Every finding on record at Trinity Village

Based on record review and staff interviews, the facility failed to provide care in a safe manner when a resident was rolled out of bed hitting the floor face first during incontinence care. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #72).The findings included:Resident #72 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, and seizure disorder.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment and required substantial to maximal assistance (helper does more than half the effort) with the ability to roll left and right while in bed.Review of Resident #72's Medication Administration Record (MAR) dated January 2026 revealed she had no orders for a anticoagulant medication.A Physical Therapy note dated 01/12/26, written by Physical Therapist #1, revealed Resident #72 required partial to moderate assistance (helper does less than half the effort) for rolling left and right in bed.On 03/11/26 at 9:03 AM, an interview was conducted with Physical Therapist #1. During the interview, she stated Resident #72 required moderate to maximum assistance of two staff members with everything. She stated Resident #72 required direction and verbal cues. Physical Therapist #1 further stated that when the resident was discharged from therapy services, she required one-person assistance with bed mobility.A review of Resident #72's care plan dated 01/16/26 revealed a focus area related to functional performance. Interventions included that Resident #72 was independent with bed mobility (rolling left and right), requiring only verbal cues and occasional hands-on prompting due to cognition.A review of Resident #72's care guide (a guide that explains to staff members what assistance each resident requires) on 03/10/26 revealed the following documentation: Roll left and right independent.An observation conducted on 03/10/26 at 11:09 AM of Resident #72 revealed she was sitting in her wheelchair in the main common area of the locked unit. Resident #72 was observed smiling at the surveyor however was unable to communicate verbally.An incident report dated 01/14/26 at 7:15 AM, written by Nurse #1, revealed she was notified by a staff member (Nurse Aide #2) that Resident #72 was on the floor. Upon entering the room, the resident was observed lying face down on the floor next to her bed. Resident #72 had rolled off the bed while care was being provided. No injuries were initially observed. The detailed report revealed Resident #72 was a two-person assistance with transfers. On 01/14/26 at 7:15 AM, NA #2 was providing care for the resident when he attempted to roll her to change her brief. She continued to roll off the side of the bed and onto the floor. Resident #72 sustained an abrasion to her face, with no other injuries noted. Interventions following the fall included placing a side rail on the left side of the resident's bed to aid in mobility while turning.A nursing progress note written by Nurse #1 dated 01/14/26 at 4:50 PM, recorded as a post-fall evaluation, revealed that at 7:15 AM Resident #72 had a witnessed fall. While staff were changing her brief, the resident rolled out of bed. As a result, she sustained an abrasion to the right side of her forehead. On 03/10/26 at 11:29 AM, an interview was conducted with Nurse Aide (NA) #2. During the interview, he stated that on 01/14/26 around 7:10 AM, he entered Resident #72's room to provide incontinence care and assist her with dressing for the day. He explained that she was awake, and he informed her he was going to change her and roll her onto her side. NA #2 stated he picked up the bed pad underneath the resident and pulled it upward, placing the resident onto her left side. He further stated that as he lifted and her weight shifted toward the other side, she continued rolling and went off the bed onto the floor face first. NA #2 stated he attempted to catch her; however, he was unable to reach her because he was positioned across the bed. He stated he ran to the other side and observed the resident face down on the carpeted floor and called out for Nurse #1. He explained Resident #72 was non-verbal and was pointing to her forehead, where there was an abrasion. NA #2 stated Nurse #1 entered the room and assessed Resident #72, and the staff then used a gait belt to assist the resident back into her wheelchair. NA #2 stated the bed was in a low position at the time of the fall. NA #2 further stated that earlier that morning he had been informed during rounds that Resident #72 had changed to requiring a two-person assist with transfers, but not with bed mobility. He explained he had not worked with the resident since that update but acknowledged he should have rolled her toward him instead of away from him during care.On 03/11/26 at 10:16 AM, an interview was conducted with Nurse #1. During the interview, she stated that on 01/14/26 she remembered NA #2 calling out for assistance from the Resident's room. She stated that upon entering the room, she observed Resident #72 face down on the carpeted floor. Nurse #1 immediately assessed the resident and obtained vital signs. No major injuries were noted; however, an abrasion was present on her forehead. Resident #72 was placed on neurological checks due to hitting her head and was assisted back into her wheelchair using a gait belt with assistance from another staff member. Nurse #1 stated that NA #2 reported that while he was rolling Resident #72 in bed to provide incontinence care, he rolled her away from him using the bed pad, which resulted in her rolling off the bed onto the floor. The interview further revealed that staff were required to provide verbal cues to Resident #72, as she would not understand what to do without guidance due to cognitive impairment. Nurse #1 stated that NA #2 should have rolled the resident toward him during care rather than away from him.On 03/11/26 at 9:05 AM, an interview was conducted with the Director of Nursing (DON). During the interview, she stated she was the interim DON and was not in that role at the time of the incident. She explained that Resident #72 required verbal cues and assistance from at least one staff member with bed mobility. The DON stated that after reviewing the incident on 01/14/26, NA #2 should have rolled the resident toward him during incontinence care rather than away from him. She also stated she would have expected him to provide appropriate verbal cues prior to rolling the resident.On 03/11/26 at 1:06 PM, an interview was conducted with the Administrator. During the interview, she stated that appropriate positioning of Resident #72 would have included rolling her toward NA #2 during care rather than away from him.

Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene Policy when the Wound Care Nurse failed to doff her gloves, sanitize her hands, and don clean gloves after cleaning Resident #57's sacral wound and surrounding area and prior to cutting and placing the alginate with silver (highly absorbent wound dressing) on his wound bed during wound care. The deficient practice occurred for 1 of 8 staff observed for infection control practices (Wound Care Nurse).The findings included:Review of the facility's policy entitled Hand Hygiene which is part of the Infection Control Policies and Procedures, last revised on 10/12/23 read in part, Policy:Practicing hand hygiene is a simple yet effective way to prevent infections. Performing hand hygiene can prevent the spread of germs, including those that are resistant to antibiotics. All teammates are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of infections. Teammates are expected to follow hand hygiene procedures to help prevent the spread of infections to other staff members, residents and visitors.Procedures:4. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:Before donning gloves and after removing glovesBefore and after handling clean or soiled dressings, gauze pads, contaminated equipment, etc.Before moving from a contaminated body site to a clean body site during resident care.6. The use of gloves does not replace handwashing/hand hygiene.Review of Resident #57's electronic medical record (EMR) revealed wound care orders for an unstageable pressure ulcer to his sacrum. The wound orders dated 03/01/26 read, cleanse with normal saline (NS), pat dry, apply alginate with silver and cover with dry dressing daily every day shift and as needed for protection.An observation was conducted on 03/11/26 at 10:12 AM of wound care being provided to Resident #57 for his sacral wound. The Wound Care Nurse with mask, gown, goggles, and gloves on cleansed the overbed table with a wipe and placed a barrier on the table and then her wound supplies. She doffed her gloves sanitized her hands and donned clean gloves and cleaned the wound bed of Resident #57's sacral wound. The Wound Care Nurse doffed her gloves, sanitized her hands, donned clean gloves and cleaned the outer wound area with NS-soaked gauze and patted the wound dry. She then, without doffing her gloves, sanitizing her hands and donning clean gloves, proceeded to cut the alginate with silver dressing and placed it on the wound bed to make sure it was covered. The Wound Care Nurse then doffed her gloves, sanitized her hands and donned clean gloves and placed a clean dressing on the wound over the alginate with silver. She doffed her gloves, washed her hands with soap and water, donned clean gloves and proceeded to Resident #57's heel wounds. After completing care to the heel wounds she gathered her trash, doffed her gloves, eye protection, gown and mask, washed her hands with soap and water, gathered her trash and left the room.An interview on 03/11/26 at 10:40 AM with the Infection Preventionist (IP) revealed the Wound Care Nurse should have doffed her gloves after cleaning the wound, sanitized her hands, donned clean gloves and then proceeded with cutting the alginate with silver dressing and applying it to the wound bed. An interview on 03/11/26 at 12:20 PM with the Wound Care Nurse and the Director of Nursing (DON) revealed that the Wound Care Nurse stated she was not aware that she had not doffed her gloves, sanitized her hands and donned clean gloves after cleansing the area around the wound bed and before cutting and applying the alginate with silver dressing to the wound bed. The Wound Care Nurse stated she should have cleansed the wound and surrounding area and then doffed her gloves, sanitized her hands, and donned new gloves prior to cutting and applying the alginate with silver dressing to the wound bed. The DON stated that she agreed that when moving from a dirty procedure (cleansing the wound and surrounding area) to a clean procedure (applying wound treatment) you should doff your gloves, sanitize your hands, and don clean gloves prior to the clean procedure.An interview on 03/11/26 at 2:15 PM with the Administrator revealed she would have expected the Wound Care Nurse to follow their Hand Hygiene policy and procedure while providing wound care.

Based on record review and staff interviews, the facility failed to update and revise an individualized person-centered comprehensive care plan for 1 of 5 residents whose comprehensive care plans were reviewed (Resident #72).The findings included:Resident #72 was admitted to the facility on [DATE] with diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, and seizure disorder.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment and required substantial/maximal assistance (helper does more than half the effort) with the ability to roll left and right while in bed. A Physical Therapy Discharge summary dated [DATE] through 01/19/26 revealed Resident #72's discharge recommendations was a two person assistance for transfers and gait. A Physical Therapy note dated 01/12/26 written by Physical Therapist #1 revealed Resident #72 required partial/moderate assistance (helper does less than half the effort) for rolling left and right in the bed.On 03/11/26 at 9:03 AM, an interview was conducted with Physical Therapist #1. During the interview, she stated Resident #72 required moderate to maximum assistance of two staff members with everything. She stated Resident #72 required direction and verbal cues. Physical Therapist #1 stated when the resident was discharged from therapy services she required one-person assistance with bed mobility.Review of Resident #72's care plan dated 01/16/26 revealed a focus area related to functional performance. Interventions included that Resident #72 was independent with bed mobility (rolling left and right), requiring only verbal cues and occasional hands-on prompting due to cognition.Review of Resident #72's care guide (a guide that explains to staff members what assistance each resident requires) on 03/10/26 revealed the following documentation: Roll left and right independent. On 03/10/26 at 11:15 AM, an interview was conducted with Nurse Aide (NA) #1. During the interview she confirmed she was caring for Resident #72. She explained Resident #72 required assistance of one to two staff members with bed mobility depending on the day and how the resident was. NA #1 explained the first thing staff members were supposed to do was check the care guide in the morning, which came from the resident's care plan, to see how each resident transferred. NA #1 stated she knew Resident #72's care guide said she was independent; however, staff working with the resident on the floor knew that the information was incorrect but had not mentioned it to anyone. On 03/11/26 at 10:16 AM, an interview was conducted with Nurse #1. During the interview, she stated Resident #72 required assistance of one staff member for bed mobility. She explained it was the MDS Nurse who would alter the care plans and update the care guide.On 03/10/26 at 11:56 AM, an interview was conducted with MDS Nurse #1. During the interview, she stated she was responsible for the care plans for the facility. She explained that the Director of Nursing (DON) could also update the care plans and care guide. She stated the former DON had updated the care plan on 01/16/26 to show Resident #72 was independent for bed mobility. MDS Nurse #1 reviewed the Physical Therapy discharge summary then explained she had discussed Resident #72 with Physical Therapist #1 and the Nurse Aides who stated Resident #72 required at least one-person assistance for bed mobility. MDS Nurse #1 stated the care plan should not have indicated that Resident #72 was independent for bed mobility and it should have been correctly reflected in the care plan and care guide. She explained the typical process was for Therapy services to call her with any updates or changes with mobility status. She did not recall being informed of a status change but stated she should have seen the therapy note. On 03/11/26 at 1:10 PM, an interview was conducted with the Administrator, who stated that she expected all residents to have an accurate comprehensive care plan, and the care plan should reflect the resident's clinical condition and care needs.

Based on record review and resident and staff interviews, the facility failed to protect resident's right to be free from abuse for 1 of 3 residents reviewed for abuse, when Nurse Aide (NA) #1 struck Resident #1 in the shoulder two times with an open hand during incontinence care, resulting in Resident #1 crying. The findings included: Resident #1 admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a stroke and dementia with mood disturbance. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively impaired without delirium, rejection of care, or instances of wandering. Resident #1 was coded as having physical and verbal behaviors directed towards others and other behaviors not directed towards others as occurring 1-3 days during the lookback period. Resident #1 was coded as frequently incontinent of bowel and bladder and was dependent on others for toilet hygiene and personal hygiene. She needed extensive assistance with rolling to the left and right. Review of Resident #1's care plan, last updated on 11/01/23, revealed the following care area: Level 2 Preadmission Screening and Resident Review with behaviors which included [Resident #1] has a history of yelling, hitting, slapping, spitting, grabbing, and uses bad language towards staff in her native language. Review of facility provided reportable incidents 12/29/23 revealed a documented incident of alleged abuse directed towards Resident #1 by Nurse Aide (NA) #1. The initial 24-hour report indicated that another nurse aide (NA #2) was assisting NA #1 with providing incontinence care to Resident #1 when Resident #1 became aggressive towards the staff which resulted in NA #1 striking Resident #1 in the left should twice. Per the facility's investigation, NA #1 was immediately suspended pending the investigation. There were written statements from NA #1 and NA #2. Review of NA #2's written statement revealed the following: Today around 4:00 PM I asked [NA #1] to help me change [Resident #1] in bed. Due to her being sick and deciding not to get up. We proceeded to gather the materials that were needed for her to be changed, after doing so we both went to a side of her bed so we could roll her back and forth. [NA #1] began to grab the padding under [Resident #1], on my side. [Resident #1] smacked her hand, and [NA #1] smacked her hand back and yelled you hit me first. [Resident #1] yelled back and began to sob. I told [NA #1] You can't do that, that isn't right. She replied, I can't stand this type of behavior, she is entitled. I said nothing. As I am cleaning [Resident #1], because she is rolled now, [Resident #1] begins to cry louder and yell. [NA #1] starts to yell at [Resident #1] telling her to stop and be quiet. [Resident #1] gets upset and tries to spit on her [NA #1]. [NA #1] says to her you want to spit? [Resident #1] tries to spit again and NA #1 smacks her face. I said, [NA #1], you cannot do that, that is not right. She begins to tell me how nice of a person she is and how she has had to deal with a lot so [she] can't tolerate this kind of behavior from [Resident #1]. At this point [Resident #1] is bawling her eyes out, holding my arm. I tell her It's ok senora. Then I left the room after cleaning up to figure out how and who to tell. An interview with NA #2 via telephone on 04/22/24 at 5:18 PM revealed she remembered that incident with Resident #1 and NA #1. She reported she had asked NA #1 to go and assist her in providing incontinence care to Resident #1. She reported they entered the room, notified Resident #1 of their intention to provide incontinence care with NA #1 on the left side of the bed and herself on the right side of the bed. NA #2 reported as NA #1 began to turn Resident #1 on her side, Resident #1 became angry, yelling, and swatted at NA #1. She reported NA #1 then popped Resident #1 back on her left shoulder with an open hand and told Resident #1 to stop. NA #2 reported she told NA #1 at that time that she could not do that and to stop. NA #2 stated the care continued and Resident #1 attempted to spit on NA #1 multiple times. She stated at that point, NA #1 popped Resident #1 again, either on the side of her face or left shoulder. NA #2 stated she again told NA #1 that she could not do that, and NA #1 responded that she would not deal with that kind of behavior. She stated at that point, she observed Resident #1 crying, and she told Resident #1 it was ok. NA #2 then reported she and NA #1 left at the completion of incontinence care and she went and immediately reported it to her hall nurse (Nurse #1). NA #2 reported she believed NA #1 was sent home almost immediately after she reported the interaction. NA #2 indicated Resident #1 was not physically injured but reported Resident #1 was emotionally upset following the interaction. NA #2 did not clarify why she did not stop the care when Resident #1 became aggressive or why the care was not stopped after the first time NA #1 struck Resident #1. Review of NA #1's written statement from the day of the incident with Resident #1 read: I was on my 2nd shift working on 400 hall. While I was working with [NA #2] helping [Resident #1] to change, she hit me multiple times and spit on my face. I witnessed several times she did it to other CNA's, but at that moment I hit her arm back. Later I realized I shouldn't, but somehow that moment I reacted. Sorry about it. An interview with NA #1 via telephone on 04/22/24 at 12;17 PM revealed she was working on the same hall where Resident #1 resided but was not Resident #1's assigned nurse aide. She continued, stating that she and another nurse aide (NA #2) had gone into Resident #1's room to provide incontinence care. She reported she was very familiar with Resident #1 and stated she had a history of bullying other nurse aides and would often punch, spit, and hit the nurse aides that provided her care. NA #1 stated when she and NA #2 entered Resident #1's room, they explained to her what care they planned to provide and when she rolled Resident #1 onto her right side, Resident #1 began to kick her. NA #1 stated she asked Resident #1 multiple times to please stop, don't do this but admitted she became frustrated and ended up hitting Resident #1 with her open hand on her left shoulder. She stated Resident #1 then began to spit in her face and she reacted by popping Resident #1 on the left shoulder again. She stated NA #2 asked her why she was did that and she told her you saw what she was doing; hitting, spitting, and kicking me. NA #1 reported her strikes were not hard and did not make any sounds, leave redness, bruising, or other marks on Resident #1. She reported I never had lost my cool before that day and stated she knew after the fact that she should not have reacted that way. NA #1 stated when she and NA #2 left the room, she knew NA #2 would have to report the incident and stated she knew she would have to report it as well. NA #1 was insistent that she only struck Resident #1 on her left shoulder and that she did not use any force. NA #1 did verify that Resident #1 did begin to cry following the interaction and stated she thought her striking her surprised Resident #1 and that Resident #1 probably did not believe that a nurse aide would stand up to her behavior. NA #1 reported she did not feel as though her actions were abusive and when asked why she did not just stop the care and come back later, NA #1 reported if they would have left and come back, Resident #1 would have acted the same way and both she and NA #2 though they needed to just get it done. NA #1 stated I don't know why I was so frustrated that day. I worked on the dementia hall several months with no issues, I'm usually so very patient and treat the residents good. I don't think what I did was wrong, I make no apology to that resident for what I did, I'm sorry I surprised the other NA. I don't think it was abusive in nature, if they didn't lay me off, I was planning on quitting because the whole interaction was traumatizing. NA #1 reported she was approached almost immediately by the Assistant Administrator and was told she needed to go home. NA #1 stated she was suspended pending an investigation and ultimately terminated. Multiple attempts to reach Nurse #1 by telephone on 04/22/24 and 04/23/24 were unsuccessful. Nurse #1 never returned any telephone calls. Review of Nurse #1's written statement dated 12/29/23 revealed the following: I was sitting in charting room when [NA #2] asked to speak to me in private. She reported what she had just seen [NA #1] had done to [Resident #1]. I immediately reported to [Assistant Administrator] who immediately spoke with [the nurse aides]. An interview with the Administrator on 04/22/24 at 2:18 PM, who was serving as the Assistant Administrator the day of the incident revealed she was approached by Nurse #1 who informed her that NA #2 had alleged that NA #1 had struck Resident #1 twice during incontinence care. The Administrator stated she went and spoke with NA #2 who recounted the incident to her. The Administrator stated she then immediately went to NA #1 and informed her of the allegations and sent her home. The Administrator stated she believed less than 10 minutes passed between her being notified and NA #1 being sent home. She stated she assigned a unit manager to escort NA #1 from the building to ensure she had no other interactions with other residents. The Administrator stated she then notified the Director of Nursing and began a full investigation into the allegations. She reported her investigation determined that due to the statements that alluded Resident #1 was tearful following the interaction, she ended up substantiating the allegation and subsequently terminated the employment of NA #1. She stated immediately after the incident, Nurse #1 completed skin checks of Resident #1 and all other cognitively impaired residents, while cognitively intact residents were interviewed with no concerns noted. She also reported assigning abuse, neglect, and exploitation training to all her staff that had to be completed before their next shift, along with training regarding employee burnout. The Administrator stated when she went to interview Resident #1 shortly after being informed of the incident, she was observed to be in her room, resting comfortably and did not appear to be upset. She stated when she questioned Resident #1, Resident #1 could only respond with yes/no answers but reported someone had been mean to her but was unable to tell her where she was hit. The Administrator stated Resident #1 did not appear tearful or fearful during questioning. She also stated a skin check was performed with no injury, redness, or swelling being observed. The Administrator stated with the statement of Resident #1 being emotional after the incident, they reached out to Resident #1's psych provider who stated they did not currently have a provider they could send to the facility to speak with Resident #1 so she reached out to the medical director who followed up a day or two later. The Administrator reported at the time of the investigation, NA #1 only ever reported to them that she struck Resident # 1 once and that she felt that NA #2 had intervened when she told NA #1 she should not be striking the resident. The Administrator reported that all staff were trained on abuse policies and procedures at the time of hire and then on an annual basis. The Administrator also reported the facility had placed the incident in their quality assurance program which included audits of staff interactions and on-going, current monitoring. An interview with Resident #1 was completed on 04/23/24 at 2:17 PM. Resident #1 was in her room, dressed, and sitting in her wheelchair. A facility provided translator was used as Resident #1's primary language was Spanish. Resident #1 reported that she was happy with the care she received, the staff were very respectful and that she felt safe at the facility. Resident #1 had no recollection of the incident with NA #1. The facility provided the following corrective action plan: 1. Corrective action for residents found to be affected: A. What are we going to do for the resident affected? Immediate skin check, physical assessment for injuries performed by nurse #1. Abuse Allegation was reported to the resident's family (RR), Administrator, DON, Provider, the Admin Office, Adult Protective Services, and the local police department. Accused NA was immediately suspended pending investigation results. Accused NA was advised to not return to the facility or the facility's property until further notice. NA was terminated once the investigation was completed. 2-hour abuse reporting to state completed on 12/29/23. Resident was assessed by the provider on 01/02/24 and new order for medication to decrease behaviors received however RR refused to allow the new medication. Alleged Abuse Incident report was completed by hall nurse on 12/29/23. Administrator observed four different employee interactions on 12/29/23 with residents to ensure that staff interactions were appropriate. Reviewed resident's care plan and added intervention for staff to leave and reapproach resident when she is combative with care on 12/29/23. B. Who is going to do it? Hall nurse performed assessment on resident and completed the incident report for alleged abuse on 12/29/23. Nurse notified Administrator and Administrator completed 2-hour abuse reporting form and sent in on 12/29/23. Nursing Supervisor notified provider on call on 12/29/23. Administrator notified resident's family(RR) and DON on 12/29/23. Hall nurse completed incident report on 12/29/23. Administrator met immediately with accused NA and suspended her immediately on 12/29/23. DON and Administrator met with NA #1 and terminated her employment once the allegation was substantiated on 12/30/23. Administrator and DON reviewed resident's care plan and added appropriate interventions. C. How will the corrective action be communicated to staff? N/A. None Needed. The NA involved was suspended immediately and then terminated. NA intervened and then reported immediately to supervisor. She received same education and training as all staff. D. Is action clearly documented and care planned? Documented in statements and in with the NA involved. Resident #1's care plan was reviewed and appropriate new interventions added on 12/29/23. 2. How will corrective action be accomplished for those residents having the potential to be affected? A. How will we identify other residents at risk? All residents in the facility have the potential to be at risk. B. After identifying at risk residents, what are we going to do for them? The hall nurse performed skin assessments on all residents that accused NA cared for on this day that were unable to be interviewed on 12/29/23. No further injuries noted. The Administrator interviewed residents and asked if they felt safe and if they had any concerns of any staff member being mean to them or rough with them. All other residents stated they felt safe and no one had been mean or rough with them. LSC Employee Interaction Audit Form for Substantiated Abuse Allegation was started immediately. That audit will be completed by Central Nurse Manager who will observe 4 different employees' interactions with residents 3 times per week for 4 weeks to ensure that staff interactions are appropriate. Staff education started immediately regarding Abuse, Intervening and Caregiver burnout. Education completed 12/29/23 for all staff in facility and all staff will be educated prior to working their next shift. Two extra Relias courses were assigned by the Staff Development Coordinator for the month of January related to Abuse and Caregiver burnout. C. Are we taking credit for interventions in the chart and on the care plan? N/A. Nothing new required to be added to care plans for residents at risk. 3. What measures will be put into place to ensure that the deficient practice will not occur? A. What system(s) will we adapt/change/implement to keep the problem from reoccurring? Abuse Investigating and Reporting education materials from Lutheran Services University that includes information on caregiver burnout along with a wallet card with signs and symptoms of staff burnout added to facility orientation and will remain part of orientation moving forward. Abuse Reporting has always been included in orientation however more focus on caregiver burnout will be added effective 12/30/23. Staff education completed on LSC Policy of Abuse Investigation and Reporting for Senior Services as well as Lutheran Services University education related to caregiver burnout and staff intervening, staff will be educated prior to their next working shift. Staff Development Coordinator assigned Relias courses on Abuse Reporting and on Caregiver burnout to all staff for the month of January. B. How will we educate/communicate any system changes to the staff? Printed Staff Education on LSC Policy of Abuse Investigation and Reporting for Senior Services and Lutheran Services University information on caregiver burnout as well as the two new Relias courses assigned to January agenda. Provided Staff Education on WHATSAPP messaging system to nursing department, and on PCC Bulletin Board to all departments on importance of recognizing caregiver burnout and importance of walking away when frustrated, importance of reporting potential abuse immediately to supervisor, and being familiar with LSC Policy on Abuse Investigation and Reporting which includes intervening. Added additional education materials to facility orientation related to caregiver burnout, how to recognize and importance of reporting to supervisor when caregiver burnout is suspected. Wallet card will also be provided to all new employees during facility orientation that contains symptoms of staff burnout. 4. How does the facility plan to monitor its performance to make sure that solutions are sustained? A. Are we evaluating actual staff practices? Yes. Administrator initiated and completed 4 audits 12/29/2023. Central Nurse Manager will observe 4 different employees' interactions with residents 3 times per week for 4 weeks to ensure that staff interactions are appropriate starting 12/29/23. B. Are we performing regular audits to ensure the corrective action/system/change is being implemented and are working? Yes. Observation of employee's interactions with residents has been started and will continue monthly x3 beginning immediately and continuing February and March 2024, and then quarterly for Q2,Q3, and Q4 in 2024. These observations will end 12/31/2024. C. Are we sharing audit results in the monthly QAPI meetings? Yes. All POCs are shared in QAPI. The next QAPI meeting is scheduled for February 1, 2024. Compliance date: January 3, 2024 The facility's corrective action plan was validated on 04/23/24. Review of facility provided monitoring tools revealed the facility had completed a 24 hour and 5 working day report upon notification of the incident and completion of their investigation. The investigation revealed written statements from all parties involved, a termination notification for NA #1, education with sign-in sheets for all staff in the facility, skin checks and interviews with alert and oriented residents, and finally monitoring tools for ongoing monitoring to ensure the issue was resolved. The completion of the self-imposed corrective action plan was verified on-site through staff interviews and record review. The compliance date of 01/03/24 was validated.

Based on observations, record reviews, staff and resident interviews the facility failed to protect a resident from further abuse when Nurse Aide #2 witnessed NA #1 striking Resident #1 when she became combative during care and did not immediately report the incident to her supervisors which resulted in NA #1 striking Resident #1 a second time, resulting in Resident #1 crying for 1 of 3 residents reviewed for abuse. The findings included: A review of the facility's policy titled Abuse Investigation and Reporting for Senior Services last revised on 01/26/23 revealed: Retaliation by staff, regardless of whether harm was intended, is also considered abuse. The policy also stated physical abuse is defined as hitting, slapping, pinching, kicking, etcetera. It also includes controlling behavior through corporal punishment, which is used as a means to correct or control behavior through such actions as pinching, spanking, slapping hands, or hitting with an object. The facility's policy stated its policy included identifying, correcting, and intervening in abusive situations. Review of facility provided reportable incidents 12/29/23 revealed a documented incident of alleged abuse directed towards Resident #1 by Nurse Aide (NA) #1. The initial 24-hour report indicated that another nurse aide (NA #2) was assisting NA #1 with providing incontinence care to Resident #1 when Resident #1 became aggressive towards the staff which resulted in NA #1 striking Resident #1 in the left should twice. Per the facility's investigation, NA #1 was immediately suspended pending the investigation. There were written statements from NA #1 and NA #2. Review of NA #2's written statement revealed the following: Today around 4:00PM I asked [NA #1] to help me change [Resident #1] in bed. Due to her being sick and deciding not to get up. We proceeded to gather the materials that were needed for her to be changed, after doing so we both went to a side of her bed so we could roll her back and forth. [NA #1] began to grab the padding under [Resident #1], on my side. [Resident #1] smacked her hand, and [NA #1] smacked her hand back and yelled you hit me first. [Resident #1] yelled back and began to sob. I told [NA #1] You can't do that, that isn't right. She replied, I can't stand this type of behavior, she is entitled. I said nothing. As I am cleaning [Resident #1], because she is rolled now, [Resident #1] begins to cry louder and yell. [NA #1] starts to yell at [Resident #1] telling her to stop and be quiet. [Resident #1] gets upset and tries to spit on her [NA #1]. [NA #1] says to her you want to spit? [Resident #1] tries to spit again and NA #1 smacks her face. I said, [NA #1], you cannot do that, that is not right. She begins to tell me how nice of a person she is and how she has had to deal with a lot so [she] can't tolerate this kind of behavior from [Resident #1]. At this point [Resident #1] is bawling her eyes out, holding my arm. I tell her It's ok senora. Then I left the room after cleaning up to figure out how and who to tell. An interview with NA #2 via telephone on 04/22/24 at 5:18 PM revealed she remembered that incident with Resident #1 and NA #1. She reported she had asked NA #1 to go and assist her in providing incontinence care to Resident #1. She reported they entered the room, notified Resident #1 of their intention to provide incontinence care with NA #1 on the left side of the bed and herself on the right side of the bed. NA #2 reported as NA #1 began to turn Resident #1 on her side, Resident #1 became angry, yelling, and swatted at NA #1. She reported NA #1 then popped Resident #1 back on her left shoulder with an open hand and told Resident #1 to stop. NA #2 reported she told NA #1 at that time that she could not do that and to stop. NA #2 stated the care continued and Resident #1 attempted to spit on NA #1 multiple times. She stated at that point, NA #1 popped Resident #1 again, either on the side of her face or left shoulder. NA #2 stated she again told NA #1 that she could not do that, and NA #1 responded that she would not deal with that kind of behavior. She stated at that point, she observed Resident #1 crying, and she told Resident #1 it was ok. NA #2 then reported she and NA #1 left at the completion of incontinence care and she went and immediately reported it to her hall nurse (Nurse #1). NA #2 reported she believed NA #1 was sent home almost immediately after she reported the interaction. NA #2 indicated Resident #1 was not physically injured but reported Resident #1 was emotionally upset following the interaction. NA #2 did not clarify why she did not stop the care when Resident #1 became aggressive or why the care was not stopped after the first time NA #1 struck Resident #1. Review of NA #1's written statement from the day of the incident with Resident #1 read: I was on my 2nd shift working on 400 hall. While I was working with [NA #2] helping [Resident #1] to change, she hit me multiple times and spit on my face. I witnessed several times she did it to other CNA's, but at that moment I hit her arm back. Later I realized I shouldn't, but somehow that moment I reacted. Sorry about it. An interview with NA #1 via telephone on 04/22/24 at 12;17 PM revealed she was working on the same hall where Resident #1 resided but was not Resident #1's assigned nurse aide. She continued, stating that she and another nurse aide (NA #2) had gone into Resident #1's room to provide incontinence care. She reported she was very familiar with Resident #1 and stated she had a history of bullying other nurse aides and would often punch, spit, and hit the nurse aides that provided her care. NA #1 stated when she and NA #2 entered Resident #1's room, they explained to her what care they planned to provide and when she rolled Resident #1 onto her right side, Resident #1 began to kick her. NA #1 stated she asked Resident #1 multiple times to please stop, don't do this but admitted she became frustrated and ended up hitting Resident #1 with her open hand on her left shoulder. She stated Resident #1 then began to spit in her face and she reacted by popping Resident #1 on the left shoulder again. She stated NA #2 asked her why she was doing that and she told her you saw what she was doing; hitting, spitting, and kicking me. NA #1 reported her strikes were not hard and did not make any sounds, leave redness, bruising, or other marks on Resident #1. She reported I never had lost my cool before that day and stated she knew after the fact that she should not have reacted that way. NA #1 stated when she and NA #2 left the room, she knew NA #2 would have to report the incident and stated she knew she would have to report it as well. NA #1 was insistent that she only struck Resident #1 on her left shoulder and that she did not use any force. NA #1 did verify that Resident #1 did begin to cry following the interaction and stated she thought her striking her surprised Resident #1 and that Resident #1 probably did not believe that a nurse aide would stand up to her behavior. NA #1 reported she did not feel as though her actions were abusive and when asked why she did not just stop the care and come back later, NA #1 reported if they would have left and come back, Resident #1 would have acted the same way and both she and NA #2 though they needed to just get it done. NA #1 stated I don't know why I was so frustrated that day. She stated I worked on the dementia hall several months with no issues, I'm usually so very patient and treat the residents good. I don't think what I did was wrong, I make no apology to that resident for what I did, I'm sorry I surprised the other NA. I don't think it was abusive in nature, If they didn't lay me off, I was planning on quitting because the whole interaction was traumatizing. NA #1 reported she was approached almost immediately by the Assistant Administrator and was told she needed to go home. NA #1 stated she was suspended pending an investigation and ultimately terminated. Multiple attempts to reach Nurse #1 by telephone on 04/22/24 and 04/23/24 were unsuccessful. Nurse #1 never returned any telephone calls. Review of Nurse #1's written statement dated 12/29/23 revealed the following: I was sitting in charting room when [NA #2] asked to speak to me in private. She reported what she had just seen [NA #1] had done to [Resident #1]. I immediately reported to [Assistant Administrator] who immediately spoke with [the nurse aides]. An interview with the Director of Nursing at the time of the incident on 04/22/24 at 4:11 PM revealed she felt that the facility's policies and procedures were followed at the time and that NA #2 intervened when she told NA #1 to stop. She indicated that NA #1 should have removed herself from the situation when she became frustrated. The Director of Nursing reported ibn response to the incident, the facility educated all staff on the policies and procedures for abuse prohibition that included intervention. An interview with the Administrator on 04/22/24 at 2:18 PM, who was serving as the Assistant Administrator the day of the incident revealed she was approached by Nurse #1 who informed her that NA #2 had alleged that NA #1 had struck Resident #1 twice during incontinence care. The Administrator stated she went and spoke with NA #2 who recounted the incident to her. The Administrator stated she then immediately went to NA #1 and informed her of the allegations and sent her home. The Administrator stated she believed less than 10 minutes passed between her being notified and NA #1 being sent home. She stated she assigned a unit manager to escort NA #1 from the building to ensure she had no other interactions with other residents. The Administrator stated she then notified the Director of Nursing and began a full investigation into the allegations. She reported her investigation determined that due to the statements that alluded Resident #1 was tearful following the interaction, she ended up substantiating the allegation and subsequently terminated the employment of NA #1. She stated immediately after the incident, Nurse #1 completed skin checks of Resident #1 and all other cognitively impaired residents, while cognitively intact residents were interviewed with no concerns noted. She also reported assigning abuse, neglect, and exploitation training to all her staff that had to be completed before their next shift, along with training regarding employee burnout. The Administrator stated when she went to interview Resident #1 shortly after being informed of the incident, she was observed to be in her room, resting comfortably and did not appear to be upset. She stated when she questioned Resident #1, Resident #1 could only respond with yes/no answers but reported someone had been mean to her but was unable to tell her where she was hit. The Administrator stated Resident #1 did not appear tearful or fearful during questioning. She also stated a skin check was performed with no injury, redness, or swelling being observed. The Administrator stated with the statement of Resident #1 being emotional after the incident, they reached out to Resident #1's psych provider who stated they did not currently have a provider they could send to the facility to speak with Resident #1 so she reached out to the medical director who followed up a day or two later. The Administrator reported at the time of the investigation, NA #1 only ever reported to them that she struck Resident # 1 once and that she felt that NA #2 had intervened when she told NA #1 she should not be striking the resident. The Administrator also reported she felt that [NAME] Administrator reported that all staff were trained on abuse policies and procedures at the time of hire and then on an annual basis. The Administrator also reported the facility had placed the incident in their quality assurance program which included audits of staff interactions and on-going, current monitoring. The facility provided the following corrective action plan: 1. Corrective action for residents found to be affected: A. What are we going to do for the resident affected? Immediate skin check, physical assessment for injuries performed by nurse #1. Abuse Allegation was reported to the resident's family (RR), Administrator, DON, Provider, the Admin Office, Adult Protective Services, and the local police department. Accused NA was immediately suspended pending investigation results. Accused NA was advised to not return to the facility or the facility's property until further notice. NA was terminated once the investigation was completed. 2-hour abuse reporting to state completed on 12/29/23. Resident was assessed by the provider on 01/02/24 and new order for medication to decrease behaviors received however RR refused to allow the new medication. Alleged Abuse Incident report was completed by hall nurse on 12/29/23. Administrator observed four different employee interactions on 12/29/23 with residents to ensure that staff interactions were appropriate. Reviewed resident's care plan and added intervention for staff to leave and reapproach resident when she is combative with care on 12/29/23. B. Who is going to do it? Hall nurse performed assessment on resident and completed the incident report for alleged abuse on 12/29/23. Nurse notified Administrator and Administrator completed 2-hour abuse reporting form and sent in on 12/29/23. Nursing Supervisor notified provider on call on 12/29/23. Administrator notified resident's family(RR) and DON on 12/29/23. Hall nurse completed incident report on 12/29/23. Administrator met immediately with accused NA and suspended her immediately on 12/29/23. DON and Administrator met with NA #1 and terminated her employment once the allegation was substantiated on 12/30/23. Administrator and DON reviewed resident's care plan and added appropriate interventions. C. How will the corrective action be communicated to staff? The NA involved was suspended immediately and then terminated. Reporting NA intervened and then reported immediately to supervisor. She received education regarding intervening, stopping what she is doing and reporting immediately via Abuse Reporting policy education and Relias online learning education. All staff in facility educated on Abuse, intervening, stopping what you are doing, reporting immediately, and investigations on 12/29/23. All additional staff will be educated prior to their next working shift. D. Is action clearly documented and care planned? Documented in statements and in with the NA involved. Resident #1's care plan was reviewed and appropriate new interventions added. 2. How will corrective action be accomplished for those residents having the potential to be affected? A. How will we identify other residents at risk? All residents in the facility have the potential to be at risk. B. After identifying at risk residents, what are we going to do for them? The hall nurse performed skin assessments on all residents that accused NA cared for on this day that were unable to be interviewed on 12/29/23. No further injuries noted. The Administrator interviewed residents and asked if they felt safe and if they had any concerns of any staff member being mean to them or rough with them. All other residents stated they felt safe and no one had been mean or rough with them. LSC Employee Interaction Audit Form for Substantiated Abuse Allegation was started immediately. That audit will be completed by Central Nurse Manager who will observe 4 different employees' interactions with residents 3 times per week for 4 weeks to ensure that staff interactions are appropriate. Staff education started immediately regarding Abuse, Intervening and Caregiver burnout. Education completed 12/29/23 for all staff in facility and all staff will be educated prior to working their next shift. Two extra Relias courses were assigned by the Staff Development Coordinator for the month of January related to Abuse and Caregiver burnout. C. Are we taking credit for interventions in the chart and on the care plan? The Resident's care plan was reviewed and updated to reflect additional interventions for staff. 3. What measures will be put into place to ensure that the deficient practice will not occur? A. What system(s) will we adapt/change/implement to keep the problem from reoccurring? Abuse Investigating and Reporting education materials from Lutheran Services University that includes information on caregiver burnout along with a wallet card with signs and symptoms of staff burnout added to facility orientation and will remain part of orientation moving forward. Abuse Reporting has always been included in orientation however more focus on caregiver burnout will be added effective 12/30/23. Staff education completed on LSC Policy of Abuse Investigation and Reporting; this policy includes education on intervening, stopping what you are doing, reporting immediately, for Senior Services as well as Lutheran Services University education related to caregiver burnout. Staff will be educated prior to their next working shift. Staff Development Coordinator assigned Relias courses on Abuse, intervening, stopping what you are doing, reporting immediately and on Caregiver burnout to all staff for the month of January. B. How will we educate/communicate any system changes to the staff? Printed Staff Education on LSC Policy of Abuse Investigation and Reporting for Senior Services and Lutheran Services University information on caregiver burnout as well as the two new Relias courses assigned to January agenda. Provided Staff Education on WHATSAPP messaging system to nursing department, and on PCC Bulletin Board to all departments on importance of recognizing caregiver burnout and importance of walking away when frustrated, importance of reporting potential abuse immediately to supervisor, and being familiar with LSC Policy on Abuse Investigation and Reporting which includes intervening, stopping what you are doing and reporting immediately. Added additional education materials to facility orientation related to caregiver burnout, how to recognize and importance of reporting to supervisor when caregiver burnout is suspected. Wallet card will also be provided to all new employees during facility orientation that contains symptoms of staff burnout. 4. How does the facility plan to monitor its performance to make sure that solutions are sustained? A. Are we evaluating actual staff practices? Yes. Administrator determined audits were needed at time of initial investigation report on 12/29/23. Audits were initiated and completed 4 audits 12/29/2023 by Administrator. Central Nurse Manager will observe 4 different employees' interactions with residents 3 times per week for 4 weeks to ensure that staff interactions are appropriate starting 12/29/23. B. Are we performing regular audits to ensure the corrective action/system/change is being implemented and are working? Yes. Audits were initiated on 12/29/23. Observation of employee's interactions with residents has been started and will continue monthly x3 beginning immediately and continuing February and March 2024, and then quarterly for Q2, Q3, and Q4 in 2024. These observations will end 12/31/2024. C. Are we sharing audit results in the monthly QAPI meetings? Yes. All POCs are shared in QAPI. The next QAPI meeting is scheduled for February 1, 2024. Date of compliance: January 3, 2024 The facility's corrective action plan was validated on 04/23/24. Review of facility provided monitoring tools revealed the facility had completed a 24 hour and 5 working day report upon notification of the incident and completion of their investigation. The investigation revealed written statements from all parties involved, a termination notification for NA #1, education with sign-in sheets for all staff in the facility, skin checks and interviews with alert and oriented residents, and finally monitoring tools for ongoing monitoring to ensure the issue was resolved. The completion of the self-imposed corrective action plan was verified on-site through staff interviews and record review. The compliance date of 01/03/24 was validated.

Based on staff interviews and record review, the facility failed to ensure a resident's lower extremities were secured in the mechanical lift during incontinence care which resulted in a fall to the floor for 1 of 3 residents reviewed for falls (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia with behavioral disturbances. A facility policy revised 7/4/19 indicated in addition to orientation training on use of the mechanical lifts, manufacturer manuals would be used to assist in the education and ensure proper usage of the lift equipment. An activity of daily living (ADL) care plan dated 6/30/22 revealed Resident #1 was to be transferred with the standup lift, a yellow medium lift sling, and 1 staff person assistance. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively impaired, was always incontinent of bowel and bladder, and required extensive assistance of 2 staff for transfers. A fall care plan dated 9/8/22 revealed Resident #1 was at risk for falls due to confusion and balance problems, and unaware of safety needs. An incident report dated 11/22/22 indicated Resident #1 was lying in the floor with her head in Nurse Aide (NA) #1's lap when Nurse #1 arrived after being summoned for assistance by an unidentified nurse aide student. The report detailed Resident #1 let go of the handlebars during a transfer and had to be lowered to the floor by NA #1. The incident report indicated Resident #1 was only oriented to person but reported no pain when Nurse #1 arrived. A disciplinary action report dated 11/22/22 reflected NA #1 was counseled and re-educated on the use of the mechanical lift secondary to a fall encountered by Resident #1 on 11/22/22 due to NA #1 not securing the buckles on the leg straps of the mechanical lift. Activity of Daily Living (ADL) documentation by NA #1 dated 11/22/22 at 4:07 PM reflected Resident #1 was dependent for transfers. A Physical Therapy Evaluation and Plan of Treatment completed by Physical Therapist (PT) #1 dated 11/22/22 reflected Resident #1 was to use the sit to stand mechanical lift with a yellow lift sling for transfers and that staff were educated on proper transfer status to maintain the safety of Resident #1 and staff. The evaluation reflected Resident #1 had a goal of improving lower extremity strength to be able to stand for greater than 10 minutes to improve transfer and sit to stand skills. An interview with NA #1 on 1/19/23 at 3:27PM revealed she was the NA assigned to provide care for Resident #1 on 11/22/22 from 7 AM to 3 PM. NA #1 indicated shortly before the end of her schedule shift; she placed Resident #1 into the mechanical sit to stand lift in to provide incontinence care. NA #1 stated she got in a hurry and did not retrieve the leg straps and attach them to the lift before attempting to stand Resident #1. NA #1 further elaborated she secured a green lift sling around Resident #1 and lifted her from her wheelchair. NA #1 stated there was a student who was observing her care but was too young to assist in the care of Resident #1 on 11/22/22. NA #1 stated she lifted Resident #1 to a standing position and began providing incontinence care. After about 8-10 minutes, she said Resident #1 started saying she needed to sit down, but NA #1 told Resident #1 she was almost finished with her care and would sit her as soon as the incontinence care was completed. NA #1 stated around 12-15 minutes into care, Resident #1 let go of the handlebars on the lift and had to be caught before she hit the floor from falling out through the lift sling. She could not recall who the student nurse aide present at the time of the fall but indicated she did not recall Resident #1 being injured when the fall occurred. A telephone interview with Nurse #1 on 1/19/23 at 3:42 PM revealed she was the nurse assigned to the unit where Resident #1 resided and was called to the room on 11/22/22 where she found Resident #1 in the floor with her head in NA #1's lap. Nurse #1 indicated she assessed Resident #1 while in the floor to have no visible injuries and she assisted NA #1 to stand her and place her back to her wheelchair with the use of a gait belt. Nurse #1 stated she was not made aware at the time of the fall that NA #1 had performed incontinence care on Resident #1 using the mechanical sit to stand lift without the use of the lower extremity straps to secure her in place. Nurse #1 stated she did not recall any complaints of pain or discomfort by Resident #1 throughout the reminder of her shift on 11/22/22. An interview with PT #1 on 1/19/23 at 4:00 PM revealed she evaluated Resident #1 on 11/22/22 for safe transfer techniques and felt she remained safe to continue use of the sit to stand lift with the use of a yellow medium lift sling for all transfers. An interview with the Director of Nursing (DON) on 1/19/23 at 4:27 PM revealed she was made aware of the fall by Nurse #1 and had reprimanded NA #1 and provided re-education following the fall on 11/22/22. The DON had not discovered during the investigation that Resident #1 was lifted using the mechanical sit to stand lift by NA #1 without the use of lower extremity lift straps being present in the room. The DON stated NA #1 was a very honest employee but did not believe that the lift straps were not attached to the lift during the transfer. She had also not been made aware Resident #1 had remained in the lift for 10-15 minutes while providing incontinence care on 11/22/22.

Based on observations, record review and staff interview the facility failed to provide twice daily treatments to a pressure ulcer as ordered by the physician. This was evident for 1 of 2 residents reviewed for pressure ulcers (Resident #51). Findings Included: Resident #51 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly minimum data set (MDS) dated [DATE] for Resident #51 identified she had a stage 3 pressure ulcer. Review of a wound assessment dated [DATE] for Resident #51 identified a stage 3 pressure ulcer to coccyx. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply silver alginate and super absorbent pad. Change twice daily. The treatment order was changed on 4/11/22 to clean open area to coccyx with Dakin ' s 0.125% solution and pat dry. Apply [MEDICATION(S)] cream to peri wound. Apply silver alginate and super absorbent pad. Change twice daily and as needed. Review of the April 2022 treatment administration record (TAR) for Resident #51 revealed the treatment was scheduled to be completed on the AM and PM shift. The wound treatment was not documented as completed on 4/2/22, 4/6/22 and 4/12/22 on the AM shift. The wound treatment was not documented as completed on 4/6/22, 4/7/22, 4/12/22, 4/15/22, 4/16/22, 4/18/22, 4/20/22, 4/22/22 and 4/25/22 on the PM shift. An observation on 4/27/22 at 10:50 am of Resident #51 ' s wound revealed there was moderate drainage with bright red blood present. An interview on 4/28/22 at 8:33 am with the wound physician revealed he had been treating Resident #51 ' s coccyx wound. He stated the treatment was ordered to be done twice daily because of the moisture associated with incontinence and the impact of moisture on the wound. He explained his preference was for the dressing to be changed twice daily because with less moisture the wound had a better change of healing. The wound physician indicated he expeceted his orders for twice daily dressing changes to be followed. An interview on 4/28/22 at 9:04 am with the Director of Nursing (DON) revealed the facility had a wound nurse who did some of the treatments, but she had recently been re-assigned to some additional nurse management duties. She stated the wound physician came weekly and the wound nurse would round with him. The DON added the hall nurses were responsible to complete the wound treatments. An interview on 4/28/22 at 10:00 am with Nurse #1 revealed Resident #51 had an order to treat her pressure ulcer twice daily and as needed. She stated on 4/6/22 she was the nurse for Resident #51, but she couldn ' t recall if she had completed the treatment to her pressure ulcer; adding sometimes the wound nurse would complete the treatment is she was rounding with the wound doctor. Nurse #1 indicated she had also worked with Resident #51 on 4/18/22 and 4/20/22 and she thought she had completed the AM treatment but was unsure about the PM treatment. An interview on 4/28/22 at 10:15 am with Nurse #2 revealed she worked routinely with Resident #51. She stated on 4/7/22 and 4/12/22 she could not remember if she had completed the treatments. She explained she would routinely get the AM treatment done and if she didn ' t ' have time to get the PM treatment done she would notify the nurse that relieved her. Nurse #2 stated the resident had a lot of drainage from her wound at times and that was why there was an order to change the dressing twice daily. An interview on 4/28/22 at 11:35 am with the DON revealed she expected Resident ' #51 ' s pressure ulcer to be treated twice daily and as needed as ordered by the wound physician.

Based on observations, record review, and staff interview the facility failed to remove expired medications from 2 of 3 medication carts (300 and 600 hall carts) and 1 of 3 medication rooms (central supply) reviewed during medication storage. The findings included: 1. Resident #254 was readmitted to the facility on [DATE] from an assisted living facility with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. An observation of the 300-hall medication cart was made on 08/01/19 at 10:52 AM along with Nurse #2. In the top drawer of the medication cart and available for use was a bottle of medication prescribed for Resident #254 of [MEDICATION NAME] 7.5 mg 30 tablets. The bottle of [MEDICATION NAME] 7.5 mg contained a use before date of 07/25/19. An interview was conducted with Nurse #2 on 08/01/19 at 10:55 AM. Nurse #2 stated that Resident #254 admitted to the 300-hall on 07/31/19 from an assisted living and the bottle of [MEDICATION NAME] came with her. Nurse #2 stated that she did not notice the expiration date of the [MEDICATION NAME] when she was moving it from the assisted living to the 300-hall within the facility. Nurse #2 stated that each nurse was responsible for making sure that there was no expired medication on their cart and the night shift staff also went through the medication carts and discarded any expired medication. Nurse #2 stated that she would dispose of the [MEDICATION NAME] 7.5 that expired on 07/25/19. An interview was conducted with the Day Supervisor (DS) on 08/01/19 at 11:14 AM. The DS stated that the night shift nursing staff were responsible for going through the medication rooms and medication carts and were to remove any expired medication they found and return them to the pharmacy. The DS stated that the [MEDICATION NAME] 7.5 mg that expired on 07/25/19 should not have been on the medication cart and should have been removed and returned to the pharmacy. An interview was conducted with the Director of Clinical Services (DCS) on 08/01/19 at 11:42 AM. The DCS stated that the facility followed manufacture guidelines for expired medication. She stated that the night shift nursing staff went through the medication carts and medication rooms and were to remove any expired medication they found. The DCS added that the pharmacy visited the facility every 3 months and assisted with medication storage during those times as well. The DCS stated that she knew the night shift staff went through the medication carts and they must have overlooked the [MEDICATION NAME] 7.5 mg that expired on 07/25/19. An interview was conducted with the Administrator on 08/01/19 at 12:25 PM. The Administrator stated that she expected the staff to follow the protocol and discard any expired medication. She added that the [MEDICATION NAME] 7.5 mg that expired 07/25/19 should not have been on the medication cart available for use, it should have been removed and returned to the pharmacy. 2. Resident #80 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. An observation of the 600-hall medication cart was made on 08/01/19 at 10:39 AM along with Nurse #1. In the second large drawer of the medication cart and available for use was a card of [MEDICATION NAME] 4 mg that contained 19 tablets and had an expiration date of 01/12/19 and was prescribed for Resident #80. An interview was conducted with Nurse #1 on 08/01/19 at 10:42 AM. Nurse #1 took the card of [MEDICATION NAME] 4 mg that expired 01/12/19 and threw in the trash can, she stated Resident #80 was not on the [MEDICATION NAME] anymore. An interview was conducted with the Day Supervisor (DS) on 08/01/19 at 11:14 AM. The DS stated that the night shift nursing staff were responsible for going through the medication rooms and medication carts and were to remove any expired medication they found and return them to the pharmacy. The DS stated that the 19 tablets of [MEDICATION NAME] 4 mg that expired 01/12/19 should not have been on the medication cart and should have been removed and returned to the pharmacy. An interview was conducted with the Director of Clinical Services (DCS) on 08/01/19 at 11:42 AM. The DCS stated that the facility followed manufacture guidelines for expired medication. She stated that the night shift nursing staff went through the medication carts and medication rooms and were to remove any expired medication they found. The DCS added that the pharmacy visited the facility every 3 months and assisted with medication storage during those times as well. The DCS stated that she knew the night shift staff went through the medication carts and they must have overlooked the [MEDICATION NAME] that expired 01/12/19. An interview was conducted with the Administrator on 08/01/19 at 12:25 PM. The Administrator stated that she expected the staff to follow the protocol and discard any expired medication. She added that the [MEDICATION NAME] 4 mg that expired on 01/12/19 should not have been on the medication cart available for use, it should have been removed and returned to the pharmacy. 3. Resident #81 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. An observation of the Central Supply room on 08/01/19 at 11:14 AM along with the Day Supervisor (DS) was made. There were 10 vials of [MEDICATION NAME] 0.5 mg/3 ml prescribed for Resident #81 that expired (MONTH) (YEAR). An interview was conducted with the DS on 08/01/19 at 11:14 AM. The DS stated that the night shift nursing staff were responsible for going through the medication rooms and medication carts and were to remove any expired medication they found and return them to the pharmacy. The DS stated that the [MEDICATION NAME] 0.5 mg/3 ml should not have been in the central supple and should have been removed and returned to the pharmacy. An interview was conducted with the Director of Clinical Services (DCS) on 08/01/19 at 11:42 AM. The DCS stated that the facility followed manufacture guidelines for expired medication. She stated that the night shift nursing staff went through the medication carts and medication rooms and were to remove any expired medication they found. The DCS added that the pharmacy visited the facility every 3 months and assisted with medication storage during those times as well. The DCS stated that she knew the night shift staff went through the medication rooms and they must have overlooked the 10 vials of [MEDICATION NAME] 0.5 mg/3 ml that expired (MONTH) (YEAR). An interview was conducted with the Administrator on 08/01/19 at 12:25 PM. The Administrator stated that she expected the staff to follow the protocol and discard any expired medication. She added that the [MEDICATION NAME] 0.5 mg/3 ml that expired (MONTH) (YEAR) should not have been in the central supply room available for use, it should have been removed and returned to the pharmacy. 4. Resident #91 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. An observation of the Central Supply room was made on 08/01/19 at 11:14 AM. There was a card of [MEDICATION NAME] 7.5 mg 15 tablets that expired on 07/31/19 in the extra medication bin and available for use that was prescribed for Resident #91. An interview was conducted with the DS on 08/01/19 at 11:14 AM. The DS stated that the night shift nursing staff were responsible for going through the medication rooms and medication carts and were to remove any expired medication they found and return them to the pharmacy. The DS stated that the [MEDICATION NAME] 7.5 mg that expired on 07/31/19 should not have been in the central supply room and should have been removed and returned to the pharmacy. An interview was conducted with the Director of Clinical Services (DCS) on 08/01/19 at 11:42 AM. The DCS stated that the facility followed manufacture guidelines for expired medication. She stated that the night shift nursing staff went through the medication carts and medication rooms and were to remove any expired medication they found. The DCS added that the pharmacy visited the facility every 3 months and assisted with medication storage during those times as well. The DCS stated that she knew the night shift staff went through the medication rooms and they must have overlooked the [MEDICATION NAME] 7.5 mg that expired on 07/31/19. An interview was conducted with the Administrator on 08/01/19 at 12:25 PM. The Administrator stated that she expected the staff to follow the protocol and discard any expired medication. She added that the [MEDICATION NAME] 7.5 mg that expired on 07/31/19 should not have been in the central supply room available for use, it should have been removed and returned to the pharmacy.

Based on record review and staff interview the facility failed to accurately code the discharge status of a resident for 1 of 3 closed records sampled (Resident #92). The findings included: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #92 was discharged on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #92 was severely cognitively impaired for daily decision making and required limited assistance with activities of daily living. The MDS further indicated that Resident #92 was discharged to the hospital. The MDS was completed by MDS Nurse #1. Review of a nurses note dated 05/23/19 read, Resident #92 was discharged to the dogwood assisted living. Family and medical provider notified. An interview was conducted with MDS Nurse #2 on 08/01/19 at 11:48 AM. MDS Nurse #2 confirmed that Resident #92 had discharged to assisted living and had not gone to the hospital on [DATE]. She added that MDS Nurse #1 was not longer working at the facility. MDS Nurse #2 stated that it was just a data entry error and she would correct the error immediately. An interview was conducted with the Administrator on 08/01/19 at 12:25 PM. The Administrator stated that MDS Nurse #1 was the one of the best MDS nurses in the entire company and it was just a data entry error. The Administrator further stated she expected the MDS assessments to be coded accurately. An interview was conducted with the Director of Clinical Services (DCS) on 08/01/19 at 2:45 PM. The DCS indicated that it was a data entry error and the staff would correct the error.

Based on observation, record reviews and interviews the facility failed implement a care plan intervention that required a dependent resident to be transferred via two-person assistance for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #13). The finding included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's quarterly Minimum Data Set ((MDS) dated [DATE] revealed, her cognition was intact, and she required extensive assistance via two persons for transfers. The MDS also indicated, Resident #13 was only steady with assistance and was coded as having a limitation in functional range of motion to one side of her body in both upper and lower extremities. Review of Resident #13's Care Plan initiated 12/07/18 revealed, a potential for falls related to left sided weakness which required interventions that included two persons assistance with transfers. Review of an Incident Report (IR) dated 03/19/19 and completed by Nurse #3 indicated, Resident #13 self-reported a fall that occurred on 03/19/19 at approximately 6:30 AM when she was being transferred from her wheelchair by Nurse Aide (NA) #1. The immediate action taken post incident was that the Resident was offered an ice pack for her right knee but was declined and pain medication was offered and administered for pain in the right knee. The IR also indicated, the Physician and Responsible Party were notified. Review of a Progress Note (PN) dated 03/19/19 at 4:54 PM written by Nurse #3 revealed, as she assessed Resident #13 for a complaint of right knee pain the Resident reported that while she was being transferred to the bed from her wheelchair that morning around 6:30 AM, NA #1 did not lock her wheelchair and the wheelchair rolled backwards which caused the NA to sit her down on the Resident's right leg as it bent underneath her. The PN indicated, upon assessment Resident #13's right knee was slightly larger than her left knee and that no bruising or redness was visible. The PN also indicated, Resident #13 initially refused pain medication but later agreed to take pain medication which she already had an order for [REDACTED].>Review of a written statement by Nurse #3 dated 03/19/19 revealed, Resident #13 had complained of right knee pain and upon assessment of her right knee the resident reported that when NA#1 was helping her back into bed after taking her to the bathroom the wheelchair was not locked and it rolled backwards which caused the NA to sit the Resident down on the Resident's right leg which had bent backwards underneath her. Resident #13 continued to explain, that she asked the NA to go get help but she didn't, and the NA got behind her and lifted the Resident up off the floor and into the bed. Nurse #3 was not available for interview. Review of Resident #13's Physician order [REDACTED].>Review of Resident #13's x-ray report dated 03/20/19 indicated, no acute fracture. Review of Resident #13's Physician order [REDACTED]. During an interview with Resident #13 on 07/29/19 at 3:29 PM she indicated that on the morning of the incident (03/19/19) NA #1 had taken her to the bathroom and when the NA stood her up to transfer her back to bed, the NA realized that she had not locked the brakes on her wheelchair. Resident #13 continued to explain, the wheelchair started to roll backwards, and the Resident's right knee started to bend which caused the NA to have to sit her down on the Resident's right leg. The Resident stated she asked the NA to get some help, but the NA wouldn't and then got behind her and lifted her up into the bed. The Resident stated she did not report the incident until her right knee started to hurt later that day because she did not want to get anyone into trouble but that she had not seen NA #1 since the incident happened. Resident #13 also stated, that after the fall her right knee became swollen and painful and was treated with pain medication and ice packs. The Resident also stated, her right knee was x-rayed but not fractured. An interview was conducted on 07/31/19 at 11:15 AM with NA #2 who explained, the facility provided the NAs with Resident Care Guides (RCG) that included specific interventions necessary to provide care to the residents and the RCG were updated as needed with new interventions. NA #2 stated, that in order to provide a safe transfer for Resident #13, she required a two person assist for transfers. An interview with the Administrator on 08/01/19 at 1:05 PM revealed, the Director of Nursing (DON) (who was currently on vacation) investigated the incident with Resident #13 on 03/19/19 and discovered that the NA involved in the incident was NA #1. The DON found that NA #1 had not followed the appropriate care planned intervention of a two person transfer for Resident #13 and also NA #1 also did not report the incident until Resident #13 reported the incident later that day on 03/19/19. NA #1 was given a written reprimand on 03/20/19 and subsequently terminated. NA #1 was not available for interview. The Director of Nursing was not available for interview. During a follow up interview with the Administrator on 08/01/19 at 4:34 PM she indicated, that the residents' safety was her utmost concern and she expected the staff to follow the Resident's care plan to assure the appropriate lift status was utilized.

Based on record review, resident and staff interviews the facility failed to safely transfer a dependent resident who needed the assistance of two persons for one of three residents reviewed for accidents (Resident #13). One staff member assisted Resident #13 alone and did not lock the wheelchair during the transfer resulting in the wheelchair rolling backwards and causing the staff to sit the resident on the Resident's leg as it bent underneath her. Resident #13 experienced pain and swelling requiring pain medication and ice pack but without fracture in her right knee. The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's quarterly Minimum Data Set ((MDS) dated [DATE] revealed, her cognition was intact, and she required extensive assistance of two persons for transfers. The MDS also indicated, Resident #13 was only steady with assistance and was coded as having a limitation in functional range of motion to one side of her body in both upper and lower extremities. Review of Resident #13's Care Plan initiated 12/07/18 revealed, a potential for falls related to left sided weakness which required interventions that included two persons assistance with transfers. Review of an Incident Report (IR) dated 03/19/19 and completed by Nurse #3 indicated, Resident #13 self-reported a fall that occurred on 03/19/19 at approximately 6:30 AM when she was being transferred from her wheelchair by Nurse Aide (NA) #1. The immediate action taken post incident was that the Resident was offered but declined an ice pack for her knee and pain medication was offered and administered for pain in the right knee. The IR also indicated, the Physician and Responsible Party were notified. Review of a Progress Note (PN) dated 03/19/19 at 4:54 PM written by Nurse #3 revealed, as she assessed Resident #13 for a complaint of right knee pain, the resident reported that while she was being transferred to the bed from her wheelchair that morning around 6:30 AM, NA #1 did not lock her wheelchair and the wheelchair rolled backwards which caused the NA to sit her down on the Resident's right leg as it bent underneath her. The PN indicated, upon assessment Resident #13's right knee was slightly larger than her left knee and that no bruising or redness was visible. The PN also indicated, Resident #13 initially refused pain medication but later agreed to take pain medication which she already had an order for [REDACTED].>Review of a written statement by Nurse #3 dated 03/19/19 revealed, Resident #13 had complained of right knee pain and upon assessment of her right knee, the resident reported that when NA#1 was helping her back into bed after taking her to the bathroom the wheelchair was not locked and it rolled backwards which caused the NA to sit the Resident down on the Resident's right leg which had bent backwards underneath her. Resident #13 continued to explain, that she asked the NA to go get help but she didn't, and the NA got behind her and lifted the Resident up off the floor and into the bed. Nurse #3 was not available for interview. Review of Resident #13's Physician order [REDACTED].>Review of Resident #13's x-ray report dated 03/20/19 indicated, no acute fracture. Review of Resident #13's Physician order [REDACTED]. During an interview with Resident #13 on 07/29/19 at 3:29 PM she reported that she required two persons to assist her for transfers, but on the morning of the incident (03/19/19) NA #1 had taken her to the bathroom and when the NA stood her up to transfer her back to bed, the NA realized that she had not locked the brakes on her wheelchair. Resident #13 continued to explain, the wheelchair started to roll backwards, and the Resident's right knee started to bend which caused the NA to have to sit her down on the Resident's right leg. The Resident stated she asked the NA to get some help, but the NA wouldn't, then she got behind the Resident and lifted her up into the bed. The Resident stated she did not report the incident until her right knee started to hurt later that day because she did not want to get anyone in trouble but that she had not seen NA #1 since the incident happened. Resident #13 also stated, that after the fall her right knee became swollen and painful and was treated with pain medication and ice packs. The Resident also stated, her right knee had an x-ray but was not fractured. An interview was conducted on 07/31/19 at 11:15 AM with NA #2 who explained, the facility provided the NAs with Resident Care Guides (RCG)s that included specific interventions necessary to provide care to the residents and the RCGs were updated as needed with new interventions. NA #2 stated, that in order to provide a safe transfer for Resident #13, she required the assistance of two persons for transfers. An interview with the Administrator on 08/01/19 at 1:05 PM revealed, the Director of Nursing (DON) (who was currently on vacation) investigated the incident with Resident #13 on 03/19/19 and discovered that the NA involved in the incident was NA #1. The DON found that along with not having followed the appropriate lift status for a two person transfer for Resident #13, NA #1 also did not report the incident until Resident #13 reported the incident later that day on 03/19/19. NA #1 was given a written reprimand on 03/20/19 and subsequently was terminated. NA #1 was not available for interview. The Director of Nursing was not available for interview. During a follow up interview with the Administrator on 08/01/19 at 4:34 PM she indicated, that the residents' safety was her utmost concern and she expected the staff to follow the appropriate lift status to ensure the residents' safety.

Based on record review, resident, and staff interviews the facility failed to provide showers as scheduled to a dependent resident for 1 of 2 residents sampled for activities of daily living (Resident #86). The findings included: Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive minimum data set ((MDS) dated [DATE] indicated Resident #86 was cognitively intact and required total assistance of 2 staff members with bathing. Review of the Nursing Assistant (NA) guidelines for daily care for Resident #86 indicated that her shower days were Sunday and Thursday on evening shift (3:00 PM to 11:00 PM). Review of the facility's bathing documentation for Resident #86 revealed the following: 05/20/18 Sunday: Shower given 05/24/18 Thursday: Shower given 05/27/18 Sunday: Bathing did not occur 05/31/18 Thursday: Shower given 06/03/18 Sunday: Bathing did not occur 06/07/18 Thursday: Shower given 06/10/18 Sunday: Bathing did not occur 06/11/18 Monday: Shower given Further review of Resident #86's medical record revealed no documentation of a refusal of showers or reason why showers were not given on 05/27/18 or 06/03/18. An interview was conducted with Resident #86 on 06/12/18 at 8:35 AM. Resident #86 stated that when she admitted to the facility on [DATE] she was told she would get 2 showers a week and that was fine with her if they would do that. She stated that she had a shower on 06/11/18 and that was the first time in a while she had a shower. Resident #86 stated she had never refused a shower but the staff just did not come to assist her to shower because she was non- weight bearing on her right lower leg and could not get there by herself. An interview was conducted with Nursing Assistant (NA) #1 on 06/13/18 at 4:23 PM. NA #1 confirmed that she cared for Resident #86 on 06/03/18 on the 3:00 PM to 11:00 PM shift. NA #1 stated that she had only worked at the facility for about a month and the weekend of 06/02/08-06/03/18 was the first time she had worked by herself out of orientation. NA #1 confirmed that she had not showered Resident #86 on 06/03/18 because she did not know that the facility gave showers on Sundays. She added that since then she has learned that they do give showers on Sunday and she now checked the shower schedule each time she works so she is aware of who needs a shower. An interview was conducted with NA #2 on 06/13/18 at 5:14 PM. Na #2 confirmed that she cared for Resident #86 on 05/27/18 from 3:00 Pm to 11:00 PM and confirmed that she had not given her a shower on that day. NA #2 stated she could not recall why she did not shower her that day but stated it was entirely possible that her showers had not been added to the shower sheet from her admission. An interview was conducted with the Nursing Supervisor (NS) on 06/13/18 at 5:31 PM. The NS stated that when showers were given the NA's documented it in the medical record and if the resident refused it then it should be documented and reported to the nurse so another attempt could be made. The NS stated that he expected for showers to be given according to the shower sheet. An interview was conducted with the Director of Nursing (DON) on 06/14/18 at 10:50 AM. The DON stated that she expected showers to be given as scheduled and if the resident refused or the shower was not performed she would expect to see it documented in the medical record.

Based on record review and staff interviews the facility failed to accurately code the minimum data set to reflect a hospice resident had a prognosis of 6 months or less to live for 1 of 1 residents reviewed for hospice services (Resident #73). The findings included: Resident #73 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. The order was signed the Medical Doctor (MD). Review of the hospice election statement dated 02/16/18 read in part, Resident #73 had been informed that hospice offers the hospice benefit program to those who have a terminal illness and meets the criteria for admission. The form was signed by Resident #73's family and the hospice staff. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #73 was severely cognitively impaired and required extensive assistance with activities of daily living. The MDS further revealed that Resident #73 was receiving hospice care but did not indicate that she had a prognosis of 6 months or less to live which is a requirement of hospice services. An interview was conducted with the MDS Nurse on 06/13/18 at 2:52 PM who stated that she had completed the MDS dated [DATE] and had coded hospice service but had not coded the prognosis of 6 months or less to live because she could not find the documentation it the medical record. The MDS Nurse indicated she reviewed a variety of things to complete the MDS like nurse's notes, physician orders, staff interviews, and any assessments that had been completed. She added that the hospice election statement had not been included in Resident #73's medical record and it should have been so she could have accurately coded the MDS. The MDS nurse further stated that she would make sure the appropriate documentation was available on Resident #73 and all the hospice patients that resided in the facility. She added that she would correct the MDS right away. An interview was conducted with the Director of Nursing (DON) on 06/14/18 at 10:44 AM. The DON stated that when Resident #73 readmitted under hospice her family requested a specific hospice agency that we did not have a contract with. She added that the whole process was a bit rushed to get the contract in place so Resident #73 could readmit under the hospice service that her family requested. The DON stated she expected the appropriate hospice information to be present in the medical record so that the MDS could be accurately coded.

Based on record review, hospice nurse, and staff interviews the facility failed to maintain a complete and accurate medical record for 1 of 1 residents sampled for hospice services (Resident #73). The findings included: Resident #73 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. The order was signed the Medical Doctor (MD). Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #73 was severely cognitively impaired and required extensive assistance with activities of daily living. The MDS further revealed that Resident #73 was receiving hospice care. Review of the medical record revealed no documentation of routine hospice visits or care. An interview was conducted with the Hospice Nurse (HN) on 06/13/18 at 2:23 PM. The HN stated that she tried to visit Resident #73 at least weekly but had to see her at least every 14 days. She added that a Nursing Assistant (NA) visited 2 times a week, the chaplain visited once a week, and a social worker would visit once a month. The HN stated that when she visited Resident #73 she would assess for any decline in her status, medication changes, pain, anxiety, falls, or wounds and she generally obtained that information from Nurse #1 or the nurse that was on the unit. The HN stated that any new orders would be communicated to the facility staff. She stated that when she had finished her visit with Resident #73 she would make a visit note in her computer but did not document in Resident #73's medical record and she did not print her notes and leave them at the facility. She explained that Resident #73 was the first resident she had at the facility and this was a new process to her and she was not sure how the facility wanted her to document but she would find out. An interview was conducted with Nurse #1 on 06/14/18 at 11:46 AM. Nurse #1 confirmed that he routinely cared for Resident #73. He stated that when the hospice nurses come to the facility they generally would ask the facility staff if there were any changes with Resident #73 and if they changed any orders the hospice nurse would make us aware. Nurse #1 stated that the hospice nurse did not document in Resident #73 ' s medical record and she did not leave a copy of her documentation that could be scanned into Residents #73's medical record. An interview was conducted with the Director of Nursing (DON) on 06/14/18 at 10:44 AM. The DON stated that when Resident #73 readmitted under hospice her family requested a specific hospice agency that we did not have a contract with. She added that the whole process was a bit rushed to get the contract in place so Resident #73 could readmit under the hospice service that her family requested. The DON stated she expected the appropriate hospice information to be present in the medical record and that she had just reached out to the HN and she would leave a copy of her notes that could be scanned into Resident #73's medical record for continuity of care.

Based on observations, record reviews, staff and physician interviews, the facility failed to maintain infection control procedures by not changing gloves during dressing changes on the same residents with two different dressing sites for 2 of 2 residents (Resident #88 and Resident #85) reviewed for wound care. The findings included: A review of the facility's Wound Care policy and procedure revealed the proper steps for dressing changes; however, the procedure did not address multiple sites on the same resident. 1. An observation on 06/13/18 at 1:16 PM of Resident #88's dressing changes to coccyx and right buttocks revealed Nurse #2 performing the dressing changes. Nurse #2 washed his hands and donned his gloves. Nurse #2 proceeded to remove the old dressings from the 2 wound sites and discarded them in the trash. Nurse #2 cleansed the coccyx wound with normal saline (NS) and applied calcium alginate to the wound bed. The wound was then covered with a foam dressing and Nurse #2 signed and dated the dressing. Nurse #2 proceeded to the second wound which was the right buttock and cleaned it with NS, patted it dry with gauze, applied silver alginate and packed the wound loosely with the use of a swab stick and then covered the wound with a foam dressing. Nurse #2 then signed and dated the second dressing. The wound care to both areas was done by Nurse #2 with the same gloves on during removal of old dressings and during both dressing changes. An interview on 06/13/18 at 2:38 PM with the wound care physician revealed he would not expect the nurse to wash his/her hands and change gloves between wounds on the same resident. The physician stated he was not concerned about cross contamination because if a resident had 2 wounds it was likely that both wounds had the same contaminant (not infection) but contaminant. The wound physician stated her wound was improving and doing much better. An interview on 06/13/18 at 3:46 PM with Nurse #2 revealed he forgot to change his gloves in between wounds and realized it after the wound care was done. Nurse #2 stated he should have doffed his gloves after the first dressing change, washed his hands and donned new gloves before moving to the second dressing change. An interview on 06/14/18 at 11:42 AM with the Director of Nursing (DON) revealed she expected dressing changes to be done correctly and expected the nurses to wash their hands and don clean gloves in between wound sites. The DON stated she would change her policy to reflect the procedure for dressing changes of multiple sites on the same resident. 2. An observation on 06/13/18 at 11:13 AM revealed Nurse #2 and the wound care nurse providing wound care to Resident #85. The wound care nurse and Nurse #2 washed their hands and donned clean gloves and the wound care nurse removed the toe and calf old dressings from the resident. Nurse #2 proceeded to cleanse the toe with wound cleanser, applied Santyl to the toe wound and wrapped with gauze and applied dressing. Nurse #2 then moved to the right calf wound and cleansed it with wound cleanser, applied [MEDICATION NAME] and plain Acquacel and wrapped in Kerlix and [MEDICATION NAME] was applied over the Kerlix. The wound care to both areas was done by Nurse #2 with the same gloves on during removal of old dressings and during both dressing changes. An interview on 06/13/18 at 3:46 PM with Nurse #2 revealed he forgot to change his gloves in between wounds and realized it after the wound care was done. Nurse #2 stated he should have doffed his gloves after the first dressing change, washed his hands and donned new gloves before moving to the second dressing change. An interview on 06/14/18 at 11:42 AM with the Director of Nursing (DON) revealed she expected dressing changes to be done correctly and expected the nurses to wash their hands and don clean gloves in between wound sites. The DON stated she would change her policy to reflect the procedure for dressing changes of multiple sites on the same resident.

Based on observation and staff interview the facility failed to prevent mold formation in the ice machine, failed to keep sanitizing solutions at the strength recommended by the manufacturer, and failed to cover baked good to prevent cross-contamination. The facility also failed to de-stain and clean kitchenware used for serving food, and failed to label and date opened and repackaged food items in storage. Findings included: 1. During initial tour of the kitchen, beginning at 8:50 AM on 07/17/17, there was a thin line of slimy pink build-up running about one and a half inches long across the back panel of the ice machine. Water was running across this build-up and into the ice being stored in the machine. During a follow-up tour of the kitchen, at 9:40 AM on 07/19/17, the thin line of slimy pink build-up was still present on the back panel of the ice machine. A steady stream of water was still running across the build-up and into ice being stored in the machine. At 9:52 AM on 07/19/17 the dietary manager (DM) stated the ice machine was completely cleaned last week. She also commented that usually there was not a steady flow of water across the back panel of the ice machine. At 10:12 AM on 07/20/17 the DM stated when the ice machine was cleaned last week the maintenance staff did not replace the wands which contained charcoal filters. She reported she thought this contributed to the pink build-up on the back panel of the ice machine. She commented the maintenance department was still trying to determine the cause of the constant flow of water across the back panel. At 10:25 AM on 07/20/17 a dietary employee/cook stated there should not be any pink or gray build-up in the ice machine because these were indicators of mold which could make residents sick. 2. During observation of food preparation, at 10:00 AM on 07/19/17, a dietary employee was observed wiping down a food preparation table where slaw had been prepared. She used a rag from a red bucket containing quaternary sanitizing solution. At 10:02 AM on 07/19/17 a strip used to measure the strength of the sanitizing solution in the red bucket registered 10 - 100 parts per million (PPM) of sanitizer. At this time the employee using the solution stated the strip should register 150 - 200 PPM per manufacturer guidelines. At 10:32 AM on 07/19/17 another dietary employee was observed wiping down a food preparation table where she had been placing cookies on dessert plates. She used a rag from a red bucket containing quaternary sanitizing solution. At 10:34 AM on 07/19/17 a strip used to measure the strength of the sanitizing solution in the red bucket registered 10 - 100 PPM of sanitizer. At this time the employee using the solution stated the strip should register 150 - 200 PPM per manufacturer guidelines. She also commented that the red buckets in the kitchen were last changed out (new solution was drawn from the sanitizer dispensing system) between 7:00 AM and 7:30 AM on 07/19/17, but additional rags had been added to the buckets since then. At 10:12 AM on 07/20/17 the dietary manager (DM) stated quaternary sanitizing solution was first placed in the red buckets around 6:00 AM and fresh solution was placed in these same buckets around 9:00 AM. She reported she thought adding too many rags into the buckets contributed to the problem with the weak sanitizing solutions. At 10:25 AM on 07/20/17 a dietary employee/cook stated red buckets were filled with sanitizing solution around 5:00 AM, and these buckets were emptied and new sanitizer was used to fill them around 7:30 AM the same morning and again around 2:00 PM the same afternoon. She commented the strength of the sanitizing solution should always be between 150 - 200 PPM in order to kill bacteria and germs effectively. 3. At 9:25 AM on 07/19/17 there were five pans of uncovered cookies stored on an open rack, and three flies were observed in the kitchen. At 9:33 AM on 07/19/17 a cook stated he removed the cookies from the ovens earlier that morning at 9:15 AM. These pans of cookies remained uncovered until 9:50 AM on 07/19/17 when dietary employees began to place them on dessert plates. The pans were at room temperature when they were touched. At 10:12 AM on 07/20/17 the dietary manager (DM) stated last week employees were in-serviced to keep items covered during operation of the trayline because of an increase in the number of flies found in the kitchen. She reported it was her expectation for staff to cover baked goods with loose plastic wrap or wax paper to keep flies and gnats off them. At 10:25 AM on 07/20/17 a dietary employee/cook stated staff were told in previous meetings to keep foods covered with plastic wrap on tin foil so that flies and gnats did not contaminate them with germs and bacteria. She commented this practice was especially important for foods which had cooled down below 135 degrees Fahrenheit because the bacteria could not be killed by heat. 4. During a kitchenware inspection, beginning at 10:35 AM on 07/19/17, 6 of 15 side dishes (small bowls), available for use at the upcoming lunch meal, had dark brown stain in them, and 1 of 15 side dishes had food particles still inside it. 15 of 33 plastic coffee mugs, available for use at the upcoming lunch meal, had dark brown stains inside of them, and 7 of 24 plastic soup/cereal bowls had a white sticky food residue inside of them. At 10:12 AM on 07/20/17 the dietary manager (DM) stated kitchenware was supposed to be de-stained weekly. She commented coffee mugs were de-stained on Fridays, and the side dishes were de-stained on Thursdays. According to the DM, the kitchen had problems getting all its kitchenware back from residents that hoarded items. She explained she thought this contributed to finding kitchenware which had not been de-stained on 07/19/17. She also reported that observation of the dish machine revealed there was excess residue inside which may have contributed to finding kitchenware that had not been cleaned properly on 07/19/17. At 10:25 AM on 07/20/17 a dietary employee/cook stated finding old food caked in/on items of kitchenware was not good because it could cause cross-contamination if not detected and make residents sick. She reported the employee putting away sanitized kitchenware as it exited the dish machine was supposed to catch items which were not properly cleaned and make sure they were run back through the dish machine until all food was removed. She commented kitchenware was supposed to be de-stained weekly using a bleach-based solution. According to the cook, stained kitchenware was not attractive to residents and could lessen enjoyment generated during the dining experience. 5. During initial tour of the kitchen, beginning at 8:50 AM on 07/17/17, an opened 40-ounce containers of mixed nuts and an opened 8.6-ounce foil bag of fruit punch mix found in the dry storage room were without labels and open dates. A gallon container of ranch dressing, a gallon container of thousand island dressing, a gallon container of dill pickle relish, a gallon container of yellow mustard, and a gallon container of spicy brown mustard were opened and stored in the walk-in refrigerator without labels and open dates on them. Two bags of sliced potatoes, a repackaged tortilla, a bag of oriental mixed vegetables, a bag of apple tarts, a bag of diced chicken, and a bag of chicken fingers were opened and stored in the walk-in freezer without labels and open dates. Part of an onion and a puree dessert found in the reach-in refrigerator were without labels and dates on them. During a follow-up tour of kitchen storage areas, beginning at 10:28 AM on 07/19/17, a bag of sweet potato fries, a bag of breaded chicken patties, and a container with a coconut cream pie were opened and stored in the walk-in freezer without labels and open dates. At 10:12 AM on 07/20/17 the dietary manager (DM) stated all dietary employees were supposed to check storage areas as they entered and exited them to make sure opened, repackaged, and leftover food items were labeled and dated. She reported this practice helped to make sure older foods were used up first to lessen the chance of spoilage and to keep food quality high. She commented labeling and dating were monitored by the assistant dietary manager as he placed orders, by the cooks as they handled foods during preparation tasks, and the stock person when putting away foods delivered by truck. At 10:25 AM on 07/20/17 a dietary employee/cook stated it was important to know the age of food items, and that was the reason the facility placed received and opened dates on containers and packaging. She reported all opened food items, all repackaged food items, and all leftovers were supposed to have labels and dates on them. She commented bacteria and mold were more prone to grow in older foods which had not been disposed of.

Based on observations, record review and family and staff interviews, the facility failed to update the care plan to include preferences for only female staff as requested by the Responsible Party (RP) for 1 of 3 sampled residents (Resident #1). Findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 with severe cognitive impairment. The MDS indicated Resident #1 required staff supervision for eating, total assistance of 1 staff member for bathing and extensive assistance of 1-2 staff members for all other activities of daily living (ADL). Further review revealed Resident #1 was continent of bowel but frequently incontinent of bladder. Review of the facility's grievance log for the period November 2016 through March 2017 revealed a grievance filed by Resident #1's family member dated 11/28/16 related to a statement made by Resident #1 alleging a male staff member had touched her inappropriately. The allegation was investigated and unsubstantiated by the facility. The grievance indicated the family member had requested only female staff due to Resident #1 being uncomfortable around men. Review of Resident #1's ADL care plan with a recent review date of 2/25/17, indicated she needed assistance of 1 staff person to complete ADL due to pain/discomfort and shortness of breath with oxygen use. Interventions included for staff to use a calm, gentle approach, explain procedures, and offer simple instructions. There was no intervention included that indicated her preference for female staff. An interview on 3/2/17 at 11:42 AM with Resident #1's RP revealed they had spoken to the Social Services Director (SSD) after Resident #1 had made the comment she had been touched inappropriately by a male staff member. The RP stated when they visited Resident #1, she became fearful whenever she saw shadows of people walking past her door and would comment he's coming back. The RP added they had requested for only female staff to provide care to Resident #1. During an interview on 3/2/17 at 2:20 PM the MDS Nurse revealed no knowledge of Resident #1's family requesting care to be provided by only female staff. The MDS Nurse acknowledged it would have been an appropriate intervention to add to Resident #1's care plan. During an interview on 3/3/17 at 8:56 AM the SSD confirmed she had spoken to Resident #1's family regarding their concerns indicated on the grievance and they had requested for only female staff to provide care to Resident #1. The SSD indicated she did not document this request in Resident #1's medical record but had informed the second shift supervisor. During a telephone interview on 3/3/17 at 10:53 AM the Nurse Supervisor (NS) for second shift confirmed she had been informed of the request for only female staff made by Resident #1's family member. The NS indicated she had not documented the request in Resident #1's medical record but had informed the third shift supervisor and staff assigned to Resident #1's hall. During an interview on 3/3/17 at 12:25 PM the Director of Nursing (DON) revealed she had been unaware Resident #1's family member had requested care provided by only female staff. She explained when a specific request was made by a resident or family member, it was not typically documented in the medical record but was discussed during shift report and relayed to the appropriate staff. The DON indicated they had not been aware such a request could be care planned. The DON added looking back, it would have been appropriate to have had it care planned as a reminder to all staff.

Based on observation and staff interviews the facility failed to secure a medication cart when left unattended for 1 of 1 observed medication carts. The findings included: On 01/30/17 at 4:13 PM an observation of the 600 hall medication cart was made. The cart was positioned halfway down the hallway, was unlocked and unattended. There was one resident sitting in a wheel chair approximately 2 feet in front of the unlocked and unattended medication cart. There were 2 other residents ambulating in the hallway directly in front of the unlocked and unattended medication cart. After 6 minutes Nurse #1 returned to the cart and verified that the medication cart was unlocked. Interview with Nurse #1 on 01/30/17 at 4:18 PM revealed that she had been called away from the medication cart by the staff on the hallway, Nurse #1 stated she thought she had pushed the lock button in but I guess it did not lock. Nurse #1 stated she always locked her cart when she walked away from it and she was aware that the medication carts should be locked at all times when not in her view. Interview with the Director of Nursing (DON) on 01/31/17 at 1:11 PM revealed that all medication carts are to be locked when not in eye sight by the appropriate staff or nurse. The DON stated that Nurse #1 had told her that she thought she had locked the cart but when she returned to the medication cart it was unlocked. Nurse #1 also told the DON that the lock would stick sometimes and the DON instructed her to fill out a maintenance form since she had not done so previously. Interview with the Administrator on 01/31/17 at 1:33 PM revealed that she routinely made rounds and checked for medication carts that were unlocked and unattended. The administrator stated she expected the medication carts to be locked when not attended by the appropriate staff.

Based on record review, resident and staff interviews the facility administered a medication which was not ordered/indicated for 1 (Resident #1) of 3 residents sampled for unnecessary medication. The Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #1 was cognitively intact and required extensive assistance with activities of daily living. Review of cumulative physician orders [REDACTED]. Review of the facility's medication error report dated 01/21/17 revealed that Nurse #2 applied a [MEDICATION NAME] to Resident #1 that was ordered and intended for another resident. The medication error report also indicated that there were no adverse reactions noted to Resident #1. Interview with Resident #1 on 01/30/17 at 4:24 PM revealed that on 01/21/17 Nurse #2 applied an [MEDICATION NAME] to him that he later learned was not intended for him. Resident #1 stated that he had the [MEDICATION NAME] on for less than an hour and he had no side effects from it, it did not make Resident #1 feel funny or different. Resident #1 explained that his family had come to visit him that day and they noticed the patch that was visible on his shoulder area. The family member had questioned staff about it, and that was when it was discovered that it was intended for my roommate. Resident #1 stated that Nurse #2 had checked his vital signs and instructed him to let her know if he started feeling differently. Interview with Nurse #2 on 01/31/17 at 11:39 AM revealed that on 01/21/17 at approximately 8:30 Am she had already medicated Resident #1 and had returned to the medication cart to sign the medication administration record. Nurse #2 stated she had started preparing Resident #1's roommate medications including the [MEDICATION NAME] when she got called away from the medication cart by staff on the hall. Nurse #2 recalled that when she returned to the medication cart she saw the [MEDICATION NAME] in the top drawer and realized she had not applied it so she returned to Resident #1's room and just accidentally applied it to Resident #1 instead of the roommate. Nurse #2 stated that Resident #1's family asked Medication Aide (MA) #1 about the patch present on Resident #1. MA#1 called Nurse #2 to inquire about the patch on Resident #1's shoulder and that was when Nurse #2 discovered she had applied the [MEDICATION NAME] to the wrong patient. Nurse #2 instructed MA#1 to remove the patch from Resident #1. Nurse #2 stated she reported the error to her nurse supervisor, obtained vital signs and observed him for any adverse reactions for the rest of her shift. Nurse #2 stated that Resident #1 had no adverse reactions. Nurse #2 stated after the error occurred she mentioned to the facility management that both Resident #1 and the roommate had the same first name and that was something she felt like contributed to the error. Nurse #2 stated she had not received any additional training on medication administration since the error occurred but she did discuss the error with her Director of Nursing (DON). Interview with Nurse Supervisor #1 on 01/31/17 at 11:51 AM revealed that on 01/21/17 Nurse #2 had reported to him that she had accidentally applied an [MEDICATION NAME] to Resident #1 instead of his roommate. Nurse Supervisor #1 stated that he advised Nurse #2 to check Resident #1's vital signs and to keep a close eye on him for any adverse reactions. Nurse Supervisor #1 stated that he had then reported the error to Nurse Supervisor #2 who was going to be contacting the physician about a list of things including the error. Interview with Nurse Supervisor #2 on 01/31/17 at 12:19 PM revealed that he had received in report from Nurse Supervisor #1 that Nurse #2 had made a medication error by accidentally applying an [MEDICATION NAME] to Resident #1 instead of his roommate. Nurse Supervisor #2 stated the he assessed Resident #1 for weakness, behavior changes, and nausea and vomiting and Resident #1 had none of those. Nurse Supervisor #2 stated he notified the physician of the error and he stated that was ok. Nurse Supervisor #2 stated that Resident #1 had no adverse reactions from the error and was his usual self the remainder of the day Interview with MA #1 on 01/31/17 at 1:00 PM revealed that on 01/21/17 she was working on the unit and Resident #1 and his family approached her and asked if she knew anything about the patch that was on Resident #1's shoulder. MA #1 stated it had been several days since she worked with Resident #1 so she called Nurse #2 and asked about the patch. MA #1 stated that Nurse #2 realized that she had applied the patch to the wrong patient and asked MA #1 to please remove the patch. MA #1 stated she removed the patch as instructed by Nurse #2. MA #1 stated that later in the day she had asked the Nurse Supervisor if he had been made aware of the error and the nurse supervisor replied yes. MA #1 stated she had not received any education on medication administration since the incident. Interview with the DON on 01/31/17 at 1:11 PM revealed that when a nurse made a medication error they were required to fill out a medication error report and notify the physician of the error for any new orders. Generally we are instructed to just monitor the resident for any adverse reactions and of course if there are any we would again notify the physician. Resident #1 had no adverse reactions from the [MEDICATION NAME] that was accidentally applied to him instead of the roommate. After the event we looked at what actually happened and I talked to Nurse #2 and found that she had been called away from her medication cart. The DON stated that when she talked to Nurse #2 it was an informative session to find out what happened and at the time. I did not think she needed any reeducation because she was able to verbalize to me what she should have done. Nurses received the medication training with their orientation process and then annually through the online course offered by the facility. The DON stated she had a nurse meeting on 12/21/16 but medication administration was not on the topic of things discussed. The DON stated she expected the nursing staff to use the 5 rights of medication administration (the right medication, with the correct dose, to the right patient, at the right time, via the correct route).

Based on observations, resident and family interviews, staff interviews and record review, the facility failed to provide pain management strategies for 1 of 2 residents (resident #235) to manage her pain. Findings included: Resident #235 was admitted on [DATE] following a brief hospitalization for displaced [MEDICAL CONDITION] neck of her left humerus. The resident ' s additional [DIAGNOSES REDACTED]. On 06/02/2016 the admission Minimum Data Set (MDS) for resident dated 05/24/2016 was reviewed and the resident was coded to be cognitively intact (BIMS scale of 13). The resident was admitted to the facility for rehabilitation with a fractured left humerus that was not a candidate for surgical repair. The care plan dated 05/18/16 was reviewed and the facility addressed pain management in the plan for her fractured arm. The resident is receiving therapy for a non-surgical fracture and requires assistance with ADL ' s due to her inability to use her left arm. On 06/01/2016 8:55:10 PM, Resident #235 and her husband were interviewed. The resident and her husband stated that she fell up against the wall in their bathroom at home and fractured her left arm. The resident and her husband stated that upon exam at the hospital, that the physician did not recommend surgery so after a brief stay at the hospital, she was transferred to this facility for rehabilitation. She currently has a sling on her left arm to keep it immobilized to promote healing. The resident and her husband stated that she had a lot of pain with her arm and that the pain medication takes the edge off but does not relieve her pain and does not last for six hours. Her husband stated that they had spoken with the head nurse (could not remember her name) last week sometime (they could not remember the day) but nothing had changed with her pain medication. 06/01/2016 10:01:17 PM, Interviewed nurse #1 who stated that when resident #235 asks for pain medication she gives it every 6 hours as needed according to the orders, but stated the pain medication usually doesn ' t last the full six hours for resident #235. Nurse #1 was asked what the procedure is when pain medication does not work for a resident and she stated that they report it to the nursing supervisor. She continued on to say that the nursing supervisor will either call the physician or place the concern on the list for the physician when he makes rounds. Nurse #1 was asked if she had advised the nursing supervisor that the pain medication was not working for the resident and she said no but she would let her know tonight and put it on the list for the physician rounding in the morning. 06/02/2016 10:07:17 AM, Resident #235 was observed sitting up in the chair in her room, eating breakfast. She was still complaining of pain but stated the physician had been in this morning and told her that he would change her medication. When asked about her pain level on a scale of 1-10, the resident stated it was a 10. 06/02/2016 3:14:56 PM, Resident #235 was observed sitting in her recliner with her legs elevated. When asked about her pain since receiving the new medication ordered, the resident stated that this was the first time since being in the facility, that she was pain free. 06/02/2016 3:26:45 PM, Interviewed nurse #2 and asked what their procedure is when a resident ' s pain is not relieved by the pain medication ordered. Nurse #2 stated that they try repositioning, give Tylenol, apply ice and if that does not work they report it to the nursing supervisor. Nurse #2 went on to say that the supervisor will then call the physician or place the concern on the list for the physician to address on his next rounds. Nurse #2 stated that resident #235 ' s pain medication was not [MEDICATION NAME] her the full six hours but the physician had been in this morning and changed her pain medication. 06/02/2016 4:28:23 PM, Nursing supervisor for 2nd shift was interviewed and asked about the facility ' s procedure for reporting to the physician when pain medication does not work for a resident. The nursing supervisor stated that the hall nurses notify the supervisor and then she will call the physician daily at 1:00 pm and 5:00 pm or the supervisor can call or text the physician anytime a resident needs something. 06/03/2016 2:24:28 PM, Nursing supervisor for 1st shift was interviewed and asked if anyone had reported to her that the pain medication ordered for resident #235 was not working. Stated that it had not been reported to her by the hall nurses that the pain medication was not working for the resident. The supervisor was asked where these issues would typically be documented and she stated that they should be documented in nurse ' s notes in the resident ' s chart. The nursing notes for the resident were reviewed with the Director of Nursing and she could not find any documentation that the hall nurses had reported to the nursing supervisors that resident #235 ' s pain medication was not working for her pain. 06/03/2016 4:21:08 PM, The Administrator stated that one morning around 7:30 am she was making rounds and resident #235 complained of pain. She stated that she notified the resident ' s nurse and the nurse said the resident had medication at 6:00 am and couldn ' t have anything else. The Administrator then stated I don ' t know what that means but we were addressing her pain. On 06/03/2016 3:41:35 PM, The Director of Nursing (DON) was interviewed and she stated that they worked with the MDS nurse on assessing resident ' s level of pain while completing the MDS assessment for all residents experiencing pain. The DON expected the hall nurses assess each resident ' s pain and give their pain medication as ordered. When the medication does not work for the resident, the DON expected the nurse to notify the supervisor who would contact the physician for a change in the resident ' s orders. The DON stated that the nurses were expected to manage the resident ' s pain and make them comfortable.