover with ABD pad, Wrap with roll gauze and secure with tape. Change QD and PRN soilage. as needed AND one time a day Right heel wound . A Physicians Order, dated 12/09/20, read in part, .PT wound care .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .URGENT REFERRAL!!! PATIENT HAS SKIN NECROSIS OF HIS LEFT ANKLE AND MAY NEED SKIN GRAFTS . A nurse Progress note, dated 12/09/20 at 3:35 p.m., read in part .Orders received from [ortho doctor] to continue with non weight bearing status to LLE, continue wound care, [family member] called and stated .had made an appointment with .wound care for 12/10/20 .Clinic stated [family member] had not told them that [Res #3] was admitted for skilled services and they cannot see him while he remains on skilled services, conference call with [LPN #1], [social services] and [family member] discussed with [family member] that wound clinic is unable to see [Res #3] d/t him being on skilled at this time .awaiting f/u appointment with [ortho doctor] . A nurse Progress note, dated 12/09/20 at 4:36 p.m., read in part, .Adjust or remove boot as needed. Wear boot as much as possible and remove for bathing every shift for fx Boot held r/t wound . A document titled, Wound or Injury Care Tracker Chart dated 12/14/20, read in part, .L leg and inner 9x7x0.3 UTD 100% black/tan .R heel 3x3x0.2 pressure UTD .L above heel 7.75 x 3 x 0.2 pressure UTD . A Skin Only Evaluation, dated 12/14/20, read in part: .Skin Issue #1 .Pressure Ulcer/Injury .Left lower leg inside .9.0 x 7.0 x 0.3 .wound bed necrotic .dressing saturation moderate 26-75% .wound odor yes . Skin Issue #2 .Pressure Ulcer/Injury .back of left foot .7.75cm x 3 cm x 0.2 cm .purulent .dressing saturation moderate 26-75% .wound odor yes . Skin Issue #3 .Pressure Ulcer/Injury .right heel .3cm x 3cm x 0.2cm .purulent .Dressing saturation moderate 26-75% .wound odor yes .Painful . No weekly wound or skin assessments were completed from 11/11/20 to 12/14/20 which addressed pressure ulcers or surgical wounds. A Physicians Progress Note, dated 12/14/20, read in part, .Nursing reports that [Res #3] has bilateral heel wounds that are without sign or symptoms of infection . A Physician order, dated 12/14/20, read in part, .Cleanse right heel with NSS, pat dry. Apply nickel thick Santyl and cover with hydrogel to open area. Cover with ABD pad, Wrap with rolls gauze and secure with tape. Change QD and PRN soilage . A Skin Only Evaluation, dated 12/18/20, read in part, .Skin Issue #1 .Other skin issue .right forearm .purulent .moderate 36-75% . A nurses Progress Note, dated 12/19/2020 at 8:59 p.m., read in part .Full body evaluation performed with a new open area observed to his upper right buttock appx. the size of a quarter. On call physician notified and aware with new orders given to cleanse open area with NSS, pat dry and apply ultra thin duoderm every 3 days and PRN soilage . A Physicians Progress Note, dated 12/21/20, read in part, .Nursing staff reports [Res #3] has wounds that are without signs and symptoms of infection . A Skin Only Evaluation, dated 12/21/20, read in part: .Skin Issue #1 .Pressure Ulcer/Injury .right heel .3 cm x 4 cm x 0.2 .wound exudate .purulent .wound odor yes .Painful . Skin Issue #2 .Pressure Ulcer/Injury .Left ankle .9cm x 7.5 cm x 0.3m .maceration .wound odor yes .painful . Skin Issue #3 .PressureUlcer/Injury .left back foot .7.5 cm x 3.2 x 0.2 .necrotic .purulent .wound odor yes .painful . A Skin Only Evaluation, dated 12/22/20, read in part: .Skin Issue #1 .Pressure Ulcer/Injury .Left foot inner ankle area .unstageable .9.0 x 8.4 x 0.8 at edge w/o eschar .necrotic .dressing saturation heavy > 75% . Skin Issue #2 .Pressure Ulcer/Injury .Left lateral ankle area .Unstageable .0.8 x 4.2 utd .wound bed necrotic .dressing saturation heavy >75% .wound odor yes .tissue mushy . Skin Issue #3 .Pressure Ulcer/Injury .Left upper heel area .7.0 x 6.5 x utd .wound bed necrotic .wound odor yes .tissue mushy . Skin Issue #4 .Pressure Ulcer/Injury .Right heel .unstageable .3.0 x 4.0 x utd .wound bed necrotic .dressing saturation heavy >75% . Skin Issue #6 .Other skin issue scab .Right 2nd toe tip .1.0 x 1.0 . Skin Issue #7 .Other skin issue .scab .Right foot 3rd toe tip .0.8 x 1.4 . A nurse Progress Note, dated 12/22/20 at 12:35 p.m., read in part, .Evaluated wounds today with charge nurse. Wounds to left outer ankle/leg and Left upper portion of heel/lower portion of Achilles tendon area have odor and large amount of serosang. drng. Called [NP] New order for [MEDICATION(S)] 500 mg tabs crush 2 tabs and place in wounds once a day x 7 days . A nurse Weekly Wound Evaluation, dated 12/23/20, read in part, .Right heel .Stage IV .necrotic tissue .100% eschar .2.8 x 4.1x UTD due to eschar .Left Lateral Heel .Stage IV .Necrotic .100 % thick adherent devitalized Necrotic Tissue .4.6 x 4.6 x UTD . A physicians note, Initial Wound evaluation & Management Summary, dated 12/23/20, read in part, .(Site 1) .Stage 4 pressure wound of the right heel .2.8 x 4.1 x not measurable cm .(Site 2) .Unstageable (Due to Necrosis) Left lateral heel .4.6 cm x 4.6 cm x not measurable .Thick adherent devitalized necrotic tissue 100% .distal lateral calf incision has putrid tissue with hardware exposure. The left lateral heel wound was debrided by the wound care physician .pick-ups were used to surgically excise 21.16 cm of devitalized tissue and necrotic tendinous and aponeurotic fibers were removed at a depth of 0.5 cm and healthy bleeding tissue was observed .Discussed goals with patient and potential risks for [CONDITION(S)], organ damage, amputatino [sic] and death. Recommend ED evaluation for labwork, imaging and surgical assessment for infected hardware and possible [CONDITION(S)] . A nurse Progress note, dated 12/23/20 at 6:32 p.m., read in part, .Wound care Dr. here to see Res was concerned [with] exposed hardware and c/o [CONDITION(S)] .sent to Hosp . The only weekly wound assessments were completed on 12/14/20 and 12/23/20. On 04/28/22 at 10:15 a.m., Res #3's weekly skin and wound assessments were reviewed with the DON. The DON was asked if there were any other weekly skin assessments completed from 11/11/20 to 11/27/20 and did the skin assessment on 11/27/20 address all of Res #3's wounds. She stated, No. The DON was asked was there a weekly wound assessment completed on Res #3. She stated, One on 12/14/20. On 04/28/20 at 11:30 a.m., LPN #1 was asked if a Braden skin assessment had been completed after Res #3 had new wounds. She stated, No. On 04/29/20 at 8:10 a.m., LPN #1 was asked what the facility did to follow the order for the urgent referral for Res #3. She stated, worked on getting him back in with [ortho specialist] and get a wound doctor in house. LPN was asked if there was any documentation of the places called for referrals. She stated, I don't know where that information is. LPN #1 was asked shouldn't it be documented in the progress notes. She stated, yes. LPN #1 was asked if the facility medical director was notified about the urgent referral for Res #3. She stated, I don't know. On 04/29/20 at 9:10 a.m., social services was asked what did the facility do to get Res #3 an appointment made for the urgent referral. She replied, she called Res #3's ortho doctor and was waiting for his office to call back for an appointment time. On 04/29/20 at 9:14 a.m., the DON was asked if the medical director was notified about the urgent referral for Res #3. She stated, I don't know. The DON was asked if the NP progress note on 12/14/20 documented Res #3 had an urgent referral. She stated, No, I don't see anything. On 04/29/22 at 1:19 p.m., the DON was asked if Res #3's weekly wound care assessment on 12/23/20 which addressed the left and right heel wounds was the only wounds documented on this assessment. She stated, Yes. 2. Res #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden skin assessment, dated 12/21/21, documented Res #4 was at risk for pressure ulcers. A Clinical Admission Evaluation, dated 12/21/21, read in part, .Skin W&D. Scabbing noted to both upper and lower extemities. No other skin issues noted. Res is non ambulatory and requires assist x2 for transferrs . There was no care plan interventions in place for prevention of pressure ulcers, prior to Res #4 developing a Stage IV wound. A Charge Nurse Weekly Skin Assessment, dated 02/01/22 at 10:50 p.m., read in part, .Res has wound to right heel unable to assess at this time r/t wound dressing see weekly wound report for details . A Physician Wound Care Telemedicine Initial Evaluation Note, dated 02/02/22, read in part, .Consult request to manage pressure injury to R heel. On examination 1.6 x 1.5 x 0.2 circumscribed Stage IV pressure injury to dorsum of R heel .necrotic wound .Necrotic tissue 60% .Slough 10% .granulation 10% .other tissue 20% . A Physician order, dated 02/03/22, read in part, .Cleanse right heel with NSS, pat dry, apply Santyl to wound bed then calcium alginate on top, wrap with Kerlix. Change QD and PRN soilage until healed . On 04/28/22 at 1:23 p.m., LPN #2 was asked when Res #4's right heel wound developed. LPN #2 stated, He got COVID. LPN #2 was asked were feet and heels routinely assessed when a daily skilled nursing assessment is completed. She replied, yes. LPN #2 was asked how Res #4 was getting skilled assessments three times a day and there was no documentation about this wound. LPN #2 stated, she was unsure. On 04/28/22 at 1:37 p.m., the DON was asked who identified the wound on 01/30/22. She stated it was identified during a skilled assessment. She stated, It was very hard to see and gotten bad because of COVID. On 04/28/22 at 2:36 p.m., LPN #1 was asked what care plan interventions were in place for Res #4 before he developed the pressure ulcer. LPN #1 reviewed the care plan and acknowledged there were no interventions in place for prevention of pressure ulcers prior to the development of right heel wound. Weekly skin assessments for Res #4 had been completed. Res #4 was referred to a wound care physician immediately after identification of right heel wound and has had weekly wound care assessments. After identification of Res #4's pressure ulcer the facility updated the care plan with pressure ulcer prevention interventions. Res #4's care plan, read in parts, .Air mattress to promote wound healing every shift 02/02/22 .Encourage good nutrition and hydration in order to promote healthier skin .Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .educate resident/family/caregivers of causative factors and measures to prevent skin injury .Weekly treatment documentation to include measurement .and exudate and any other notable changes or observation .02/07/22 .Float heels while in bed, every shift for Right Heel Wound 02/18/22 .

Based on observation, record review and interview, it was determined the facility failed to ensure: ~ residents did not have unplanned, weight loss for three (#1, 2 and #3) of three sampled residents reviewed for nutrition and weight loss; and ~ a resident received physician ordered supplements for one (#2) of three sampled residents reviewed for supplements. The facility identified 35 residents resided in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 12/08/21, documented, monitor, record and report to the physician signs/symptoms of malnutrition and significant weight loss of three pounds in one week, greater than 5% in one month, greater than 7.5% in three months and greater than 10% in six months. An admission assessment dated , 12/13/20, documented the resident was moderately impaired for daily decision making and required supervision and set-up assistance with meals. A weight log for the resident documented the resident weighed: ~193.0 pounds on 12/09/20; ~180 pounds on 01/12/21; and ~175 pounds on 03/15/21. The resident had an 18 pound weight loss in three months. A consultant dietitian recommendation form, dated 01/28/21, documented the resident had a weight loss of 6.7% in one month. The form documented she recommended the resident be weighed weekly for four weeks and be administered boost (supplement) twice a day between meals for thirty days. There was no documentation the recommendation was sent to the physician for review. On 03/19/21 at 10:56 a.m., resident #1 stated he had lost weight. He stated he did not like a lot of the food the facility served. The resident was asked if he was receiving a nutritional supplement drink. He stated no. At 11:57 a.m., the director of nursing (DON) was asked about the dietitian recommendation made on 01/28/21. She stated the recommendation had not been sent to the physician for review. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan, dated 08/21/20, documented weigh as ordered and notify the physician with variances of 5% in one month or 10% in six months. A quarterly assessment, dated 12/28/20, documented the resident was severely impaired for daily decision making and required limited physical assistance of one person for meals. A consultant dietitian recommendation form, dated 01/28/21, documented the resident had a weight loss of 5.5% in one month. The form documented she recommended the resident be administered boost twice a day between meals for thirty days. There was no documentation the recommendation was sent to the physician for review. A progress note for resident #2, dated 01/28/21, documented an annual nutrition risk assessment was completed by the dietitian. The note documented the resident was at high risk due to significant weight changes, decreased meal/fluid intake, nutrition related to medications, medical diagnosis, the need for assistance with meals and frequent incontinence. On 03/19/21 at 10:04 a.m., the minimum data set (MDS) coordinator stated after a recommendation was written it was given to the DON who was responsible for submitting it to the physician for approval. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan, dated 07/22/20, documented weigh as ordered and notify the physician with variances of 5% in one month and/or 10% in six months. An assessment, dated 01/09/21, documented the resident was severely impaired for daily decision making, and required extensive physical assistance of one person for meals. A dietitian progress note for resident #3, dated 01/28/21, documented the resident weighed 111 pounds and had significant weight loss of 9.8% in one month. The note documented the weight was obtained upon return from the hospital and boost twice a day between meals and at bedtime was recommended. There was no documentation the recommendation was sent to the physician for review. On 03/19/21 at 12:28 p.m., the DON stated the recommendation had not sent to the physician. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A dietitian recommendation, dated 02/25/21, documented four ounces of boost (supplement) twice a day between meals was recommended. The physician put an X next to the word YES. The recommendation form was signed by the physician on 03/01/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/18/21 and 03/19/21 the resident was observed sitting in a recliner or wheelchair in the common area between meals. She was not administered a supplement drink at the time of the observations. On 03/19/21 at 9:58 a.m., certified medication aide (CMA) #1 was asked if the resident was administered boost. She stated no, the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated on the MAR. At 10:18 a.m., the MDS coordinator was asked about the dietitian recommendations. She stated the dietitian made the recommendation and it became an order after it was signed by the physician. At 12:28 p.m., the DON stated the boost had not been administered as ordered by the physician.

Based on observation, record review and interview, it was determined the facility failed to implement measures to provide a safe environment to help prevent the potential development and transmission of COVID-19 by ensuring: ~ residents wore masks while in the common areas of the facility; ~ visitors were actively screened prior to visiting the residents for three (#1, 2 and #4) of three residents who were reviewed for visitors: and ~ visitors and employees were screened for all possible signs and symptoms of COVID-19. The facility identified 35 residents resided in the facility. Findings: The CDC guidance titled, Preparing for COVID-19 in Nursing Homes, documented, .Screen all HCP (health care provider) at the beginning of their shift for fever and symptoms of COVID-19 (Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea) .Screen visitors for fever for temperature of 100.0 Fahrenheit or greater and symptoms consistent with COVID-19 or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility .Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility . 1. The care plans for resident #1, 2 and #3 was reviewed for COVID-19 interventions and goals. None of the care plans reviewed documented the residents refused to wear a mask while outside of their rooms. On 03/18/21 at 11:03 a.m., residents were observed in the common area without wearing a mask. The facility staff did not encourage the residents to wear a mask. At 12:58 p.m., the administrator was asked if the residents wore a mask when outside of their rooms. She stated the residents refused to wear a mask. At 1:03 p.m., the minimum data set (MDS) coordinator stated the facility staff went around and asked the residents if they wanted to wear a mask while outside of their room; she stated the residents voiced they did not want to be forced to wear a mask. She was asked about the documentation of the residents who refused to wear a mask. She stated it was documented on the residents' care plan under COVID-19. On 03/19/21 at 3:24 p.m., resident #1 was asked if he had a mask. He stated no, he did not have to wear one. The resident was asked if the staff encouraged him to wear a mask. He stated no. He was asked if he wanted to wear a mask when he was outside of his room. He stated it would not bother him. At 3:27 p.m., resident #5 was asked if he wore a mask when he was in the common area of the building. He stated no, the staff did not make him wear a mask. 2. On 03/18/21 at 3:04 p.m., visitors were observed in the visiting room. They filled out a screening form. No staff members checked the screening form or took the visitors temperatures. At 3:33 p.m., a visitor for resident #4 was asked if the staff screened her before she entered the building. The visitor stated no, she filled out a form and took her own temperature. She stated the staff instructed her on how to do it the first time and she had done it on her own since then. A guest log for the residents documented resident #1 had two visitors on 12/24/20. The log documented resident #2 had a visitor on 09/14/20, 11/11/20 and 03/14/21. The log documented resident #4 had visitors on 11/27/20, 11/29/20, 12/24/20, 01/12/21, 02/04/21 and 03/10/21. No screening forms were found for the visitors. On 03/19/21 at 1:44 p.m., the infection preventionist (IP) was asked if the facility had a staff member assigned to screen the visitors. She stated, Not as of yet. At 2:01 p.m., the social service director was asked for the screening forms for the visitors. She stated she could not find the missing screening forms for resident #1, 2 and #4's visitors. 3. The screening form for visitors and employees did not document the visitors or employees had been screened for nausea/vomiting, diarrhea, headache, muscle ache, fatigue, and/or new loss of taste or smell. On 03/19/21 at 1:44 p.m. the IP was asked if the screening forms documented the possible signs and symptoms of COVID-19 listed on the CDC website. She stated the forms did not include the following symptoms: headache, nausea/vomiting, diarrhea, fatigue, muscle ache and/or new loss of taste or smell.

Based on record review and staff interview, it was determined the facility failed to complete a facility assessment. The Resident Census and Conditions of Residents report, dated 08/26/19, documented 42 residents resided in the facility. Findings: On 08/26/19 at 8:52 a.m., during an entrance conference with the administrator (ADM), she was asked to provide a copy of the facility assessment. On 08/28/19 at 11:17 a.m., the ADM stated she couldn't locate the facility assessment.

Based on observation and staff interview, it was determined the facility failed to ensure: ~ soiled rags were properly stored and ~ food service equipment and the building was maintained clean and in good repair. The facility identified 41 residents received services from the kitchen. One resident received nutrition and hydration solely through a feeding tube. Findings: On 08/26/19 at 7:55 a.m., a tour of the kitchen was conducted. The following observations were made: ~ a soiled rag was laying on the shelf below the the steam table wells next to clean plates in the serving area, ~ there was an accumulation of black residue on the floor along the baseboards in the serving area, ~ a floor tile was cracked in the serving area near the ice container, ~ a foot of the leg was missing on the stainless steel plastic utensils table in the serving area, ~ caulking was missing around the hand sink in the microwave area, ~ the lights were not working and the lights were not shielded in the microwave area, ~ there was an accumulation of red and brown slime residue inside of the juice nozzles in the microwave area, ~ a foot was missing on the leg of the fryer table in the cook area, ~ there was an accumulation of grease on the fryer, ~ there was an oven hood light burned out, ~ the black cart used to store clean utensils was dirty with food debris in the cook area, ~ there was an accumulation of lint and grease on the metal storage rack next to the stove in the cook area, ~ there was an accumulation of lint, food and grease on the stove, ~ there was an accumulation of lint on the food preparation tables in the food preparation area, ~ wall tiles were missing in the food preparation area, ~ there was an accumulation of black residue on the table mounted can opener in the food preparation area, ~ paint was peeling off of the wall near the wall clock/calendar in the food preparation area, ~ an accumulation of food debris was on the white shelving in the food preparation area, ~ paint was peeling off of the white shelving in the food preparation area, ~ floor tiles were missing and the concrete was not level in front of the back door, ~ floor tiles were missing in the dry goods storage room, ~ the light wasn't shielded/shatterproof in the dry goods storage area, ~ there was an accumulation of food on the floor in the dry goods storage area, ~ the light wasn't shielded/shatterproof in the dry food storage area, ~ water was leaking from the piping below the three compartment sink into a container in the dish wash area. There was standing water in the container, ~ material was peeling off of the walls in the dish wash area, ~ baseboards were missing in the dish wash area, ~ floor tiles were missing in the dish wash area, ~ there was an accumulation of white, brown and black residue on the dish machine, tables and piping in the dish wash area and ~ there was a soiled rag hanging on the spray nozzle hose in the dish wash area. At 1:05 p.m., the dietary manager was asked how staff ensured the walls and the floor were kept clean and maintained in good repair. She stated they cleaned daily. She stated they reported maintenance issues to the maintenance department for repairs. The dietary manager was asked how staff ensured food service equipment was maintained clean and and maintained in good repair. She stated equipment was cleaned daily and they deep cleaned once a week. She stated they reported maintenance issues to the maintenance department for repairs. The dietary manager stated they had outside companies they leased equipment from and they would repair or replace equipment as needed. She was asked how staff were to store soiled rags. She stated they were to be stored in a sanitizer solution. She was made aware of the above observations. She acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to develop a comprehensive care plan for one (#37) of nine sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 08/26/19, documented 42 residents resided in the facility. Findings: Resident #37 had [DIAGNOSES REDACTED]. An admission assessment, dated 08/09/19, documented cognitive loss/dementia, communication, activities of daily living function/rehabilitation potential, urinary incontinence/indwelling catheter, falls, nutritional status, dental care, pressure ulcer and [MEDICAL CONDITION] drug use were triggered care areas and care plan decisions. There was no documentation a care plan had been fully developed for the care areas. On 08/27/19 at 9:23 a.m., the minimum data set nurse was asked to provide a comprehensive care plan. She stated one had not been completed.

Based on observation, record review and staff interviews, it was determined the facility failed to maintain an accurate account of a controlled substance ([MEDICATION NAME] 7.5/325 milligram (mg)) for one (#20) of one sampled resident observed during a medication pass. The director of nursing (DON) identified 15 residents with physicians' orders for [MEDICATION NAME] 7.5/325mg. Findings: Resident #20 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 1 (one) Tablet 4 (four) times a day PO (by mouth) (7.5-325 MG TABS (tablets)) . On 08/27/19 at 11:05 a.m., certified medication aide (CMA) #1 was observed preparing medication for the resident. She was observed punching one tablet of [MEDICATION NAME] out of the medication card. Eight tablets of [MEDICATION NAME] were observed remaining in the medication card. She was observed signing the medication out on the [MEDICATION NAME] narcotic record. The record documented seven tablets remained. At 11:35 a.m., CMA #1 was asked how staff were instructed to sign out controlled substances. She stated staff were to check the Medication Administration Record, [REDACTED]. She was asked to observe the [MEDICATION NAME] medication card. Seven tablets were observed in the medication card. The CMA was made aware the amount remaining at the time of administration was observed to have been eight tablets. She was asked to explain the discrepancy. She stated, I don't know. At 11:50 a.m., the DON was made aware of the above observations.

Based on record review and staff interview, it was determined the facility failed to ensure physician ordered laboratory (lab) tests were obtained for one (#37) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 08/26/19, documented 42 residents resided in the facility. Findings: Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. There was no documentation the labs were collected. On 08/27/19 at 1:55 p.m., the director of nursing (DON) was asked to locate the above labs. On 08/28/19 at 7:53 a.m., the DON stated the labs had been collected on 08/21/19. She stated they were three weeks late. She was asked how often lab services were provided. She stated everyday.

Based on observation, record review and staff interviews, it was determined the facility failed to assess and provide appropriate interventions to decrease the risk of falls and/or injury for six (#2, 4, 6, 7, 11 and #12) of twelve sampled residents who experienced multiple falls. Resident #12 had 5 falls with 3 head injuries since November 2015. Resident #7 had 4 falls within 52 days of being admitted to the facility. She acquired one head injury which required transport to the ER. Resident #4 had experienced three falls with acquired bruises and skin tears within 17 days of admission. Findings; A facility policy titled, Fall risk Assessment documented, Fall risk assessment will be completed upon admission, quarterly and following a fall or significant change of condition effecting balance to identify and, assess resident at risk for falls. Procedure .any resident identified as high risk will have fall prevention approaches initiated and documented on the care plan .the residents assessed as high risk for falls will be refereed to the interdisciplinary team for evaluation. 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 11/18/15, documented the resident was a low risk for falls with a score of 4. A score of 10 or above represented a high risk. An 'Incident Report' dated 11/18/15, documented the resident was found to have a bruise on her right thigh. When interviewed by the staff the resident told them she had fallen a few days ago. The reports recommendation to prevent reoccurrence documented staff was to reorient the resident to report any incidence of falls or other accidents to the nurse immediately. The resident was also reoriented to call for assistance as it was needed. A fall risk assessment, dated 11/28/15, documented the resident was a low risk for falls with a score of 8. A score of 10 or above represented a high risk. An 'Incident Report' dated 11/28/15, documented, Resident was found on the floor in her room with a small bump on the side of her head. The resident stated, She had rolled out of bed. The recommendation to prevent reoccurrence documented the resident was reoriented to call for assistance as needed. Bed/chair alarm on at all times due to weakness, increased confusion and an unsteady gait. The recommendation also documented a new physicians order for therapy to evaluate and treat as indicated for cognitive and fall prevention. A nurses note, dated 12/01/15, documented the resident was to be evaluated by physical therapy to decrease the incidence of falls. The clinical record failed to include any physicians orders for physical therapy. The record did not contain any documentation related to the resident receiving an evaluation by physical therapy. An 'Incident Report' dated 12/05/15 at 2:30 a.m., documented the resident slid out of a recliner landing on her shoulder and back. The steps taken to prevent reoccurrence documented, Resident laid on couch in back lobby with fall mat bedside couch. Additional documentation made by the director of nursing (DON) followed with, Reoriented resident not to get up or sit down unassisted, call for assistance for all transfers . A fall risk assessment, dated 12/07/15, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. A physician's progress note, dated 12/08/15, documented, Resident is completely disoriented, total care patient except she does take a few steps with assistance . An 'Incident Report' dated 12/12/15 at 1:15 a.m., documented, Heard a resident scream and found res (resident) sitting on floor in her room in front of sink with back to the sink. Blood was dripping onto her shoulders and clothes onto the floor. Got resident up in wheelchair, cleansed head wound and called 911. A corresponding nurses note documented, Heard a resident scream and went to investigate, (Resident) was sitting up at sink area w (with) shelves all turned over, she had blood dripping over shoulders and on clothes. When assessed she had approx.(approximately) 2 cm (centimeters) laceration to back of her head. The resident was transferred to a local emergency room where she received treatment which included three staples to the laceration. A fall risk assessment, dated 12/12/15, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. A quarterly assessment, dated 12/16/15, documented the resident was severly impaired in cognition, exhibited disorganized thinking and sometimes rejected care. The assessment further documented the resident required extensive assistance from one staff person for bed mobility, transfers, walking in her room and in the hall. The range of motion (ROM) portion of the assessment documented the resident was not steady, unable to stabilize unassisted when moving from a seated to standing position, walking, turning and/or performing surface to surface transfers. The care plan, dated 12/26/15 documented, Problem Confusion/Paranoia. Delusions Dx; (diagnosis) Alzheimer's c (with) paranoid D/L (delusions). The approach documented, Resident will have 1 or less episodes of Delusions or Paranoia/day through next review. The care plan also documented the resident was at risk for falls secondary to weakness and limited mobility. The goal documented the resident would not have any injuries from falling through the next review date. The approaches documented the staff was to remind the resident to not stand without assistance, assess for safety alternative as needed, ensure room is well lit and free from clutter, and encourage resident to ask for assistance as needed. On 03/01/16 at 8:45 a.m., Resident #12 was observed in the main lobby area sitting in a recliner. The resident was observed to have swelling and discoloration near the upper left side of her face, including the eye area. The area was observed to be edematous with blue/purple and blackened marks. A nurse aide was observed sitting next to the resident, engaging her in conversation. The staff member was asked what happened to the resident's face. She stated she had a fall early this morning. An 'Incident Report' dated 03/01/16 at 5:40 a.m., documented, Upon enterin (sic) lobby area, noted res (resident) lying on L (left) side on floor in front of w/c (wheelchair). Upon assessement noted laceration and hematoma to L side of head. The steps taken to prevent reoccurrence was to reorient the resident to call for assistance as needed. Staff to continue to monitor resident for behavior i.e. (for example) agitation, anxiety. Interventions to include redirection, one - on - one and or medication review. At 11:00 a.m., licensed practical nurse (LPN) #1 was interviewed and asked what had happened to the resident. She stated, She stood up from her recliner and fell . The LPN was asked where the resident was when she fell . She stated she had been sitting in a recliner in the lobby. She was asked why the resident was already up in the lobby (at 5:40 a.m.) She stated the resident liked to sleep in the recliner in the lobby, She always sleep in the recliner here, She further stated, She fell during shift change. The physician's nurse practioner was interviewed regarding the fall. He was asked what their plan was to provide the resident with a safer environment. He stated, I don't know what we're gonna do with Mrs (Resident). Bless her heart. They didn't send her out because the son doesn't want her sent out and put through all the head scans and things that come with an ER (emergency room ) visit. A physician's progress note, dated 03/01/16, documented, Impression/Plan 1. Left periorbital trauma/laceration/fall-neurological status improving slowly back to baseline, family declines additional evaluation inpatient for head trauma will continue with palliative and supportive care. Resident #12 had suffered five falls (with 3 head injuries) since November 2015, without the facility attempting any new measurable interventions to aid in the prevention of falls. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 12/15/15, documented the resident had a fall risk score of 13. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/16/15 at 7:00 p.m., documented, Resident found on floor sitting down. She told nurse she fell getting out of bed; nurse assessed her but found no injuries. Steps taken to prevent reoccurrence documented, Resident reoriented to call for assistance as needed. Call light is within reach. Resident demonstrated understanding. A(awake) & O (oriented) x 3 w (with) some confusion. Bed/Chair alarms; floor mat by bedside while resident in bed; staff is to assist to toilet Q (every) 2 h (hour) & PRN (as needed). A facility 'Incident Report' dated 12/16/15 at 11:50 p.m., documented, Observed res sitting on bottom on floor in front of recliner. No apparent injuries noted upon assessment. ROM to extremities s (without) pain. res denies bumping head, Res stated, I scooted to the floor. The steps taken to prevent reoccurrence was to reorient resident to call for assistance as needed. Resident demonstrated understanding. Reoriented resident to recline and or sit properly in recliner. Reoriented resident not to get up from recliner unassisted. Resident demonstrated understanding. Bed/chair alarms and floor mat by bedside while resident in bed. Therapy to eval and treat for therapy services diagnosis; fall/safety precautions. A fall risk assessment, dated 12/17/15, documented the resident had a fall score of 13. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/18/15 at 2:50 p.m., documented, Alarm sounded and by the time staff got to resident she was already on the floor. Resident rocking back and forth while leaning forward she slipped out of w/c and on the floor. Resident did not hit her head and no injury noted at this time. The steps taken to prevent reoccurrence was to reorient resident to call for assistance. Call light is within reach. Staff is to monitor resident closely due to high fall risk. Bed/chair alarms on at all times. Floor mat by bedside while resident in bed. Staff is to assist to toilet Q 2 h & PRN. Continue w therapy services A fall risk assessment, dated 12/18/15, documented the resident had a fall score of 13. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/19/15 at 2:27 p.m., documented, CMA (certified mediation aide) assist res to restroom in her room. She got up unattended and apparently fell in shower. She was found lying in half her shower and bathroom. She denies pain, no injury found. Family notified, Res assisted to her feet x 2 assists s difficulty. Res amb (ambulate) c assist to w/c. The steps taken to prevent reoccurrence was to reorient resident to call for assistance. Call light is within reach. Resident demonstrated understanding. A & O x 2 c some confusion. Bed/chair alarms, floor mats by bedside while in bed, and continue to receive therapy services . A facility 'Incident Report' dated 12/19/15 at 5:50 p.m., documented, Res was in w/c and then she was on floor in living area. No injury noted. Res stood to feet x 2 assist. VSS (vital signs and symptoms) Res very confused and upset. She said her son was supposed to meet her up front, resident was upset. Unable to reorient. Assisted res to recliner to calm down. The steps taken to prevent reoccurrence was to reorient resident to call for assistance as needed. Reoriented resident to sit properly and not to lean forward while in wheelchair or recliner. Resident demonstrated understanding. A & O x 2 w some confusion. Continue c bed/chair alarms; floor mat by bedside while resident in bed and continue to received therapy services . A fall risk assessment, dated 12/21/15, documented the resident had a fall score of 13. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/21/15 at 11:10 a.m., documented, This nurse sitting @ (at) nurse station. res fall alarm going off. res slid from w/c to floor in sitting position. res did not hit head. V/S (vital signs) head to toe assess (assessment) done. res denies pain from hips and legs during assessment . The steps taken to prevent reoccurrence was to reorient resident to call for assistance as needed. Reoriented resident to sit properly in wheelchair and not to lean forward. Resident demonstrated understanding. A & O X 2 w some confusion. Contin (continue) c POC (plan of care). Bed/Chair alarms and floor mat by bedside while resident in bed; continue w therapy services . A facility 'Incident Report' dated 12/21/15 at 2:00 p.m., documented, This nurse sitting @ nurses station, res fall alarm going off. This nurse observed res standing. This nurse rushed to get to res. res lowered self to floor between recliner and w/c res stated I was just trying to get in the recliner' this nurse v/s and head to toe assessment, res denies pain or discomfort. The steps taken to prevent reoccurrence was to reorient resident to call for assistance as needed. Reoriented resident to not lean forward while in recliner or w/c. Resident demonstrated understanding. Continue POC bed/chair alarms; floor mat by bedside while resident in bed. Res to continue w therapy services . A fall risk assessment, dated 12/22/15, documented the resident had a fall score of 17. A score of 10 or above represented a high risk. A 5 day admission assessment, dated 12/22/15, documented the resident was moderately impaired in cognition, exhibited disorganized thinking and was totally dependent on staff for all aspects of activities of daily living (ADLs) except eating. The ROM assessment documented the resident was not steady when moving on or off the toilet, moving from seated to standing position or during surface to surface transfers. The resident also exhibited limitations on one side of the upper and lower extremities. A facility 'Incident Report' dated 12/27/15 at 5:53 p.m., documented, Resident was sitting in recliner in living area & she stood up and fell down in front of recliner. No injury noted x 2 lift to recliner. Resident asked if she needed to go to restroom. She denied this. The steps taken to prevent reoccurrence was to reorient resident to call for assistance and to wait for assistance with transfer or ambulation. Resident demonstrated understanding. A & O x 2 c some confusion. Continue receiving therapy services A fall risk assessment, dated 01/05/16, documented the resident had a fall score of 17. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 01/05/16 at 8:00 a.m., documented, Physical therapist reports to this nurse res on floor in sitting position against w/c. Therapist states res did not hit head. assessment done, no injuries or bruising noted at this time. Alarm on and working. No pain or discomfort at this time. The steps taken to prevent reoccurrence was to reorient resident to call and wait for assistance. Reoriented resident to sit properly and not to lean forward while sitting in w/c. Resident demonstrated understanding. Resident is to continue c POC for fall and safety precautions. Bed/chair alarms, floor mat at bedside while resident in bed, toileting Q 2 hr and PRN X 2 persons assist. Res continues w therapy services . A facility 'Incident Report' dated 01/09/16 at 7:00 p.m., documented, This nurse and 2 CNA (certified nurses aide) was assisting res to toilet. res grabbed CNA head and slammed CNA head to the wall. This nurse excused CNA and assisted res on toilet. When res calmed, skin tear noticed to L hand. steri strips applied res tolerated well. Steps documented to prevent reoccurrence was to transfer the resident to a local psychiatric facility for evaluation. The resident was in fact transferred out of the facility for an evaluation of her behaviors. The resident had experienced nine falls in 25 days while residing in the facility. The facility failed to implement any type of measurable interventions to prevent the frequent falls/incidents. 3. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 10/12/15, documented the resident was moderately impaired in cognition, required extensive assistance for bed mobility and dressing, and was totally dependant for transfers. The assessment further documented the residents ROM was limited to surface to surface transfers, which were unsteady and required assistance to stabilize. A care plan, dated 10/19/15, documented the resident was at risk for falling due to a recent hip fracture and a decline in self care abilities. The goal was for the resident to not have any further injuries from falls through the next review date. The approaches were to remind the resident to not attempt to stand without assistance. Assess for safety and alternative as needed. Ensure room is well lit and free from clutter. Encourage to ask for assistance. Bed/chair alarms, low bed and mat at bedside when occupied. A second problem on the care plan documented the resident had short term memory deficit related to intermittent delirium and decreased safety awareness. The goal was to keep the resident clean, dry, well groomed and comfortable. The approach was to encourage/remind resident to request assistance as needed. Discourage residents attempts to manage her own care without assistance due to decreased safety awareness. A facility 'Incident Report' dated 11/13/15, documented, Upon entering room noted resident sitting on buttocks on floor mat next to bed. Alarm sounding Res denies pain upon ROM to extremities. No apparent injuries noted, denies bumping head. Steps taken to prevent reoccurrence documented, Reoriented resident to call for assistance. call light is within reach. Resident demonstrated understanding. Residents to continue w POC to include bed/chair alarms; bed in lowest position while in bed; floor mat by bedside while resident in bed. Staff is to assist to toilet Q 2 hr and PRN x 1 person assist A fall risk assessment had not been conducted on the resident prior to the fall. A facility 'Incident Report' dated 12/05/15 at 5:45 p.m., documented, Another resident reported this resident on floor in her room. Upon entering room res found on floor bedside her bed lying on her right side. Res denies hitting her head. Res O x 3 at this time. Res lifted x two to bed. No injuries noted. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance as needed. Call light is within reach. Resident demonstrated understanding. Continue w POC. bed/chair include bed/chair alarms, bed in lowest position while in bed; floor mat by bedside while resident in bed, and toilet Q 2 hr and PRN x 1 person assist. A facility 'Incident Report' dated 12/06/15 at 9:30 a.m., documented, CMA heard res calling from room. res on floor beside bed. No injuries noted. Res lifted x 2 to her bed. Bed remains low, fall mat on floor. Bed alarm in place and working. Call -light W/I (within) reach. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance as needed. Call light is within reach. Resident demonstrated understanding. A & O x 3. Some confusion at times. Continue w POC to include bed/chair alarms bed in lowest position while in bed; staff to assist to toilet q 2 hr and PRN x 1 person assist. A fall risk assessment, dated 12/07/15, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 02/29/16 at 3:06 p.m., documented, Res stated I slid off the bed. No apparent injuries. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance as needed. Call light is within reach. Resident demonstrated understanding. A & O x 3 w some confusion at times bed in lowest position while in bed, review of medication regime. A fall risk assessment, dated 02/29/16, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 03/01/16 at 12:15 a.m., documented, Upon entering res room, noted on res lying on R side on floor, Upon assessment, No injuries noted, Res denies bumping head, Res stated 'I slid off the bed to the floor. I tried to stop myself but couldn't. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance as needed. call light is within reach . resident demonstrated understanding. A & O X 3 with some confusion at times. bed in lowest position while in bed, assisted to toilet Q 2 hr and prn x one person assist. Review of medication. The resident had experienced a fall in September 2015, which resulted in a hip fracture followed by five additional falls/incidents since November 2015. The facility failed to implement any type of new/different interventions to aid in the prevention of frequent falls and/or incidents. 4. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A 5 day admission assessment documented the resident was moderately impaired in cognition and required extensive assistance from one staff member for all aspects of ADLs. The ROM portion of the assessment documented the resident did not ambulate during the look back period and required assistance to stabilize when repositioning. The assessment also documented the resident had experienced one fall since the admitted . A fall risk assessment, dated 01/04/16, documented the resident had a fall score of 7. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 01/07/16 at 6:15 p.m., documented, Res found by CNA , res tried to get from w/c to bed s help. fell to floor on buttocks. Res denies injury's or pain. No skin tears, redness or discoloration found. Redirected res on use of call light. Steps taken to prevent reoccurrence documented, Reoriented resident to call for assistance as needed. Reoriented resident to wait for assistance and not to transfer herself without assistance by staff. Call light is within reach. Resident demonstrated understanding. A & O x 4. Will review medication. A fall risk assessment, dated 01/08/16, documented the resident had a fall score of 9. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 01/17/16 at 4:25 p.m., documented, Res found sitting on floor in front of her bed. She stated she got up to her w/c & it moved on her & she missed & landed in floor. No injuries, she denied pain, vss, res up x 2 staff assist to feet s difficulty. Steps taken to prevent reoccurrence documented, Reoriented resident to make sure to lock and or unlock the wheel of her wheelchair during transport and or transfer. Reoriented resident to get up and down slowly. Reoriented res to call for assistance as need. Call light is within reach. Res demonstrated understanding. A & O x 4. A fall risk assessment, dated 01/18/16, documented the resident had a fall score of 11. A score of 10 or above represented a high risk. A care plan, dated 01/22/16, documented the resident was at risk for falls due to forgetfulness and required frequent verbal cueing. The goal was for the resident to have no falls through the next review date. The approaches documented the resident was to be assisted with transfers, ambulation, bed mobility, keep the call light within reach, make sure proper footwear was on at all times, adequate lighting in the room and keep the room free of clutter. The care plan also documented the resident was cognitively impaired. A facility 'Incident Report' dated 01/23/16 at 2:15 a.m., documented, Res stated she tripped over fall mat going into bathroom. Hit the right side of her face on the bathroom door. Res stated that she tripped on her roommates floor mat. Res denies pain of discomfort. No injury noted at this time. Steps taken to prevent reoccurrence documented, Reoriented resident to call for assistance as needed. Call light is within reach. Resident demonstrated understanding. A & O x 4, Recommend Maintenance to install night light for visibility at bedtime. A fall risk assessment, dated 01/25/16 and 02/24/16, documented the resident had a fall score of 11. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 02/24/16, documented, Upon entering res room, noted res lying on R side on floor @ foot of bed. Upon assessment noted redness & swelling to nose & L side of face. The resident was sent to a local ER for evaluation and treatment. A nurses note dated 02/24/16 at 9:30 a.m., documented the resident returned to facility with swelling to her nasal cavity and abrasions to both knees. The resident had experienced four falls within 52 days of being admitted to the facility. She acquired one head injury requiring transport to the ER. The facility failed to have measurable interventions implemented to aid in the prevention of the falls. 5. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment, dated 01/14/16, documented the resident had a fall score of 13. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 01/17/16 at 6:25 a.m., documented, Resident found on floor on right side. No apparent injuries. Resident stated he did not bump his head. Res denies pain or discomfort at this time. Steps taken to prevent reoccurrence documented, Reoriented resident to call for assistance as needed call light is within reach. Resident is to continue with therapy services PT (physical therapy/OT (occupational therapy) /ST (speech therapy). Review of medication regime. A fall risk assessment, dated 01/18/16, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. A care plan, date 01/20/16, documented the resident was at risk for falls, was totally dependant on staff for all ADLs and was confused. The goals were for the resident to have no falls through the next review date. Approach's included placing the resident on a fall prevention program, assist with transfers, ambulation, bed mobility. Remind resident to use assistive devices, call light in reach, assure proper footwear and keep area clutter free. A facility 'Incident Report' dated 01/22/16 at 9:10 p.m., documented, Aide saw resident standing in front of closet c walker saw him sliding down wall and assisted him to the floor. The report documented steps to prevent reoccurrence, Reoriented resident to call for assistance as needed. Call light is within reach. A & O x 3 with some confusion at times. Therapy to follow up with PT/OT/ST. Review of medication regime. A facility 'Incident Report' dated 01/24/16 at 8:00 a.m., documented, Housekeeping staff noted resident on floor bedside bed. Res was found c his head @ foot of bed laying diagonal from bed. No injuries noted, Res uncertain of why he was on floor, he did not even recall what he was doing in the first place. vss, res assist x 4 back to his bed. Steps taken to prevent reoccurrence documented, Reoriented resident to call for assistance as needed. Call light is within reach. A & O x 3 w some confusion. Res. demonstrated understanding. continue with therapy services. Review of medication regimen. Psychiatrist consult eval (evaluate) and tx (treat) as indicated. A fall assessment, dated 01/25/16, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. An admission assessment dated [DATE], documented the resident was severly impaired in cognition and required extensive assistance with all aspects of ADLs. The assessment further documented the resident did not ambulate during the look back period and was unable to transition from a seated to a standing position unassisted by staff. A facility 'Incident Report' dated 02/23/16 at 11:00 p.m., documented, Upon entering res room, noted res sitting on floor between w/c and sink. Upon assessment noted red area to R side of head and ear. Res stated I bumped my head on the counter. Steps taken to prevent reoccurrence documented, Reoriented resident to call for assistance as needed. Call light is within reach. Res. demonstrated understanding. A & O x 3 w some confusion at times. Therapy services to follow up. Review of medication regime. The resident had experienced four falls with one head injury within 40 days of being admitted to the facility. The facility failed to have measurable interventions implemented to aid in the prevention of the falls. 6. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 12/22/15, documented, Problem short term memory due to recent decline with extended hospital stay. Goal; will be kept clean, dry and well groomed with assistance as needed on a daily basis. Approaches included to ensure ADLs have been performed to standards, allow ample time for self care, staff to encourage/remind resident to request assistance when needed. A second problem documented the resident was at risk for falls due to weakness and limited mobility. The goal was to have no injury from falls, with approach's to remind resident to not stand without assistance and encourage resident to ask for assistance. A fall risk assessment, dated 12/02/15, documented the resident had a fall score of 15. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/06/15 at 10:15 p.m., documented, Upon entering room, noted res sitting on buttocks on floor beside bed. No apparent injuries noted upon assessment. Denies pain upon ROM to all extremities. Denies bumping head. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance. Call light is within reach. A & O X 3 w some confusion p (after) stroke. Bed in lowest position while resident in bed; alarm in bed while resident in bed; 1/4 rails upper bilateral for bed mobility/positioning. PT/OT/ ST for therapy services. A fall risk assessment, dated 12/07/15, documented the resident had a fall score of 17. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/11/15 at 6:30 p.m., documented the resident had slipped out of his wheelchair, receiving a skin tear to his left hand. No other injury noted on the assessment. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance as needed. Reoriented resident to sit upright in wheelchair and not to lean forward. Resident demonstrated understanding. A & O X 3 w some confusion. A fall risk assessment, dated 12/12/15, documented the resident had a fall score of 17. A score of 10 or above represented a high risk. A facility 'Incident Report' dated 12/23/15 at 11:00 p.m., documented, Observed res sitting on buttock on floor, Bruises noted to R upper arm & elbow. res denies pain @ this time. ROM to extremities without difficulty or pain. Denies bumping head. An additional note by the DON further documented, Resident was soaking wet saying that he wanted to go to bathroom and couldn't make it. Steps taken to prevent reoccurrence, Reoriented resident to call for assistance as needed. C

Based observation, interview and record review, it was determined the facility failed to ensure; a. targeted behaviors were documented as exhibited to justify the initiation and administration of [MEDICATION NAME] (an anti-depressant) and [MEDICATION NAME] (an antipsychotic) for behaviors of yelling. and b. a resident exhibited signs and symptoms of a urinary tract infection [MEDICAL CONDITION] prior to administering antibiotics for one (#36) of five sampled residents reviewed for unnecessary medication administration. The Resident Census and Condition of Residents Report, dated 10/07/15, documented two residents were receiving antibotics, five were receiving antipsychotic medications and 21 were receiving antidepressant medications. The census was 45. Findings; Resident #36 was admitted to the faciltiy with [DIAGNOSES REDACTED]. Sicca disease. A physicians order dated 07/10/15, documented, [MEDICATION NAME] 5 mg (milligrams) QD (every day) for senile delusion, and [MEDICATION NAME] 50 mg QD for mental disorder. An admission assessment dated [DATE], documented the resident was moderately impaired in cognition, exhibited mild depression, and often rejected care. The assessment further documented the resident exhibited daily verbal behaviors which were directed toward others one to three days a week, this behavior impacted the resident's ability to participate in activities/social interactions. A nurse's note, dated 09/02/15 at 10:00 p.m., documented the resident called her roommate names because the volume on the TV was not turned up loud enough for the resident to hear. On 10/06/15 at 1:15 p.m., licensed practical nurse (LPN) #1, was asked if she was familiar with the resident. She stated she was. She further stated the resident is a Night owl and is hard of hearing. On 10/06/15 at 3:15 p.m., the director of nursing (DON) was interviewed. He was asked what kind of behaviors were exhibited. He stated, She yells at her roommate. She thinks the roommate is her husband. He was asked if the facility tried to find out what triggers her behaviors. He stated, Mainly she yells. He was asked if anything had been tried other than administering antipsychotics for the yelling. He stated, We have had to call her daughter to try and calm her down. At 3:30 p.m., the assistant director of nursing (ADON) was interviewed with the DON regarding the residents medication usage. They were asked if the facility had ever arranged for a psych (psychiatric) consult to discuss the residents behaviors of yelling. The ADON stated, We have not had a psych consult or attempted any other interventions that weren't in the care plan. She was asked what [DIAGNOSES REDACTED]. She stated the resident had [DIAGNOSES REDACTED]. (term sicca refers to the dryness of the eyes and mouth). They were asked to review the nurses note, dated 09/02/15, which documents the residents hearing deficit. They were asked to describe the interventions initiated after the episode. They stated they told the resident not to yell at her roommate. They were asked if they had re-evaluated the suitability of her roommate, since the episode was about the resident needing the television volume turned up louder. They stated they had not. They were asked if they had tried hearing devices to help her hear the TV without disturbing the roommate. They stated they had not. They were asked if they had followed their care plan and arranged for the resident to be evaluated by an audiologists (hearing specialist). The ADON stated the resident had refused. They were asked if they had tried again, as their care plan had documented for them to do. The ADON stated they had not. They were asked if they had tried to determine what triggered the residents outbursts. They stated they had not, she just had outbursts of yelling and screaming. She was asked if the resident was violent. She stated she was not. She was asked if the facility had tried to determine if an antipsychotic was the approporiate drug and or treatment for [REDACTED]. She was asked if they had tried a less severe drug to help with her outbursts. She stated they had not. The ADON stated the resident was not easily redirected. The ADON was asked if a PRN (as needed) drug for agitation had been tried. She stated nothing else had been tried. They were asked to provide documentation of behavior/side effect monitoring. The DON provided a behavior sheet and an AIMS. The documented behaviors that were being monitored were refusing care and extreme agitation. On 10/08/15 at 9:29 a.m., certified nurse aide (CNA) #1 was interviewed about the resident. She was asked if the resident had any behaviors. She stated the resident would become upset and yell. The CNA was asked if the resident had any other behaviors. She stated, No. Not really, she is easily re-directed if you offer to play cards with her. The CNA stated that always worked because the resident loved to play cards. The CNA was asked about the residents sleep pattern. She stated the resident was a night owl and would sleep during the day. The CNA added the resident was never violent or anything like that. b. antibiotic A physicians telephone order dated 08/20/15, documented, Cipro (oral antibotics) 500 mg, PO (oral) BID (twice daily) x (times) 7 days [MEDICAL CONDITION] (urinary tract infection). A urinalysis laboratory report dated 08/20/15, documented, Urinalysis Plus Culture: Color ~ Yellow Appearance ~ clear (normal = clear) PH ~ 6.0 (normal = 5.0 - 8.0) Specific gravity ~ 1.023 (normal =1.010-1.030) Illegible measurement ~ Negative Glucose ~ Negative [MEDICATION NAME] ~ Negative Bilirubin ~ Negative Blood/Hemoglobin ~ Negative Urobilinogen ~ 0.2 (0.2 -1.0) Leukocyte Esterase ~ Negative [MEDICATION NAME] ~ Negative 08/19/15, culture report; 10,000 - 100,000 CFU (colony forming unit) /ML (milliliter) Gram Negative Rods, sensitivities to follow. 08/20/15, Culture report: 10,000 - 100,000 CFU/ML Proteus Mirabilis. consistent with normal urethral flora and/or colonizing bacteria. On 10/08/15 at 8:41 a.m., an interview was conducted with the DON regarding the use of the prescribed antibotics. He was asked what [DIAGNOSES REDACTED]. He was asked to review the clinical record for documentation of signs and symptoms which supported the [DIAGNOSES REDACTED]. He stated the only documentation he saw was that the resident had increased confusion. He was asked if an assessment had been conducted on the resident prior to starting the medication. He stated he didn't see any documentation for an assessment. He was asked if the resident still exhibited increased confusion. The DON said he didn't see any further documentation of continued confusion. The DON then pointed out the culture portion of the urinalysis completed on 08/20/15. He stated she had grown gram negative rods and Proteus mirabilis. The DON was asked to read the next sentence which documented the mixed growth was consistent with urethra flora and/or colonizing. He verbalized understanding this did not necessarily indicate antibiotic treatment was necessary. The DON provided a page from the infection control log which documented the resident had dysuria. He stated he had documented dysuria because the nurse told him the resident complained. I asked if the [DIAGNOSES REDACTED]. He stated he didn't think so. The DON was asked if he could contact the nurse who advised him of the residents dysuria. He stated that wouldn't help because he didn't remember who told him. I asked him if he would like to call the nurse that made the entry about the increased confusion. He stated no because she was a weekend nurse and she probably wouldn't remember.

Based on record interview and interview, it was determined the facility failed to notify the residents' physician when the resident had a change in condition related to pain for two (#59 and #14) of two sampled residents reviewed for pain. This resulted in actual harm for resident #59 when her uncontrolled pain was not communicated to the resident's physician for treatment and for resident #14 who developed a tooth abscess and the physician was not notified until four days after staff identified teeth pain. The facility identified 10 residents who were on a pain management program. Findings: 1. Resident #59 was admitted to the facility on [DATE] at 3:00 p.m., with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A pain assessment, dated 06/19/14, documented the resident's acceptable level of pain was a three on a scale of 0-10. The resident denied pain at the time of the assessment. A skilled nurse's note, dated 06/19/14, on the 2:00 p.m. to 10:00 p.m. shift, documented the resident had remained in bed since her arrival. The un-timed note documented the resident complained of pain, but the medications had not arrived from the pharmacy. The narcotic sheet documented the resident's medications were received on 06/20/14 at 1:00 a.m., but the first dose of [MEDICATION NAME] 7.5/325 mg and [MEDICATION NAME] 0.5 mg were not administered until 2:15 a.m. There was no documentation on the June 2014, Medication Administration Record [REDACTED]. There was no documentation to indicate the resident's level of pain was assessed for the relief of the resident's pain after receiving the medication. The resident did not receive pain medication for approximately 11 hours after requesting it, due to the medication not being available. There was no documentation to verify the physician had been notified of the resident's pain and/or the unavailability of pain medication. Nurse's notes documented: ~ 06/21/14 - The resident complained of difficulty breathing and back pain at 10:00 a.m. The nurse verified the resident had received pain medication 45 minutes prior to the resident's complaint of pain. The physician was not notified of the resident's continued pain following medication administration. Nurse's notes, dated 06/22/14, documented: ~ 6:00 a.m. to 2:00 p.m. shift - The resident continued to complain of pain. The resident had received [MEDICATION NAME] and [MEDICATION NAME] at every interval ordered by the physician. ~ 2:00 p.m. to 10:00 p.m. shift - The resident requested pain medication every two hours and stated her pain was not controlled with the medication. The physician was not notified of the resident's uncontrolled pain. A nurse's note, dated 06/24/14 on the 2:00 p.m. to 10:00 p.m. shift, documented the resident complained of pain, was confused and seeing things and was on the call light frequently. She was medicated for pain and agitation one time. The notes also documented the resident's abdominal girth was increasing. There was no documentation to verify the physician was notified of the resident's frequent pain, hallucinations or an increase in the resident's abdominal girth. The admission assessment, dated 06/26/14, documented the resident's cognition was intact. She was able to understand others and was able to make herself understood. The assessment documented the resident was on a scheduled pain management program and received prn pain meds. It documented the presence of pain was almost constant and the pain made it difficult for her to sleep at night and also limited her day to day activities. The resident's assesses documented she rated the intensity of the pain at a nine on a scale of 0-10 and had received an antianxiety medication seven of the past seven days. A skilled nurse's note, dated 06/28/14, documented on the 10:00 p.m. to 6:00 a.m. shift the resident complained of pain and pain medications were administered. The 6:00 a.m. to 2:00 p.m. shift notes documented the resident complained of pain and pain medications were administered. Biofreeze was applied to areas where pain was present. The notes documented the resident was crying, "I wish God would just take me." The 2:00 p.m. to 10:00 p.m. shift documented the resident was on the call light every 10-15 minutes with complaints of pain. Staff had given all of the prn and scheduled pain meds, including the Biofreeze. There was no documentation to verify the physician had been notified of the residents continued lack of relief from the pain. A nurse's note, dated 06/28/14 at 5:00 p.m., documented the resident had been administered [MEDICATION NAME] 4 mg (a schedule II narcotic) and [MEDICATION NAME] 1 mg. The resident's record did not contain orders for the medications. The notes documented the nurse who administered the medications without a physician's orders [REDACTED]. The notes documented the family and physician were notified and the resident was assessed and was stable. Vital signs and neuro checks were WNL (within normal limits). The resident complained of pain at a ten on a 0-10 scale, and was administered [MEDICATION NAME] 7.5 mg/325 mg at 5:00 p.m. There was no documentation to indicate the nurse notified the physician of the resident's uncontrolled pain on 06/27/14 during the 10:00 p.m. to 6:00 a.m. shift, when the incident occurred. A skilled nurse's note, dated 06/29/14, documented on the 6:00 a.m. to 2:00 p.m. shift, there were no signs or symptoms of adverse reactions to the medications given to the resident without an order. The resident complained of pain and stated while sobbing, "I'm depressed." The 2:00 p.m. to 10:00 p.m. shift documented the resident had received as needed pain medication and Biofreeze for pain relief. The MAR indicated [REDACTED]. There was no documentation to verify the physician was notified of the resident's statement of being depressed and continued complaints of pain. The care plan, dated 07/02/14, documented the resident was at risk for pain related to her limited mobility and generalized weakness due to her recent hospital stay. She had a L3 fracture and a [DIAGNOSES REDACTED]. The goal for the resident was to rate her pain with a decrease to three or less. Approaches included for staff to evaluate the resident's pain every shift and prn, assist with diversional activities, distraction techniques, monitor for worsening of her pain symptoms and report to the physician. Staff was to provide medications as ordered. A nurse's note dated 07/11/14 on the 2:00 p.m. to 10:00 p.m. shift, documented the resident had been on her call light 15 times with complaints of pain and depression. There was no documentation to indicate the physician had been notified of the repeated complaints of depression and pain voiced by the resident. A skilled nurse's note, dated 07/18/14, documented on the 10:00 p.m. to 6:00 a.m., the resident was observed moaning in pain and pain medication was administered. The resident's level of pain was not assessed. On the 2:00 p.m. to 10:00 p.m. shift the resident was crying frequently complaining of pain. The routine and prn pain meds were administered as ordered. There was no documentation to verify the physician was notified of the resident crying and frequent complaints of pain. A skilled nurse's note, dated 07/22/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was observed to be moaning and groaning and complaining of pain that interfered with her sleep and activity. The resident's level of pain was not assessed nor was the physician notified. On 07/31/14 at 12:15 p.m., the assistant director of nurses (ADON) was asked if the physician should be notified about a resident's uncontrolled pain. She stated, "Yes." She stated she would anticipate the nurses' would call the doctor and review the resident's pain and current medication regime with the physician. She stated the physician should be notified of any uncontrolled pain at any time. The ADON was asked if the physician had been notified in regard to the resident's continued and uncontrolled pain. She said, "No." The ADON was asked how the facility would determine if the pain medication was effective for the resident. She stated the nurse should reassess the effectiveness of the medication 30-45 minutes after administration. If the medication did not effectively relieve the pain the physician should be notified and any new orders or interventions should be documented in the nurse's notes. On 08/01/14 at 9:15 a.m., the nurse practitioner was asked if she was notified of the resident's uncontrolled pain. She stated she did not think so, but it would be documented on her notes if she was. There was no documentation on the nurse practitioner's notes of staff having reported the resident's uncontrolled/continued severe pain. 2. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 06/21/13, documented the resident had his own lower teeth and received a regular diet. The quarterly assessment, dated 04/02/14, documented the resident had moderately impaired cognition, was on scheduled pain medication, had no mouth pain, discomfort or difficulty chewing and wore dentures. The care plan, dated 06/21/14, documented the resident was at risk for self-care deficit. The care plan documented the resident had impaired cognition, required extensive assist of one to two staff members with activities of daily living care, and had episodes of pain. Approaches to care included staff was to observe for signs and symptoms of pain and offer effective pain management as ordered. A nurse's note dated, 05/04/14 at 4:00 p.m., documented the resident had been refusing to eat due to his teeth hurting. He stated it hurt when he attempted to chew even softened food. The nurse had left contact with the social services director for assistance. The resident's level of pain was not assessed, no prn pain med was provided and the physician was not notified of the resident's teeth pain. A physician's telephone order, dated 05/08/14 (four days after complaint of teeth pain) at 7:00 p.m., documented to start PCN VK (an antibiotic) 500 mg by mouth twice daily for seven days. A nurse's note, dated 05/09/14 at 8:00 p.m. (five days after complaint of tooth pain), documented the resident was started on an antibiotic for a tooth abscess. A social services note, dated 05/30/14 (26 days after complaint of tooth pain), documented the resident was seen by the dentist and a dental note, dated 05/30/14, documented the resident had a lower front extraction. On 08/01/14 at 8:45 a.m. the director of nurses (DON) was asked if the physician had been notified of the change in condition for the resident related to his tooth pain which then became an abscess. He stated, "No."

Based on observation, interview and record review, it was determined the facility failed to thoroughly perform assessments in regard to pain for two (#14 and #59) of two sampled residents who were reviewed for pain. This resulted in actual harm for resident #59 when her uncontrolled pain was not communicated to the resident's physician for treatment; and for resident #14 who developed a tooth abscess and the physician was not notified until four days after staff identified teeth pain. The facility identified 10 residents who were on a pain management program. Findings: 1. Resident #59 was admitted to the facility on [DATE] at 3:00 p.m. with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. An admission nursing pain assessment, dated 06/19/14, documented the resident's acceptable level of pain was a three on a scale of 0-10. A skilled nurse's note, dated 06/19/14, documented on the 2:00 p.m. to 10:00 p.m. shift, the resident had remained in bed since her arrival. The notes documented the resident complained of pain, but the medications had not arrived from the pharmacy. There was no documentation to indicate the actual time the resident complained of pain. The resident's level of pain was not assessed. A skilled nurse's note, dated 06/20/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was agitated. The narcotic sign out record for the resident documented the resident received the first dose of [MEDICATION NAME] 7.5/325 mg and [MEDICATION NAME] 0.5 mg at 2:15 a.m. There was no documentation to indicate the resident's level of pain was assessed following the use of the pain medication. The 2:00 p.m. to 10:00 p.m. shift documented the resident was in pain related to her back and had received pain medication. The resident's level of pain was not assessed following the use of the pain medication. A skilled nurse's note, dated 06/21/14, documented on the 6:00 a.m. to 2:00 p.m. shift, the resident complained of difficulty breathing and back pain. The resident's level of pain was not assessed at that time. A nurse's note, dated 06/21/14, documented at 10:00 a.m., the resident complained of pain. The nurse verified the resident had received pain medication 45 minutes prior to this time. The resident's level of pain was not assessed at that time. The June 2014 MAR indicated [REDACTED]. A nurse's note, dated 06/22/14, documented on the 6:00 a.m. to 2:00 p.m. shift, the resident continued to complain of pain. The resident had received [MEDICATION NAME] 7.5 mg and [MEDICATION NAME] 0.5 mg at 7:00 a.m. and 7:00 p.m., and [MEDICATION NAME] 50 mg at 11:00 p.m. The resident's level of pain was not assessed before or after the medication was given. The nurses' note documented on the 2:00 p.m. to 10:00 p.m. shift, the resident requested pain medication every two hours. The resident stated her pain was uncontrolled by the medication she was being given. There was no documentation to verify a thorough assessment of the resident's pain had been completed. The June 2014 MAR indicated [REDACTED]. A skilled nurse's note, dated 06/24/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident, "rested with irritation," and had complaints of pain to her abdomen and lower back. The note documented prn pain meds were given. The resident's level of pain was not assessed before or after the medication was given. The 2:00 p.m. to 10:00 p.m. shift, documented the resident complained of pain, was confused and seeing things and was on the call light frequently. She was medicated for pain and agitation one time. The resident's level of pain was not assessed before or after the medication was given. The narcotic sign out sheet documented on 06/24/14, the resident was administered [MEDICATION NAME] 7.5 mg at 12:00 a.m. and 4:30 p.m. The resident's level of pain was not assessed. The 2:00 p.m. to 10:00 p.m. shift documented the resident had been on the call light numerous times requesting pain medication. She had been administered all ordered pain meds without relief. The resident was crying and requested [MEDICATION NAME] (a pain medication), stating, "That's what they gave me in the hospital. This stuff isn't working." There was no documentation of a pain assessment being done at that time. The narcotic sign out sheet documented the resident received [MEDICATION NAME] 7.5 mg on 06/25/14 at 10:00 a.m., 4:30 p.m. and at 11:00 p.m. The resident's level of pain was not assessed. The admission assessment, dated 06/26/14, documented the resident was on a scheduled pain management program and received prn pain medication. The assessment documented the resident's presence of pain was almost constant. The pain made it hard for her to sleep at night and limited her day to day activities. She rated the intensity of the pain at nine on a scale of 0-10. A skilled nurse's note, dated 06/26/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain and was administered prn pain medication. The resident's level of pain was not assessed before or after the medication was given. The June 2014 MAR indicated [REDACTED]. A skilled nurse's note, dated 06/27/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain. Pain medication was administered. The resident's level of pain was not assessed before or after the medication was given. The June 2014 MAR, documented the resident received [MEDICATION NAME] 7.5 mg at 2:00 p.m., [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 50 mg at 3:00 p.m., and [MEDICATION NAME] 7.5 mg at 8:30 p.m. The resident's level of pain was not assessed before or after the medication was given. A skilled nurse's note, dated 06/28/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain and pain medication was administered. The resident's level of pain was not assessed before or after the medication was given. The 6:00 a.m. to 2:00 p.m. shift, documented the resident complained of pain. Pain medication was administered and Biofreeze was applied to areas where pain was present. The resident was crying, "I wish God would just take me." The MAR indicated [REDACTED] A skilled nurse's note, dated 06/29/14, documented on the 6:00 a.m. to 2:00 p.m. shift, the resident complained of pain and stated while sobbing, "I'm depressed." The 2:00 p.m. to 10:00 p.m. shift documented the resident had received prn pain medication and Biofreeze for pain relief. The June 2014 MAR indicated [REDACTED]. The resident's level of pain was not assessed before or after the medication was given for any of the times above. The care plan, dated 07/02/14, documented the resident was at risk for pain, related to her limited mobility and generalized weakness, due to her recent hospital stay. She had a L3 fracture and a [DIAGNOSES REDACTED]. The goal for the resident's care was to verbalize her pain was decreased to three or less on a 0-10 pain scale. Approaches for care included for staff to evaluate the resident's pain every shift and prn, assist with diversional activities, distraction techniques, monitor for worsening of her pain symptoms and report to the physician. Staff were to provide medication as ordered. A skilled nurse's note, dated 07/11/14 at 12:00 a.m., documented the resident complained of pain at 10:00 p.m. and [MEDICATION NAME] 5/325 mg was administered. The 2:00 p.m. to 10:00 p.m. shift documented the resident had been on her call light 15 times with complaints of pain and depression. A skilled nurse's note, dated 07/14/14, documented on the 10:00 p.m. to 6:00 a.m. and 6:00 a.m. to 2:00 p.m. shifts the resident complained of pain. Pain medication was administered. A skilled nurse's note, dated 07/16/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident had complained of pain and pain medication was administered. A skilled nurse's note, dated 07/18/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was observed moaning in pain and pain medication was administered. On the 2:00 p.m. to 10:00 p.m. shift the resident was crying frequently complaining of pain. The routine and prn pain medications were administered as ordered. A skilled nurse's note, dated 07/22/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was observed to be moaning and groaning and complaining of pain that interfered with her sleep and activity. A skilled nurse's note, dated 07/23/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain and was administered pain medication. A skilled nurse's note, dated 07/25/14, documented the resident complained of pain that interfered with her sleep and was administered pain medication. The resident's level of pain was not assessed before or after the medication was given for any of the times above. On 07/29/14 at 7:50 a.m., the resident was observed in the entrance to the dining room. The resident was talking to certified medication assistant (CMA) #1 and stated she had a rough night and did not sleep well. The CMA then wheeled the resident to the family area. The CMA told licensed practical nurse (LPN) #2 that the resident wanted to lay down. The nurse asked the resident if she wanted to stay up since she would be leaving soon for a physician's appointment. There was no reply and the resident was left to sit in her wheelchair in the family room. At 8:00 a.m., the resident was asked if she felt like talking to the surveyor. She stated, "Yes," but wanted to lay down while talking. The resident was assisted to her room by the activities director (AD). The resident stated her head hurt as the AD pushed her to her room. The AD then left the room with the resident remaining in her wheelchair. At 8:02 a.m., the resident stated she needed to go to bed and rest; she did not feel good. At that time she began to transfer herself to the bed without assistance. The call light was initiated to ask for assistance in helping the resident. As the resident transferred herself to the bed she stated she hurt so bad. She exhibited facial grimacing and began crying, repeating she just felt so bad. At 8:11 a.m., the CNA (certified nurse aide) #4 came into the room and asked the resident what she needed. The resident attempted to explain and began crying. She stated she was going to get the nurse and have her come check on the resident. At 8:21 a.m., CMA #1 came into the room with [MEDICATION NAME]. The resident stated to the CMA she felt terrible. The CMA rubbed the gel on the resident's arm and then left the room. At approximately 8:45 a.m., the resident was transported to a physician's appointment. On 07/30/14 at 2:50 p.m., LPN #2 was asked if staff and/or resident #59 had voiced any concerns before her departure to the hospital on [DATE]. She stated she did not recall but they could have. She stated the resident voiced that she wanted to lay down in bed. She stated she told the resident she was going to be leaving the facility for a doctors appointment soon and informed a staff member to ensure the resident was comfortable. She was asked if any staff had brought to her attention the resident's request for pain med. She stated she was not aware of any request and had not assessed the resident for the presence of pain. On 07/31/14 at 12:15 p.m.,the assistant director of nursing (ADON) was asked when and how the nurse should assess the pain. She stated they should assess for pain when the resident complained of pain and document the severity level, the location and find out how long it had been going on. She was asked where the information should be documented. She stated in the nurse's notes. No documentation could be found. 2. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 06/21/13, documented the resident had his own lower teeth and received a regular diet. The quarterly assessment, dated 04/02/14, documented the resident had moderately impaired cognition, was on scheduled pain medication, had no mouth pain, discomfort or difficulty chewing and he wore dentures. The May 2014 MAR, documented the resident received Tylenol 1000 mg three times a day and [MEDICATION NAME] tablet 400 mg daily routinely for pain. The resident could receive [MEDICATION NAME] every 6 hours prn for pain. The May 2014 monthly physician's orders [REDACTED]. A nurse's note dated, 05/04/14 at 4:00 p.m., documented the resident had been refusing to eat due to his teeth hurting. He stated it hurt when he attempted to chew even softened food. The resident's level of pain was not assessed at that time. There was no documentation of a comprehensive pain assessment having been completed with the onset of the resident's tooth pain. A nurse's note, dated 05/09/14 at 8:00 p.m. (five days after complaint of tooth pain), documented the resident was started on an antibiotic for a tooth abscess. There was no documentation of a comprehensive pain assessment being completed. On 07/31/14 at 12:15 p.m., the assistant director of nurses was asked how the nurse should assess the pain. She stated they should assess the severity level, the location of the pain, rate the pain and find out how long it has been going on. She was asked where the information should be documented. She stated in the nurse's notes. No documentation could be found.

Based on observation, record review and interview, it was determined the facility failed to: A. assess the cause of unrelieved pain and implement pain management interventions for one (#59), and B. ensure pain medication was administered for complaints of pain for one (#14) of two sampled residents with identified pain concerns during resident interviews. This resulted in actual harm to resident #59 when the facility did not act upon the complaints of unrelieved pain and resident #14 when the facility failed to ensure pain medication was administered upon complaints of pain. The facility identified ten residents who were on a pain management program. Findings: 1. Resident #59 was admitted to the facility on [DATE] at 3:00 p.m. with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. An admission nursing pain assessment, dated 06/19/14, documented the resident's acceptable level of pain was a three on a scale of 0-10. A skilled nurse's note, dated 06/19/14, documented on the 2:00 p.m. to 10:00 p.m. shift, the resident had remained in bed since her arrival. The notes documented the resident complained of pain, but the medications had not arrived from the pharmacy. There was no documentation to indicate the actual time the resident complained of pain. The resident's level of pain was not assessed. A skilled nurse's note, dated 06/20/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was agitated. The narcotic sign out record for the resident documented the resident received the first dose of [MEDICATION NAME] 7.5/325 mg and [MEDICATION NAME] 0.5 mg at 2:15 a.m. There was no documentation to indicate the resident's level of pain was assessed following the use of the pain medication. The 2:00 p.m. to 10:00 p.m. shift documented the resident was in pain related to her back and had received pain medication. The resident's level of pain was not assessed following the use of the pain medication. A skilled nurse's note, dated 06/21/14, documented on the 6:00 a.m. to 2:00 p.m. shift, the resident complained of difficulty breathing and back pain. The resident's level of pain was not assessed at that time. A nurse's note, dated 06/21/14, documented at 10:00 a.m., the resident complained of pain. The nurse verified the resident had received pain medication 45 minutes prior to this time. The resident's level of pain was not assessed at that time. The June 2014 MAR indicated [REDACTED]. A nurse's note, dated 06/22/14, documented on the 6:00 a.m. to 2:00 p.m. shift, the resident continued to complain of pain. The resident had received [MEDICATION NAME] 7.5 mg and [MEDICATION NAME] 0.5 mg at 7:00 a.m. and 7:00 p.m., and [MEDICATION NAME] 50 mg at 11:00 p.m. The resident's level of pain was not assessed before or after the medication was given. The nurses' note documented on the 2:00 p.m. to 10:00 p.m. shift, the resident requested pain medication every two hours. The resident stated her pain was uncontrolled by the medication she was being given. There was no documentation to verify a thorough assessment of the resident's pain had been completed. The June 2014 MAR indicated [REDACTED]. A skilled nurse's note, dated 06/24/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident, "rested with irritation," and had complaints of pain to her abdomen and lower back. The note documented prn pain meds were given. The resident's level of pain was not assessed before or after the medication was given. The 2:00 p.m. to 10:00 p.m. shift, documented the resident complained of pain, was confused and seeing things and was on the call light frequently. She was medicated for pain and agitation one time. The resident's level of pain was not assessed before or after the medication was given. There was no documentation to verify the physician was notified of the resident's frequent pain, hallucinations or an increase in the resident's abdominal girth. The narcotic sign out sheet documented on 06/24/14, the resident was administered [MEDICATION NAME] 7.5 mg at 12:00 a.m. and 4:30 p.m. The resident's level of pain was not assessed. The 2:00 p.m. to 10:00 p.m. shift documented the resident had been on the call light numerous times requesting pain medication. She had been administered all ordered pain meds without relief. The resident was crying and requested [MEDICATION NAME] (a pain medication), stating, "That's what they gave me in the hospital. This stuff isn't working." There was no documentation of a pain assessment being done at that time. The narcotic sign out sheet documented the resident received [MEDICATION NAME] 7.5 mg on 06/25/14 at 10:00 a.m., 4:30 p.m. and at 11:00 p.m. The resident's level of pain was not assessed. The admission assessment, dated 06/26/14, documented the resident was on a scheduled pain management program and received prn pain medication. The assessment documented the resident's presence of pain was almost constant. The pain made it hard for her to sleep at night and limited her day to day activities. She rated the intensity of the pain at nine on a scale of 0-10. A skilled nurse's note, dated 06/26/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain and was administered prn pain medication. The resident's level of pain was not assessed before or after the medication was given. The June 2014 MAR indicated [REDACTED]. A skilled nurse's note, dated 06/27/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain. Pain medication was administered. The resident's level of pain was not assessed before or after the medication was given. The June 2014 MAR, documented the resident received [MEDICATION NAME] 7.5 mg at 2:00 p.m., [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 50 mg at 3:00 p.m., and [MEDICATION NAME] 7.5 mg at 8:30 p.m. The resident's level of pain was not assessed before or after the medication was given. A skilled nurse's note, dated 06/28/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain and pain medication was administered. The resident's level of pain was not assessed before or after the medication was given. The 6:00 a.m. to 2:00 p.m. shift, documented the resident complained of pain. Pain medication was administered and Biofreeze was applied to areas where pain was present. The resident was crying, "I wish God would just take me." The MAR indicated [REDACTED] There was no documentation to verify the physician had been notified of the residents continued lack of relief from the pain. A nurse's note, dated 06/28/14 at 5:00 p.m., documented the resident had been administered [MEDICATION NAME] 4 mg (a schedule II narcotic) and [MEDICATION NAME] 1 mg. The resident's record did not contain orders for the medications. The notes documented the nurse who administered the medications without a physician's orders [REDACTED]. The notes documented the family and physician were notified and the resident was assessed and was stable. Vital signs and neuro checks were WNL (within normal limits). The resident complained of pain at a ten on a 0-10 scale, and was administered [MEDICATION NAME] 7.5 mg/325 mg at 5:00 p.m. There was no documentation to indicate the nurse notified the physician of the resident's uncontrolled pain on 06/27/14 during the 10:00 p.m. to 6:00 a.m. shift, when the incident occurred. A skilled nurse's note, dated 06/29/14, documented on the 6:00 a.m. to 2:00 p.m. shift, the resident complained of pain and stated while sobbing, "I'm depressed." The 2:00 p.m. to 10:00 p.m. shift documented the resident had received prn pain medication and Biofreeze for pain relief. The June 2014 MAR indicated [REDACTED]. The resident's level of pain was not assessed before or after the medication was given for any of the times above. The care plan, dated 07/02/14, documented the resident was at risk for pain, related to her limited mobility and generalized weakness, due to her recent hospital stay. She had a L3 fracture and a [DIAGNOSES REDACTED]. The goal for the resident's care was to verbalize her pain was decreased to three or less on a 0-10 pain scale. Approaches for care included for staff to evaluate the resident's pain every shift and prn, assist with diversional activities, distraction techniques, monitor for worsening of her pain symptoms and report to the physician. Staff were to provide medication as ordered. A skilled nurse's note, dated 07/11/14 at 12:00 a.m., documented the resident complained of pain at 10:00 p.m. and [MEDICATION NAME] 5/325 mg was administered. The 2:00 p.m. to 10:00 p.m. shift documented the resident had been on her call light 15 times with complaints of pain and depression. A skilled nurse's note, dated 07/14/14, documented on the 10:00 p.m. to 6:00 a.m. and 6:00 a.m. to 2:00 p.m. shifts the resident complained of pain. Pain medication was administered. A skilled nurse's note, dated 07/16/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident had complained of pain and pain medication was administered. A skilled nurse's note, dated 07/18/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was observed moaning in pain and pain medication was administered. On the 2:00 p.m. to 10:00 p.m. shift the resident was crying frequently complaining of pain. The routine and prn pain medications were administered as ordered. There was no documentation to verify the physician was notified of the resident crying and frequent complaints of pain. A skilled nurse's note, dated 07/22/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident was observed to be moaning and groaning and complaining of pain that interfered with her sleep and activity. A skilled nurse's note, dated 07/23/14, documented on the 10:00 p.m. to 6:00 a.m. shift, the resident complained of pain and was administered pain medication. A skilled nurse's note, dated 07/25/14, documented the resident complained of pain that interfered with her sleep and was administered pain medication. The resident's level of pain was not assessed before or after the medication was given for any of the times above. On 07/29/14 at 7:50 a.m., the resident was observed in the entrance to the dining room. The resident was talking to certified medication assistant (CMA) #1 and stated she had a rough night and did not sleep well. The CMA then wheeled the resident to the family area. The CMA told licensed practical nurse (LPN) #2 that the resident wanted to lay down. The nurse asked the resident if she wanted to stay up since she would be leaving soon for a physician's appointment. There was no reply and the resident was left to sit in her wheelchair in the family room. At 8:00 a.m., the resident was asked if she felt like talking to the surveyor. She stated, "Yes," but wanted to lay down while talking. The resident was assisted to her room by the activities director (AD). The resident stated her head hurt as the AD pushed her to her room. The AD then left the room with the resident remaining in her wheelchair. At 8:02 a.m., the resident stated she needed to go to bed and rest; she did not feel good. At that time she began to transfer herself to the bed without assistance. The call light was initiated to ask for assistance in helping the resident. As the resident transferred herself to the bed she stated she hurt so bad. She exhibited facial grimacing and began crying, repeating she just felt so bad. At 8:11 a.m., the CNA (certified nurse aide) #4 came into the room and asked the resident what she needed. The resident attempted to explain and began crying. She stated she was going to get the nurse and have her come check on the resident. At 8:21 a.m., CMA #1 came into the room with [MEDICATION NAME]. The resident stated to the CMA she felt terrible. The CMA rubbed the gel on the resident's arm and then left the room. At approximately 8:45 a.m., the resident was transported to a physician's appointment. On 07/30/14 at approximately 9:00 a.m., a family member informed the surveyor that the resident was admitted to the hospital. Hospital records were then obtained. A hospital history and physical note, dated 07/29/14, documented during a radiology appointment, the specialist observed the resident to be drowsy and with altered mentation. The resident was sent from the physician's office to the emergency room for admission. The hospital assessment and plan documented the resident had an altered mental status, rule [MEDICAL CONDITION]/spontaneous bacterial peritonitis and drug overdose with opioids/hepatic [MEDICAL CONDITION]. On 07/30/14 at 2:50 p.m., LPN #2 was asked if staff or resident #59 had voiced any concerns before her departure to the hospital on [DATE]. She stated she did not recall, but they could have. She stated the resident voiced that she wanted to lay down in bed. She stated she told the resident she was going to be leaving the facility for a doctors appointment soon. She informed a staff member to ensure the resident was comfortable. She was asked if any staff had brought to her attention the resident's request for pain med. She stated she was not aware of any but she could go look and see if she was administered any. After reviewing the MAR, the LPN stated the resident did not receive any prn pain medication before she left. At 3:15 p.m., LPN #2 was asked when residents, who frequently requested pain medication, were reassessed for the effectiveness of the medication. She stated she would visit with the doctor and/or the nurse practitioner when they made their visits. On 07/31/14 at 12:15 p.m., the assistant director of nurses (ADON) was asked if the physician had been notified about the resident's lack of pain control with the medication being used for her pain. She stated, "No." She was asked if the physician should be notified about a resident's uncontrolled pain. She stated, "Yes." She stated she would anticipate the nurses' would call the physician and review the resident's pain and current medication regime with the physician. She stated the physician should be notified of any uncontrolled pain at anytime. The ADON was asked how the nurse should assess the pain. She stated they should assess the severity level, the location of the pain, rate the pain and find out how long it has been going on. She was asked where the information should be documented. She stated in the nurse's notes. No information was found. She was asked how would the facility would determine if the pain medication was effective. She stated the nurse should reassess the effectiveness of the med 30-45 minutes after administration. If the medication did not effectively relieve the pain, the physician should be notified and any new orders or interventions should be documented in the nurse's notes. On 08/01/14 at 9:15 a.m., the nurse practitioner was asked if she was notified of the resident's uncontrolled pain. She stated she did not think so, but it would be documented in her notes if she was. There was no documentation in the nurse practitioner's notes of staff notifying her of the resident's severe and/or uncontrolled pain. 2. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 06/21/13, documented the resident had his own lower teeth and received a regular diet. The quarterly assessment, dated 04/02/14, documented the resident had moderately impaired cognition, was on scheduled pain medication, had no mouth pain, discomfort or difficulty chewing and he wore dentures. The May 2014 MAR, documented the resident received Tylenol 1000 mg three times a day and [MEDICATION NAME] tablet 400 mg daily routinely for pain. The resident could receive [MEDICATION NAME] every 6 hours prn for pain if necessary. The May 2014, monthly physician's orders [REDACTED]. A nurse's note dated, 05/04/14 at 4:00 p.m., documented the resident had been refusing to eat due to his teeth hurting. He stated it hurt when he attempted to chew even softened food. The nurse had left contact with (Name-deleted social services director) for assistance. The resident's level of pain was not assessed; no prn pain medication was provided and the physician was not notified. A physician's telephone order, dated 05/08/14 at 7:00 p.m., documented to start PCN VK (an antibiotic) 500 mg by mouth twice daily for seven days. A nurse's note, dated 05/09/14 at 8:00 p.m. (five days after the complaint of tooth pain), documented the resident was started on an antibiotic for a tooth abscess. The initial dose was given 25 hours after the order was received. The May 2014, treatment administration record (TAR), documented per physician's request on 05/08/14, an order for [REDACTED]. A social service's note, dated 05/30/14 (26 days after complaint of tooth pain), documented the resident was seen by the dentist. A dental note, dated 05/30/14, documented the resident had a lower front extraction. The care plan, dated 06/21/14, documented the resident was at risk for self care deficit. The care plan documented the resident had impaired cognition, required extensive assist of one to two staff members with activities of daily living care, and had episodes of pain. Approaches for care included staff were to observe for signs and symptoms of pain and offer effective pain management as ordered. On 08/01/14 at 8:45 a.m. the director of nurses (DON) was asked if the physician had been notified of the change in condition for the resident related to his tooth pain. He stated, "No." The DON was asked to review the MAR indicated [REDACTED]. After reviewing the MAR, he stated it documented he received an extra dose of [MEDICATION NAME] on 05/02/14. According to documentation, there was no pain medication administered after that incident. On 08/01/14 at 12:06 p.m., LPN #1 was asked if she administered prn [MEDICATION NAME] to the resident due to his complaint of tooth pain. She stated she did not.

Based on record review and interview, it was determined the facility failed to ensure a resident was provided dental services in a timely manner for one (#14) of one sampled residents with dental concerns. This resulted in actual harm with the development of a tooth abscess. This had the potential to affect all 43 residents who resided in the facility. Findings: Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 06/21/13, documented the resident had his own lower teeth and received a regular diet. The quarterly assessment, dated 04/02/14, documented the residents had moderately impaired cognition, was on scheduled pain medication, had no mouth pain, discomfort or difficulty chewing and he wore dentures. The care plan, dated 06/21/14, documented the resident was at risk for self care deficit. The care plan documented the resident had impaired cognition, required extensive assist of one to two staff members with activities of daily living care, and had episodes of pain. Approaches of care included staff were to anticipate/ensure his needs were met and observe for signs and symptoms of pain and offer effective pain management as ordered. The May 2014 MAR, documented the resident received Tylenol 1000 mg three times a day and [MEDICATION NAME] tablet 400 mg daily routinely for pain. The resident could receive [MEDICATION NAME] every 6 hours prn for pain. The May 2014 monthly physician's orders [REDACTED]. A nurse's note dated, 05/04/14 at 4:00 p.m., documented the resident had been refusing to eat due to his teeth hurting. He stated it hurt when he attempted to chew even softened food. The nurse had left contact with the social services director for assistance. The resident's level of pain was not assessed; no prn pain medication was provided; the physician was not notified and no attempts to obtain dental services were initiated at that time. A physician's telephone order, dated 05/08/14 at 7:00 p.m., documented to start PCN VK (an antibiotic) 500 mg by mouth twice daily for seven days. The May 2014 treatment administration record (TAR), documented an order, staff were to make a dental appointment due to tooth abscess per physician's request on 05/08/14. A nurse's note, dated 05/09/14 at 8:00 p.m. (five days after complaint of tooth pain), documented the resident was started on an antibiotic for a tooth abscess. The initial dose was given 25 hours after the order was received. A social service's note dated 05/30/14, which was 26 days after the staff identified tooth pain, documented the resident was seen by the dentist. A dental note, dated 05/30/14, documented the resident had a lower front extraction. On 08/01/14 at 8:45 a.m. the director of nurses (DON ) was asked if the physician had been notified of the change in condition for the resident related to his tooth pain. He stated, "No." He was asked if timely dental services had been provided and he stated, "No."