Every finding on record at Tygart Valley Health & Rehabilitation

Based on observation, staff interviews and record review the facility failed to ensure it had a complete and accurate medical record related to dental status. This failed practice was found true for (1) one of (3) three residents reviewed for dental during the Long-Term Care Survey Process. Resident identifier #54. Facility census: 54. Findings Include: a) Resident #54 An observation on 11/17/25 at 3:15 PM revealed Resident #54 sitting in the hallway in her wheelchair. She had several teeth missing and some were decayed and broken off at the gums.A record review on 11/18/25 at 12:30 PM, revealed that Resident #54 had seen an in-house dentistry on 02/06/25. The dental consult showed the following:Teeth numbers 11, 21, 22, and 6 are decayed. Teeth numbers 1-3, 13-20, 31 and 32 are missing. Teeth numbers 7-10 and 25-30 are retained root.The summary of the dental consult read as follows: Limited tolerance with treatment will attempt to complete extractions on 29 and 30 next time. PC/SC left with facility to have them next time. Will see how patient tolerates with them to determine future treatment. She may need to be referred out to have other things completedFurther record review revealed that Resident #54 was also seen by in-house dentistry on 08/15/25. Summary of the dental consult read as follows:States she does want to start with removing teeth, will start still with LR side 29/30 area, if tolerant with us, papers left with facility again for extractions. Next visit plan: extractions.A review of Resident #54's last annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/25 section L, question 2 is marked Good for oral cavity/teeth condition. Question 4 indicates that no natural teeth are missing, A review of Resident #54's last Nutritional Risk assessment dated [DATE], question #4 indicated that the resident has her own teeth with no issues noted. During an interview on 11/20/25 at 9:17 AM, with the Administrator and the Regional Risk Management Director (RRMD), both confirmed Resident #54's MDS and nutritional assessment did not match her current dental status.A continuous observation of Resident #54 on 11/19/25 revealed the resident was eating her lunch meal. The meal consisted of beef stew, carrots, and a biscuit. Resident #54 finished eating her lunch at approximately 1:10 PM. Left on the tray was about seven (7) carrots, the entire bowl of beef stew and about 1/2 of a biscuit. The amount eaten was 25% to 50%. The Activity Director (AD) confirmed what was left on the lunch tray for Resident #54. A record review on 11/19/25 at 1:30 PM, showed that the recorded amount in the chart was 75% to 100%, and it was documented at 12:45 PM, before the resident finished eating. During an interview, on 11/20/25 at 9:17 AM, the Regional Risk Management Director (RRMD) confirmed that the meal percentage entered for Resident #54 was incorrect.

Based on observations, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases, to help prevent cross-contamination and infections including Covid-19 in regard to, follow CDC (Centers for Disease Control) guidelines for use of PPE (Personal Protective Equipment) and ensure staff donned appropriate personal protective equipment (PPE) prior to wound care for a resident on (Enhanced Barrier Precautions). The facility also failed to ensure a barrier was maintained in the laundry area and failed to repair unhygienic wheelchair surfaces. These failed practices had the potential to affect every resident currently residing in the facility. Resident identifiers: #4, #24, #8, #46, and #50. Facility census: 54. Findings included: a) Resident #8 A record review revealed Resident #8 was in Enhanced Barrier Precautions (EBP) due to wound care. On 11/19/25 at 2:00 PM, Licensed Practical Nurse (LPN) #66 was observed providing wound care on Resident #8's pressure Ulcer without proper Personal Protective Equipment (PPE). She was only wearing gloves. Continued observation found that LPN #66 removed packaging from wound supplies and placed them in the trash receptacle and pushed the packaging down with her gloved hand. Without changing her gloves, she continued to prepare wound supplies. Subsequent observation found LPN #66 using her wound scissors to cut negative pressure wound therapy (NPWT) drape after it was affixed to Residents wound area, she did not clean the scissors after and continued to use the scissors to cut additional supplies. Observation of a sign on the wall above Resident #8's bed read: Enhanced Barrier Precautions -Attention: Caregivers, Staff, and Visitors --Wear Gown and Gloves prior to these activities: During high contact resident care activities. - Dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (i.e. central line, urinary catheters, feeding tube, tracheotomies, ventilators), and wound care: any skin opening requiring a dressing. - Face protection may also be needed if performing activity with risk of splash or spray. -See the care plan for additional information. During an Interview with LPN #66 on 11/19/25 at 2:35 PM she stated that she should have had a gown on during wound care. During an interview with the administrator on 11/19/25 at approximately 3:25 PM she stated that LPN #66 was reeducated on EBP, and the facility was starting whole house reeducation at this time. No further information was provided prior to the end of the survey on 11/20/25. b) Laundry Services An observation during the laundry tour on 11/19/25 at approximately 12:30 PM found the window open in the dirty laundry room breaking the negative air pressure, preventing the system from containing contaminants to the dirty area. Laundry was being processed in the dirty area, and clean area, the clean laundry was out on the folding table at this time. During an interview on 11/19/25 at 12:30 PM the Maintenance Director (MD) the MD verified that the air was pulling from the dirty area to the clean area. He closed the window in the dirty laundry area to reestablish the negative area flow at this time. a) Resident #50 During the entrance interview with Resident #50, on 11/17/25 at 3:34 PM, it was observed that a wheelchair in his room had tears in the plastic cover on both arm rests. Resident # 50 stated he used that wheelchair when going out to activities, dining room, and to activities. During a facility walk through on with the DON on 11/18/25 at 3:20 PM, it was observed that wheelchairs belonging to Resident #4, #24, and #46 were sitting in the hallway in the 200 hall with tears in the arm rests exposing inner padding. In an interview with the Director of Nursing, on 11/18/25 at 11:05 AM, she acknowledged the wheelchairs had tears in the plastic arm pads and agreed the above-mentioned chairs could not be cleaned to prevent infection.

Based on observation, and staff interview, the facility failed to properly store food in accordance with professional standards. This is true for the kitchen walk in cooler and utensil storage.This had the potential to affect all residents in the facility. Facility census: 54.Findings included:a) On 11/17/2525 at 12:27PM, during Initial Brief Tour of Kitchen with the facility Kitchen Manager, who acknowledged the following in the walk-in cooler, an opened plastic bag of lettuce with no label or dates and in the utensil drawer, the utensils were incorrectly placed in different directions. On 11/18/25 at 1:30 PM, the Cooperate Kitchen Manager (CKM) acknowledged the bag of lettuce in the walk-in cooler without a dated label 9/25 and the utensils were not stored correctly in the utensil drawer. On 11/19/25 at 2:25PM, during an interview with the Director of Nursing, she stated she was aware of the unlabeled lettuce in the walk-in cooler and the incorrectly stored utensils.

Based on observation and staff interview, the facility failed to allow Resident #46 to have a dignified dining experience. This finding was related to the facility failing to serve his meal with the other residents at his table before serving other tables. This failed practice was a random opportunity for discovery. Resident identifier: #46. Facility Census: 54.Findings Included:a) Resident #46 On 11/17/25 at 12:46 PM, during a dining room observation, It was observed that Resident #46 was not served his lunch tray with the rest of his tablemates before staff began serving other tables. In an interview with Certified Nurse Assistant(CNA) employee identifier # on 11/17/20250 at 1:14 PM, she acknowledged Resident #46 was not served correctly with the other resident at his table.During an interview on 11/19/2025, at approximately 2:45 PM, the facility Director of Nursing stated she was made aware that Resident #46 was not served his lunch with his tablemates in the dining room on 11/17/25.

Based on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority,to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASSR). Resident identifier #34. Facility Census: 54Findings Included:a) Resident # 34Review of the PASSR dated 11/18/24 found the following medical diagnosis was not identified on the Pre admission Screening and Resident Review.Major Depressive Disorder onset 04/29/25,Schizophrenic Disorder onset 12/03/24The above information was confirmed with the Director Of Nursing (DON) on 11/18/25 at 2:20 PM. The DON agreed that the additional medical diagnosis should be on the PASSR.

Based on record review, resident interview and staff interview the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (4) four residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #54. Facility census: 54. Findings Include:a) Resident #54 An observation on 11/17/25 at 3:15 PM, revealed Resident #54 sitting in the hallway, she had several hair stubbles on her chin and her mustache area. During an interview on 11/17/25 at 3:15 PM, Resident #54 stated, I would like for them to shave them off every time, but they don't.During an interview on 11/17/25 at 3:20 PM, The Director of Nursing (DON) stated, Her shower day is today. The system shows she had her shower today already. I will get it taken care of. A review on 11/17/25 at 3:30 PM, revealed an ADL care plan for Resident #54 with a focus that reads as follows:(Resident #54 name) is a long-term care resident and requires assistance with their ADL's related to chronic health conditions, congestive heart failure, dementia , muscle weakness The care plan includes an intervention that read as follows Substantial or maximal assistance with bathing-may require more assistance at times.The DON further confirmed that Resident #54 had not been shaven.

Based upon Record review and interviews, the facility failed to provide one on one activities fo one (1) of four 4) residents that were unable to participate in group activities. Residents identifier: #7. Census: 54. Findings included:a) Resident #7Record review on 11/18/25 at 9:20 AM revealed Resident #7 was receiving dialysis on Monday, Wednesday and Friday. This had an impact on how the resident was able to participate in activities due to the energy level after dialysis. Resident #7 was not listed on any 1:1 activity sheets or the sunshine visit list. The residents on the sunshine visit list get morning visits or non-group activities provided.During an interview with Resident #7 on 11/18/25 at 9:20 AM the resident stated, No one comes into my room for activities. I don't do well in group activities because I am always tired. I don't have a lot of chances to talk with people. My roommate doesn't talk so I don't even get the chance to talk to them. I don't have the energy to go out and participate most days.The Activities Director (AD), was interviewed on 11/19/25 at 12:13 PM, and stated that she knew the resident was unable to participate in group activities due to her medical conditions and being tired from treatment. She knew that the resident enjoyed going to devotionals and could not really participate in them any longer. Activities director (AD) stated she will go later and have a talk with the resident to see what she would like to do in her room for activities. The AD stated, She shouldn't just have to lay there.

Based upon Record Review and Interviews, the facility failed to promote Resident #7's self determination through choices for her shower preference and time. This was true for one (1) out of four (4) residents reviewed. Resident identifier: #7. Census: 54. Findings include:a) Resident #7 Record review on 11/18/25 showed the care plan reflected showers three (3) times a week, but no preferences noted. The shower tracking sheet confirmed that showers were given on 11/18/25 and on 11/11/25. Task record on system showed shower/bathe self-Monday, Wednesday and Friday nights and PRN (as needed).During an interview, on 11/18/25 at 9:09 AM, with Resident #7, she stated they do not get many showers due to being scheduled on the same days as their dialysis (M-W-F) nights.Resident #7 said she had previously requested the staff move it because she was so exhausted from the treatments. I have not gotten a shower in lord knows how long. The facility is ok with me wanting three showers a week, but that's very hard with my treatments.During an interview with the Director of Nursing #20 (DON) she confirmed that Resident #7 was on the bathing schedule for three (3) nights a week (M-W-F). She said the resident got a shower on 11/18/2025 and 11/11/2025, as well and some bed baths between. She was not aware of any requests made to have the shower days moved or what times they were done but would talk to the shower scheduler and have that addressed.

Based on observation, record review, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice by not following physician orders related to insulin and weights. This failed practice was found true for (2) two of 25 residents reviewed for physician order accuracy during the long term care survey process. Resident identifiers: #11 and #4. Facility census: 54.Findings included: a) Resident #4 Record review of the facility's policy titled, Weight Assessment and Intervention, with a date 10/01/21 showed: Any weight (wt.) change of 5% or more since last weight will be retaken for confirmation. If the weight is verified, nursing will immediately notify the physician/practitioner and dietary team. Medical record review on 11/20/25, showed a 14.12 % weight increase for Resident #4, 11/17/25 at 4:02 PM 187.5 lbs. 10/01/25 1:55 PM 185.1 lbs. 09/05/25 5:11 PM 164.8 lbs. 09/02/25 7:15 PM 162.2 lbs. During an interview on 11/20/22 at 2:45 PM the Director of Nursing (DON) verified a reweight was not completed and the physician/practitioner and dietary team were not notified of a significant weight change. b) Resident # 11 A record review on 11/19/25 at 10:30 am, revealed a physician order for Resident #11 that read as follows: Inject 40 units subcutaneously before meals for DM II related to Type 2 Diabetes Mellites with Hyperglycemia. Hold if Blood Glucose Level (BGL) less than 180. Further record review of the Medication Administration Record (MAR) for 09/25, 10/25, and 11/25 noted that in Residents #11's BGL was less than 180, 38 times and insulin was not held as ordered. During an interview on 11/19/25 at 11:02 AM, the Director of Nursing (DON), confirmed that Resident #11 was given insulin, when the BGL was below 180, not as the Physician ordered.

Based on observation, record review, and staff interview the facility failed to ensure emergency dental services were provided to Medicaid funded residents in a timely manner. This failed practice was found true for (2) two of (3) three residents reviewed for dental services during the Long-Term Care Survey Process. Resident identifiers: #54 and #20. Facility census: 54. a) Resident #20 On 11/17/2025 at 2:55 PM, during interview and observation with Resident #20, it was observed that the resident had some missing, and decayed teeth. Resident #20 stated, I have asked to have some pulled and a plate put in a while back and nothing has been done. She pointed to one tooth that had been cracked and stated that had happened about a week ago. Record review on 11/18/25 at 12:30 PM, revealed that Resident #20 had seen an in-house dentist on 08/15/25. The dental consult showed the following: Teeth numbers 1-16, 17-19, 24, 25, 29-32, are missing. Teeth number 28 retained root. The summary of the dental consult reads as follows: Pt. wants to have remaining lower teeth extracted and the after healing time can make dentures, requested. Next visit plan: Extractions. On 11/17/25 a record review of Resident #20's progress notes, dated 11/13/25, revealed a note stating Resident broke a tooth and asked me to make her an appointment to the dentist. She asked me to call Dr (name) to schedule. I called and had to leave a voicemail because they were closed at 3 pm and on Fridays. I let (Resident name) know I left a voicemail and I would call them again on Monday and follow up with her after. On 11/18/25 at 5:00PM a further record review of Resident # 20's progress noted revealed a note dated 11/18/25 at 2:18 PM stating social services spoke with 360 care following a report from the resident that she had a chipped tooth. The note stated (Name) stated they were awaiting the surgical consent form. Upon review of the chart, the family surgical consent was not found scanned into the record. The physician consent form was scanned and signed and was emailed 11/18/25. The note revealed that a call was placed to Resident's MPOA to follow up on obtaining the consent form at 360 Care. The note also revealed that it was confirmed that the resident was able to sign her own consent since she had capacity. The note went on to state that a new consent form would be sent to the resident directly to sign and that an appointment was scheduled with the dentist in January 2026. On 11/19/25 at 2:30PM, During an interview with the Administrator, she stated the social worker had made calls in the community working on getting Resident #20's tooth taken care of. The administrator said she would check with the social worker. During an interview, on 11/20/25 at 9:17 AM, with the administrator and the Regional Risk Management Director (RRMD), both confirmed that the resident's teeth were not in the best shape, and the RRMD stated, We are not sure what happened with the paperwork. It seems like it was a miscommunication between the dental service and the facility on who was going to get the consent. b) Resident #54 An observation on 11/17/25 at 3:15 PM, revealed Resident #54 sitting in the hallway, she had several teeth missing, and some that appeared broken off and decayed. A record review on 11/18/25 at 12:30 PM, revealed that Resident #54 had seen an in-house dentistry on 02/06/25. The dental consult showed the following: Teeth numbers 11, 21, 22, and 6 are decayed. Teeth numbers 1-3, 13-20, 31 and 32 are missing. Teeth numbers 7-10 and 25-30 are retained root. The summary of the dental consult reads as follows: Limited tolerance with treatment will attempt to complete extractions on 29 and 30 next time. PC/SC left with facility to have them next time. Will see how patient tolerates with them to determine future treatment. She may need to be referred out to have other things completed Further record review revealed that Resident #54 was also seen by in-house dentistry on 08/15/25. Summary of the dental consult reads as follows: States she does want to start with removing teeth, will start still with LR side 29/30 area, if tolerant with us, papers left with facility again for extractions. Next visit plan: extractions. During an interview on 11/20/25 at 9:17 AM, with the Administrator and the Regional Risk Management Director (RRMD), both confirmed that Resident #54's teeth were not in the best shape, and the RRMD stated, We are not sure what happened with the paperwork. It seems like it was a miscommunication between the dental service and the facility on who was going to get the consent.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to three (3) of three (3) residents reviewed for the facility's beneficiary protection notification practice. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #38, #40, and #5. Facility census: 47 Findings Included: a. Failure to Issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2018) indicates Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary; or - considered custodial. The SNF ABN provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. On 01/09/24 at 8:55 AM, a brief medical record review revealed: -Resident #38 began Medicare Part A skilled service on 05/01/23. The last day of offered Medicare Part A skilled services was 06/20/23. There was no evidence in the medical record that a SNF ABN had been issued. -Resident #40 began Medicare Part A skilled service on 09/13/23. The last day of offered Medicare Part A skilled services was 10/10/23. There was no evidence in the medical record that a SNF ABN had been issued. -Resident #5 began Medicare Part A skilled service on 09/26/23. The last day of offered Medicare Part A skilled services was 11/07/23. There was no evidence in the medical record that a SNF ABN had been issued. During an interview on 01/09/24 at 2:15 PM, the Social Worker reported he had not issued Residents #38, #40, and #5 a SNF ABN form. The Social Worker noted he was not familiar with the form and would need to begin to issue the required SNF ABN for residents who remained in the facility with benefit days remaining, following their last covered day of Medicare Part A skilled services.

Based on record review, observation, and staff interview, the facility failed to ensure it was free from accident hazards in which it had control. One (1) medication cart was left unlocked and unattended. Additionally, the facility failed to complete a safety assessment on Resident #195 related to his use of smokeless tobacco in his room. These were random opportunities for discovery and had the potential to effect more than a limited number of residents. Resident identifier: #195. Facility census: 47. Findings included: a) Unlocked Medication Cart on 3 [NAME] Hall The facility's Medication Storage policy states, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 01/10/24 at 11:33 AM, Surveyor observed the medication cart on the 3 [NAME] Hall was unlocked and unattended. The Regional Director of Clinical Operations #72 confirmed the medication cart was unlocked and unattended and immediately secured the medications by locking the medication cart. Surveyor remained with the unlocked cart until RN #2 came back on the unit at 11:37 AM. RN #2 stated, I've been running around everywhere and must have forgot. 45171 b) Resident #195 On 01/08/24 at 01:11 PM, observation found Resident #195 sitting at his bedside. During our conversation I observed a round tin of Grizzly long cut tobacco product on his over the bed table. I questioned if he used tobacco, and he replied I use snuff, (pointing to the tin) been using it since I was 11. The tobacco at bedside was confirmed with Licensed Practical Nurse #2. The facility was a smoke free facility, however; smokeless tobacco was permitted. On 01/09/24, record review showed a Safety Resident Evaluation dated 01/02/24, completed by Registered Nurse (RN) #29. Section #4 on the evaluation was for smoking safety. Question #1 for tobacco utilization, asked, Does the resident use tobacco products? RN #29 marked - b as (No.) On 01/09/24 at 11:00 AM, review of Resident #195s care plan showed he was not care planned for tobacco use of any kind. This was confirmed with the Director of Nursing, who stated I didn't even know he had it.

Based on record review, staff interview observation the facility failed to develop and or implement the comprehensive person-centered care plan as required. This was true for four (4) of twenty-three (23) care plans reviewed during the long-term care survey. Resident identifiers: #195, #21, #15, #27 Facility Census: 47. Findings included: a) Resident 195 On 01/08/24 at 1:11 PM observation of Resident #195 sitting at his bedside. During our conversation a round tin of Grizzly long cut tobacco product was observed on his over the bed table. The surveyor questioned if he used tobacco, and he replied, I use snuff, (pointing to the tin) been using it since I was 11. The tobacco at bedside was confirmed with Licensed Practical Nurse #2. The facility was a smoke free facility; however, smokeless tobacco was permitted. On 01/09/24, record review shows a Safety Resident Evaluation dated 01/02/24, completed by Registered Nurse (RN) #29. Section #4 on the evaluation is for smoking safety. Question #1 for tobacco utilization ask: Does the resident use tobacco products? RN #29 marked b) No. On 01/09/24 at 11:00 AM, review of Resident #195's care plan shows he was not care planned for tobacco use of any kind. This was confirmed with the Director of Nursing, who stated I didn't even know he had it. b) Resident #21 On 01/10/24 1:15 PM record review found the following medical diagnoses listed for Resident #21: Alzheimer's disease, unspecified Unspecified dementia, unspecified severity with other behavioral disturbance Adjustment disorder with mixed disturbance of emotions and conduct Unspecified dementia, moderate, with mood disturbance Anxiety disorder, unspecified. Resident #21 had an order dated 05/23/23 for an anti-anxiety agent, Buspirone HCL Oral Tablet 5 milligrams (mg), give one tablet by mouth three times a day related to dementia with other behavior disturbances, anxiety disorder On 01/04/24 the medication was increased to 7.5 mg give 1 tablet by mouth three times a day related to anxiety disorder. Review of the Minimum Data Sheet, Section N (medications) with an Assessment Reference Date (ARD) date of 12/22/23 is marked that Resident #21 does not receive any anti anxiety medication. Review of the care plan shows no focus, goal or interventions for a diagnosis of anxiety. This was confirmed with the Director of Nursing on 01/10/24 at 2:00 PM. No additional information was obtained prior to completing the long term survey process. c) Resident #15 On 1/08/24 02:45 PM record review shows Resident #15 had an outstanding urine culture at the laboratory. The preliminary urinalysis showed Escherichia coli (E Coli) and she was started on Augmentin 250-62.5 milligrams (mg) three times a day for seven (7) days. Once the culture report was returned to the facility on [DATE], the physician was contacted, and the antibiotic was changed to Nitrofurantoin 100 mg twice a day for 7 days for Extended-spectrum beta-lactamases (ESBL) in the urine. This was due to the bacteria being resistant to Augmentin. Upon review of Resident #15's care plan it was found that there was no care plan for a urinary tract infection (UTI). Further review shows she had several UTI's in the past. There is a documented medical diagnosis of Urinary Tract Infection / Acute Infections dated 07/14/23. On 01/10/24 10:35 AM during an interview with the Director of Nursing (DON) she confirmed that Resident #15 does have a history of UTI's. d) Resident #27 A medical record review on 01/09/24 for Resident #27,with a hearing deficit had a comprehensive care plan with an intervention for the resident to have a communication book to assist her in communicating with the staff. In an interview on 01/09/24 at 1:35 PM, with the Licensed Social Worker (LSW), the LSW explained Resident #27 used a dry erase board, when she was unable to read your lips. During an observation on 01/09/24 at 1:40 PM, the LSW and the Minimum Data Set (MDS) Coordinator, both were unable to locate the communication book or dry erase board. 45171

Based on observation, resident interview and staff interview the facility failed to ensure the temperatures were within the required parameters, which is 71 degrees Fahrenheit (F) to 81 Degrees F. in the shower room. In addition, the facility failed to ensure Resident #1's room was clean. This failed practice has the potential to affect more than a limited number of residents. Resident Identifiers #1. Facility census 47. Findings Included: a) Resident #1 During an observation on 01/08/24 at 12:00 PM, in Resident #1's room, under the bed there is a very sticky substance with black dirt and dust buildup on it. There were also 6 caps of what appears to be tops to the tube feeding bolus under the bed. During an observation on 01/09/24 at 10:00 AM, of Resident #1's room under the bed there is a very sticky substance with black dirt and dust buildup on it. There were also 6 caps of what appears to be tops to tube feeding bolus under the bed. During an interview on 01/09/24 at 1:31 PM, with the facilities Maintenance Director, he stated, They clean these rooms daily. Yes, that is dirty under his bed and that looks like the caps to the tube feeding During a record review on 01/09/24 at 2:00 PM, of the facilities Daily Cleaning and Disinfecting Checklist dated for 01/09/24, it showed that Resident #1's room had already been cleaned for the day. During a record review on 01/09/24 at 2:10 PM, of the listed housekeeping duties it reads {sweep and mop, making sure to get under the beds}. b) Shower rooms During the resident council meeting on 01/09/23 at 11:00 AM, multiple resident council members said the shower rooms are cold when they take a shower. During an observation on 01/10/23 at 1:00 PM, the shower room on 200 hall felt cool. No thermometer was in the room. There is a baseboard heater covered in dust. On 01/10/23 at 1:15 PM, the maintenance director checked temperatures in the bathroom. The temperatures read as follows: 64.5 degrees F. by the wall, 66 degrees F. at the shower head and 67 degrees F. by the heater that was off. During an observation on 01/10/23 at 1:30 PM, the shower room on 300 hall felt cool. No thermometer was in the room. There was a baseboard heater that was on, but the bathtub is in front of it. On 01/10/23 at 1:35 PM, the maintenance director checked temperatures in the shower room. The temperatures read as follows: 68.5 degrees F. by the wall, 69.5 degrees F. by the shower head and 74 degrees F. by the heater that is blocked by the bathtub During an interview on 01/10/23 at 1:38 PM, the maintenance director stated, No I don't feel that's warm enough to take a shower in there and its not up to the correct temperature. I will check into it. During an interview on 01/10/24 at 01:44 PM, Nurse Aide (NA) 15 stated, Sometimes they complain that it is cold, I shut the door and turn on the heat.

Based on observation and staff interview, the facility failed to ensure the staff posting was accurate and correct. This had the potential to affect more than a limited number of residents residing at the facility. Facility census: 47. Findings included: a) Staff posting During a random opportunity for discovery on 01/09/24, the staff posting had not been updated from 01/08/24 to 01/09/24. Also the staff posting was not in a prominent place readily accessible to residents and visitors. In an interview with the Director of Nursing (DON) on 01/10/24 at 11:00 AM, the DON verified the staff posting had not been updated and it was not posted in a prominent place accessible to residents and visitors.

Based on observation and staff interview the facility failed to support the residents' rights, by not placing the name and contact information for the State Ombudsman in a location that was easily accessible for all residents to read. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 47. Findings included: a) During the Resident Council meeting, on 01/09/24 at 11:00 AM, the resident council members all said they did not know where the information was located for the Ombudsman. An observation, on 01/09/24 at 11:45 AM, of the posting for the Ombudsman information revealed the information was posted in a case mounted to the wall on 100 hall. The case was high on the wall and was not accessible for residents who were in wheelchairs. During an interview, on 01/10/24 at 10:28 AM, with Registered Nurse (RN) Assessment Coordinator, she stated, Well I can see it, if I was in a wheelchair I couldn't see it and especially with that glare off that glass.

Based on staff interview, resident interview, and record review the facility failed to ensure food was served at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Facility census 47. Findings included: a) Dining Services Based on anonymous resident interviews during the long term care survey process, multiple residents had complaints of the hot food being cold. During the resident council meeting on 01/09/23 at 11:00 AM, the resident council members made complaints that the food being served at meals is cold. Observation on 01/10/24 01:10 PM, found the temperatures of the last tray served on 300 hall were: noodles with meat sauce tempted at 122 degrees Fahrenheit and the vegetable barley soup tempted at 122 degrees Fahrenheit. During an interview on 01/10/24 at 1:15 PM, the facilities Dietary Manager (DM) stated, The food normally temps at 165 degrees before we serve the residents. When it is served to the residents it should be between 135 degrees and 140 degrees. Observation of the temperature log in the kitchen with the DM on 01/10/24 at 1:30 PM, found temperatures were not recorded for the lunch or breakfast meal on 01/09/24 at the time of service to the residents.

Based on observation and staff interview the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. It was discovered the ice machine was not draining properly, there was expired food found in walk-in cooler and food stored on the floor in the storage area. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 47. Findings included: a) Ice machine During a random opportunity for discovery, on [DATE] at 2:10 PM, it was discovered the ice machine was not draining properly. The drain was located below the floor drain, which provided for a no stop gap of one (1) inch to prevent backflow. In an interview with the Director of Maintenance on [DATE] at 2:50 PM, verified the drain line did not have a stop gap between the floor and the drain. b) Initial tour of the kitchen At 11:45 AM on [DATE], a tour of the kitchen with Dietary Manager (DM) #25 found the following items in the walk-in refrigerator that were expired: A plastic container labeled as Lunch Meat, had two dates written on the lid, [DATE] and [DATE]. The DM said she assumed the lunch meat should have been discarded on [DATE]. Sliced Ham, out of the original packaging, was stored in a plastic container with 2 dates written on the lid, [DATE] and [DATE]. The DM said the ham should have been discarded on [DATE]. A plastic container of beef stew had 2 dates written on the lid, [DATE] and [DATE]. The DM said the stew should have been discarded on [DATE]. In addition, the DM confirmed the step-on trash can by the employee hand washing sink was broken. This would not allow employees to discard hand drying paper towels after sanitizing their hands without touching the lid of the trash can to get it open. The DM manager confirmed a 50-pound bag of sugar was sitting on the stock room floor. She said, I guess the bin was full, but it shouldn't be on the floor. 31498

Based on observation and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than an isolated number of residents. Resident Identifiers: #194 and #11. Facility Census: 47. Findings Included: a) 300 [NAME] hallway On 01/08/24 at 12:50 PM during observation of the lunch meal trays being passed on the 300 [NAME] hallway, no hand hygiene was provided to the residents prior to their meal. When Nurse Aide (NA) #69 and #27 were asked how they provide hand hygiene, they looked at each other and laughed. NA #27 stated, 'they use to put hand wipes on the trays, but they don't anymore. They both then continued to pass the remaining meal trays without providing hand hygiene. It was confirmed with NA #69 and #27 that they did not provide hand hygiene. This was confirmed with the Director of Nursing on 01/08/24 at 1:10 PM. b) Resident #194 On 01/08/24 at 2:38 PM record review shows Resident #194 has a stage 2 pressure ulcer to the right buttock. There is a dressing change order as follows: Cleanse stage 2 with soap and water. Pat dry. Cover with border dressing daily and porn if loose or soiled until clear one time a day for Stage 2 pressure Ulcer related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear AND as needed for of loose or soiled related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear. On 01/09/24 at 01:50 PM wound care was observed with Licensed Practical Nurse (LPN) #1 performing the care. The Resident was in bed on her side and had a brief on, she had had a bowel movement. The LPN placed her gloves on, removed the old dressing in place and cleaned the resident of the bowel movement. She then proceeded to place a clean dressing on the wound without changing her gloves throughout the process. This was confirmed with LPN #1 on 01/09/24 at 1:56 PM and the Director of Nursing on 01/09/24 at 2:00 PM. c) Resident #11 On 01/08/24 at 02:12 PM record review revealed Resident #11 had a stage 2 pressure ulcer to his right shoulder. There was a dressing change order that stated: Pressure Ulcer stage two to the right shoulder rear: cleanse area with normal saline. Apply calcium alginate then cover with ABD (abdominal) pad and PORN if dressing becomes soiled, loose, or detached, one time a day related to PRESSURE ULCER OF OTHER SITE, STAGE 2 Discontinue when site is clear. AND every 24 hours as needed related to PRESSURE ULCER OF OTHER SITE, STAGE 2 Discontinue when site clear. On 01/09/24 at 11:19 AM wound care was observed when Licensed Practical Nurse (LPN) #2 performed the dressing change. When Resident #11 was turned to his side, it was noted that the old dressing was not in place, there was however a hand towel under his shoulder at the ulcer site. LPN #2 stated your old dressing is off. He then took the towel from under the resident's shoulder and placed it on the floor and not in a laundry bag or on a barrier. The towel contained a brown colored drainage and blood on it from the wound. The above was confirmed with LPN #2 on 01/09/24 at 11:25 AM and then with the Director of Nursing at 11:30 AM. d) No resident hand hygiene on the 2 [NAME] Hall. On 01/08/24 at 12:40 PM, the delivery of lunch trays began on the 2 [NAME] Hall. NA #54 and NA #31 were the staff members who passed the lunch trays on the 200 hall. No hand hygiene was provided to residents when their meals were delivered to their rooms. During an interview, on 01/08/24 at 12:57 PM, NA #31 reported she had worked in the building for approximately six (6) years and no hand hygiene is typically done with residents when they eat in their rooms. NA #31 reported that residents who eat in the dining room are given washcloths/green rags to sanitize their hands before their meals are served. NA #31 stated staff did not offer residents who choose to eat in their rooms the opportunity to sanitize their hands before the meal was served. During an interview on 01/09/24 at 3:30 PM, the DON reported she had been made aware of the issue. 45171

Based on observation and staff interview the facility failed to promote a dignified dining experience by not providing meals to all residents seated at the same table at the same time. This failed practice was a random opportunity for discovery. Resident identifiers: #5 and #30. Facility census 47. Findings included: a) Resident #5 During an observation, on 01/08/24 at 1:00 PM, Resident #5 was seated at a dining room table for lunch. Two (2) other residents seated at the same table were served their lunch tray. Staff then served 2 residents seated at another table. Another resident seated by herself was served at another table. Resident #5 still did not have her tray. During an interview, on 01/08/24 at 1:10 PM, with the Activity Director, she stated, I'm not really sure how they have them , maybe the resident is at the wrong table. During an observation on 01/08/24 at 1:12 PM, Resident #5 received her lunch tray. During an interview on 01/08/24 1:12 PM, Nursing Assistant (NA)# 36 stated, She must have parked herself there. During an interview on 01/10/24 at 10:54 AM, with the Director of Nursing ( DON), she stated, I don't think that there is a specific policy on that. They typically try to go in order unless someone is disruptive or something like that. b) Resident #30 During observation, on 01/10/24 at 1:19 PM, Resident #30 was seated at a table in the dining room. Everyone else at her table had finished eating and had left the dining room. The Resident did not have her meal. During an interview on 01/10/24 at 1:20 PM, NA #15 stated, Resident # 30 has been here the entire time, but she is an assistant. We will get her. Observation on 01/10/24 at 1:23 PM, found Resident #30's tray was still in the kitchen on the steam table. During an interview on 01/10/24 at 01:25 PM, with the administrator, she stated, Well I think they are perceiving it as she is asleep so she doesn't know, but I don't guess it's right.

Based on record review, resident interview, and staff interview, the facility failed address Resident #27's potentially avoidable and unplanned weight loss. The resident primarily ate Jello and cereal for lunch and dinner resulting in actual harm to the resident who wished to lose weight, but not this way. This was true for one (1) four (4) residents reviewed for weight loss during Stage 2 of the survey. Resident #27 experienced a significant unplanned weight loss in six (6) months. Resident identifier: #27. Facility census: 48. Findings include: a) Resident #27 On 06/06/16 at 3:14 p.m., a review of the resident's medical record found the Resident #27, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed Resident #27 did have capacity to make health care decisions. In addition, according to the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 04/16/16, Resident #27 had a score of 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident was cognitively intact. Both of the quarterly MDSs identified Resident #27 was not on a physician ordered weight loss program. During an interview on 06/07/16 at 10:52 a.m., Resident #27 revealed she had requested to have breakfast, and cereal and Jello for lunch and dinner. Resident #27 stated she could not eat the food as it was prepared by the facility because it made her sick. When ask if she had lost weight she stated she weighed 209 pounds when she was admitted and how weighed 185. When asked if she had informed the Dietary Manager (DM) about issues with the food she said, Yes. I have even called the Ombudsman. Resident #27 explained the DM told her, We have to do what the state says. In addition, she stated she knew she was overweight, but I don't want to lose weight this way. On 06/07/16 at 11:11 a.m., a review of the Dietitian note dated 05/23/16 at 15:18 (3:18 p.m.) revealed the following Note Text: Nutrition Risk Meeting: 191.6# (pounds) -21.8# (minus 21.8 pounds) (10.2%) x (times) 6 mo. (months) IBWR (ideal body weight range) 125-145#. PO (by mouth) average intake 76% x 7 days. Res (resident) consumes snacks during the day. Will D/C (discharge/discontinue) from list (the list of residents reviewed for weight loss). A review of Resident #27's weights on 06/08/16 at 2:55 p.m., revealed the resident's weights on the following dates: - 01/03/16 203.5 - 02/01/16 199.0 - 03/02/16 198.2 - 04/02/16 194.3 - 05/03/16 191.6 - 06/02/16 185.2 During an interview on 06/07/16 at 3:44 p.m., the Dietary Manager DM), revealed she was aware Resident #27 only ate cereal and Jello for lunch and dinner. She stated she thought she had been eating the cereal and Jello for approximately six (6) months. The DM confirmed physician had prescribed a diet of consistent carbohydrate, no added salt, regular texture, and regular fluid consistency. When asked if Resident #27 was losing weight she stated I don't think so. When asked if Resident #27 had been given supplements for weight loss, she stated, We provide them if she will take them. No evidence was provided prior to leaving the facility on 06/09/16, that a supplement had been ordered by the physician or given to this resident. The facility failed to address this resident's unplanned weight loss, failed to ensure this diabetic resident received a consistent carbohydrate diet as ordered by the physician, and failed to try to resolve issues with the resident's dietary concerns. This resulted in actual harm to the resident who wanted to lose weight, but not this way.

Based on record review, review of information from the National Pressure Ulcer Advisory Panel, review of the Resident Assessment Instrument (RAI) Users Manual, review of information from the Wound Ostomy and Continence Nurses Society, and staff interview, the facility failed to ensure residents admitted without pressure ulcers, and identified to be at risk for the development of pressure ulcers, received the necessary preventative treatment and services to prevent the development of a pressure ulcer. This practice was found for two (2) of three (3) Stage 2 sample residents reviewed for pressure ulcers during the Quality Indicator Survey (QIS). Resident identifiers: #29 and #69. Facility census: 48. Findings include: a) Resident #29 Review of the resident's medical record on 06/07/16 at 12:25 p.m. found she was admitted to the facility on [DATE] for therapy following a right femur fracture and repair. She was discharged to home with her family on 05/07/16. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 02/04/16 found the resident assessed to be at risk for the development of pressure ulcers and had no pressure ulcers at the time of admission. The 30-day MDS with an ARD of 02/25/16, was also coded NO for Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? The pressure ulcer/body audit completed on 02/22/16, indicated she developed a right heel fluid filled blister, Stage 2, measuring 3.7 centimeters (cm) in length and 3.7 cm in width. The wound was first observed on 02/20/16 and was in-house acquired. The wound progressed quickly to an unstageable wound according to a notation dated 02/26/16, then was documented as healed on 03/31/16. Although the resident was assessed as being at risk for pressure ulcers, the care plan dated 01/29/16 included no individualized measurable goals or established intervention to meet the immediate needs of the resident at the time of admission. A focus (problem) statement, goals, and interventions were initiated on 02/23/16 after the resident developed a right heel pressure ulcer. During an interview and review of the record on 06/07/16 at 1:15 p.m., Registered Nurse #47 (treatment Nurse) stated, Yes I remember her because she (Resident #29) did develop a Stage 2 fluid filled blister on 02/20/16, it was on the heel of her right leg where she had her fracture and happened in the facility and then it progressed to an unstageable which is a stage 4 pressure ulcer because she developed eschar (a collection of hardened dead tissue) covering the wound. Upon further inquiry if preventative measures were in place at the time of admission when the resident was identified to be at risk for pressure ulcer RN #47 replied, No nothing was in place to prevent heel pressure ulcer such as heel protectors or floating heels while in bed until after the pressure ulcer developed. It may or may not have been prevented, but yes it could have been avoided with preventative measures. After reviewing the MDS and care plan on 06/07/16 at 2;45 p.m., the MDS Coordinator #21 stated, Yes it is not accurate and should have been coded as a pressure ulcer but it wasn't. We talked about that since the physician called it a blister, we went with that being a blister. Yes, as a nurse, I know it is a stage 2 pressure ulcer, but just didn't code it as a pressure ulcer on the MDS. The MDS Coordinator further stated, No nothing is in the care plan for pressure ulcer prevention or being at risk on admission, but it is in there for when the blister happened. Yes, it should have been care planned on admission since she was [AGE] years old and at risk for pressure ulcer and maybe it would not have happened. (Note: according to pressure ulcer staging definitions from the National Pressure Ulcer Advisory Council,The Resident Assessment Instrument Manual, The wound ostomy and Continence Nurses Society, a pressure ulcer does not display necrotic tissue until it is a least a Stage III (3) or greater to Stage IV (4).) During an interview with the Director of Nursing (DON) on 06/07/2016 3:00 p.m., she verified no preventative measures were in place to prevent the development of a pressure ulcer for Resident #29. She stated, My nurses should have implemented preventative measures on admission. This was an in-house acquired pressure ulcer that could have been prevented with the appropriate interventions, like heel protectors and floating her heels. She was only here for therapy so she could get stronger and go home, which the resident did go home in May. b) Resident 69 Review of medical records, on 06/06/16 at 2:22 p.m., revealed Resident #69 was admitted to the facility on [DATE] without any pressure ulcers. A nursing progress note, dated 02/20/16, revealed the nurse found a soft blister area on resident's right heel measuring 3 cm x 3 cm (three centimeters by three centimeters), and the physician was notified of a suspected deep tissue injury of the right heel. An order dated 02/23/16 was for, Skincote apply topically to blister on right heel On 06/07/16 at 11:13 a.m., review of the resident's admission Braden Score dated 02/04/16, revealed a score of 18. (A score of 18 or below is indicative of the resident being at risk for development of pressure ulcers.) On 06/07/16 at 1:29 p.m., review of the wound data collection progress note dated 02/22/16, revealed, right heel 100% eschar, measuring 2.3 cm x 2.3 cm. Review of the resident's care plan on 06/07/16 at 1:13 p.m., revealed a care focus initiated on 03/23/16 that addressed the soft blister 3 cm x3 cm on the resident's heel found on 02/20/16. Interventions included elevate heels off bed, heel protectors while in bed, and treat as ordered. Upon review of the medical records with the director of nursing (DON), on 06/07/16 at 2:52 p.m., the DON agreed the pressure ulcer on the right heel could have been prevented if the area had been addressed sooner. The DON stated, Due to the resident's clinical picture upon admission, skin breakdown prevention should have been a priority. DON stated it should have been assessed and care planned upon admission. Review of the admission/5-day minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/10/16, revealed the resident was assessed as being at risk for developing a pressure ulcer, and was totally dependent for bed mobility with the assistance of two (2) persons. On 06/08/16 at 2:07 p.m., an interview with the wound nurse revealed resident was admitted first with surgical wound from repair of right femur fracture. The Wound Care Nurse stated, She (Resident #69) got a blister, a Stage 2 ulcer on her right heel - she got it while she was here. Technically it became an unstageable, it did get worse while she was here and she did have go to the wound clinic for debridement. Records showed resident first went to wound clinic on 03/01/16.

Based on record review, staff interview, and resident interview, the facility failed to develop a comprehensive care plan with individualized measurable goals and interventions for pressure ulcer prevention for Resident #29 and failed to address Resident #27's weight loss and inability to eat foods served for lunch and dinner resulting in actual harm to these residents. This practice was found for two (2) of twenty-four (24) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #29 and #27. Facility census: 48. Findings include: a) Resident #29 Review of the resident's closed medical record on 06/07/16 at 12:25 p.m., found she was admitted to the facility on [DATE] for skilled care following a right femur (bone between the knee and hip) fracture and repair. The pressure ulcer/body audit completed on 02/22/16, identified she had developed a Stage 2 fluid filled blister on her right heel measuring 3.7 centimeters (cm) in length and 3.7 cm in width. The wound, first observed on 02/20/16, was in-house acquired Review of the admission MDS with an assessment reference date (ARD) of 02/04/16, found the resident assessed as at risk for the development of pressure ulcers and no pressure ulcer was present on admission. The coding on the resident's 30-day MDS with an ARD of 02/25/16, indicated NO for Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? The interim care plan dated 01/29/16, developed prior to the admission MDS assessment, did not have a focus (problem statement), goals and interventions related to pressure ulcer prevention. Focus, goals and interventions were initiated on 02/23/16 for the discovered appearance of a right heel pressure ulcer. During an interview and review of the record on 06/07/16 at 1:15 p.m., Registered Nurse #47 (treatment Nurse) stated, Yes I remember her because she (Resident #29) did develop a Stage 2 fluid filled blister on 02/20/16. It was on the heel of her right leg where she had her fracture and happened in the facility and then it progressed to an unstageable which is a stage 4 pressure ulcer. Upon further inquiry regarding whether preventative measures were in place at the time of admission when the resident was identified to be at risk for pressure ulcer, RN #47 said, No nothing was in place to prevent heel pressure ulcer such as heel protectors or floating heels while in bed until after the pressure ulcer developed. It may or may not have been prevented, but yes, it could have been avoided with preventative measures. After reviewing the MDS and care plan on 06/07/16 at 2:45 p.m., MDS Coordinator #21 stated, Yes, it is not accurate and should have been coded as a pressure ulcer, but it wasn't. We talked about that since the physician called it a blister, we went with that being a blister. Yes, as a nurse, I know it is a Stage 2 pressure ulcer, but just didn't code it as a pressure ulcer on the MDS. The MDS Coordinator further stated, No, nothing is in the care plan for pressure ulcer prevention or being at risk on admission, but it is in there for when the blister happened. Yes, it should have been care planned on admission since she was [AGE] years old and at risk for pressure ulcers. The facility failed to develop a care plan for a resident identified as being at risk for pressure ulcer development, that included preventative measures. The resident developed a pressure ulcer on her heel that worsened during her stay at the facility resulting in actual harm. b) Resident #27 On 06/06/16 at 3:14 p.m., a review of the resident's medical record found Resident #27, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed Resident #27 did have capacity to make health care decisions. In addition, according to the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 04/16/16, Resident #27 had a score of 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident was cognitively intact. An interview with Resident #27, on 06/07/16 at 10:52 a.m., revealed this resident has not been able to eat for two (2) months. Resident #27 stated she only eats breakfast and eats cereal and Jello for lunch and dinner. Resident #27 further explained that cereal and Jello were the only foods that she could eat without becoming ill. When asked if she had lost weight she responded Yes. She stated she weighed 209 pounds when she was admitted and now weighed 185 pounds. Resident #27 confirmed she was overweight and needed to lose weight but not this way. On 06/08/16 at 11:22 a.m., a review of the resident's care plan, dated 05/25/16, revealed an intervention to monitor and record intake at each meal, and that she told staff what she wanted to eat. There were no individualized interventions that Resident #27 requested only cereal and Jello for the lunch and dinner meals. In addition, no interventions were found dealing with this resident's weight loss. A concurrent review of the Dietary Manager (DM) assessment, dated 05/03/16, revealed the quarterly review care plan included a goal for the resident to maintain weight within 3-5# (pounds) was not met. The DM's assessment included, Current weight 191.6 # (pounds) on 05/03/16. Last review weight 199# on 02/01/16. Admit weight 193.5# on 08/12/15. Shows a 7.4# loss since last review. Shows a 1.9# gain since admit. Currently eating 74-93% of meals. Receives a diet 4 (four) consistent carbohydrate NAS (no added salt) diet. In an interview on 06/08/16 at 1:34 p.m., the DM stated she was not sure when Resident #27 started requesting cereal and Jello for lunch and dinner, but thought it was about six (6) months ago. The facility failed to address this resident's unplanned weight loss, failed to ensure this diabetic resident received a consistent carbohydrate diet as ordered by the physician, and failed to try to resolve issues with the resident's dietary concerns. This resulted in actual harm to the resident who wanted to lose weight, but not this way.

Based on record review and staff interview, the facility failed to provide one (1) one of 45 Stage II sample residents with sufficient fluid intake to maintain proper hydration and health. The resident's care plan did not contain interventions to ensure the resident was provided and accepted sufficient fluids daily. Additionally, there was no ongoing monitoring of the resident's fluid intake to determine if her intake was adequate and/or if there was a need for interventions to ensure adequate fluid intake. The resident was hospitalized with dehydration. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 Record review revealed this [AGE] year old resident had [DIAGNOSES REDACTED]. Record review also revealed this resident was dependent on staff for feeding and fluid intake. Review of the most recent care plan, dated 01/25/12, found an intervention to "offer fluids frequently while awake." This intervention did not provide a distinct action plan for offering fluids, or improving fluid intake. Review of the former care plan, dated 10/26/11, found another generic intervention to "Encourage adequate fluid intake q. (every) shift." Review of the consultant registered dietitian (RD) notes, dated 02/16/12, revealed a description that the most recent lab results "indicate pos (possible)/slight dehydration." The RD recommended staff to encourage fluid intake and monitor for changes. Record review revealed the most recent BMP (basic metabolic profile) the dietitian referred to was completed on 01/28/12. The BUN (blood urea nitrogen) was elevated at 32, with the normal reference range between 8 and 27. The BUN/creatinine ratio was elevated at 42, with the normal reference range between 11-26. These values can be indicative of dehydration. Record review found no further dietitian notes prior to discharge from the facility on 04/23/12. Review of a discharge summary from the hospital, dated 04/19/12, revealed Resident #33 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The admitting laboratory work, completed at the hospital on [DATE], included an elevated BUN of 70, with the normal reference range between 6-19. The urea/creatinine ration was also elevated at 65, with the normal reference range between 12-20. During an interview with Employee #44 (DON), on 07/23/12, at approximately 11:00 a.m., the estimated daily fluid needs for this resident, who weighed 120 pounds (50 kilograms) was discussed. At 30 cc per kilogram, she would have required 1500 cc of fluids daily. Review of the March 2012 and April 2012 intake reports for Resident #33 found there were no days in this time period where she consumed 1500 cc daily. The daily average fluid and supplement intake recorded for March 2012 was 968 cc for 29 days; two (2) days had no recordings. The daily average fluid and supplement intake recorded for 04/01/12 through 04/15/12 was 701 cc. Review of the dietary manager's note, dated 02/15/12, revealed the resident's average fluid intake at that time was 554 cc. Daily supplements of 300 cc would bring that total to 854 cc, if she accepted them. When asked if this resident's fluid or food intake had been discussed in daily or monthly meetings in March 2012, or prior to hospitalization on [DATE], Employee #44 checked with the Employee #46 (director of dietary services). Employee #44 then reported Resident #33's fluid and/or food intake was not discussed in daily or monthly meetings in March 2012, or prior to hospitalization on [DATE]. She stated the resident was offered food and fluid frequently, but would often refuse. During an interview with Employee #46 on 04/23/12, at approximately 2:00 p.m., she said residents who triggered for weight loss received follow-ups. Since Resident #33 did not trigger for weight loss in March 2012 and April 2012, there was no follow-up by dietary in those two (2) months. This resulted in a failure to to monitor the resident's fluid intake to identify potential risks for dehydration. Review of dietary notes found the last entry for this resident, prior to her final discharge to the hospital on [DATE], was dated 02/28/12. There was nothing in the notes related to the assessment and/or monitoring of the resident's fluid intake. .

Based on record review and staff interview, the facility failed to provide one (1) one of 45 Stage II sample residents with sufficient fluid intake to maintain proper hydration and health. The resident's care plan did not contain interventions to ensure the resident was provided and accepted sufficient fluids daily. Additionally, there was no ongoing monitoring of the resident's fluid intake to determine if her intake was adequate and/or if there was a need for interventions to ensure adequate fluid intake. The resident was hospitalized with dehydration. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 Record review revealed this [AGE] year old resident had [DIAGNOSES REDACTED]. Record review also revealed this resident was dependent on staff for feeding and fluid intake. Review of the most recent care plan, dated 01/25/12, found an intervention to "offer fluids frequently while awake." This intervention did not provide a distinct action plan for offering fluids, or improving fluid intake. Review of the former care plan, dated 10/26/11, found another generic intervention to "Encourage adequate fluid intake q. (every) shift." Review of the consultant registered dietitian (RD) notes, dated 02/16/12, revealed a description that the most recent lab results "indicate pos (possible)/slight dehydration." The RD recommended staff to encourage fluid intake and monitor for changes. Record review revealed the most recent BMP (basic metabolic profile) the dietitian referred to was completed on 01/28/12. The BUN (blood urea nitrogen) was elevated at 32, with the normal reference range between 8 and 27. The BUN/creatinine ratio was elevated at 42, with the normal reference range between 11-26. These values can be indicative of dehydration. Record review found no further dietitian notes prior to discharge from the facility on 04/23/12. Review of a discharge summary from the hospital, dated 04/19/12, revealed Resident #33 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The admitting laboratory work, completed at the hospital on [DATE], included an elevated BUN of 70, with the normal reference range between 6-19. The urea/creatinine ration was also elevated at 65, with the normal reference range between 12-20. During an interview with Employee #44 (DON), on 07/23/12, at approximately 11:00 a.m., the estimated daily fluid needs for this resident, who weighed 120 pounds (50 kilograms) was discussed. At 30 cc per kilogram, she would have required 1500 cc of fluids daily. Review of the March 2012 and April 2012 intake reports for Resident #33 found there were no days in this time period where she consumed 1500 cc daily. The daily average fluid and supplement intake recorded for March 2012 was 968 cc for 29 days; two (2) days had no recordings. The daily average fluid and supplement intake recorded for 04/01/12 through 04/15/12 was 701 cc. Review of the dietary manager's note, dated 02/15/12, revealed the resident's average fluid intake at that time was 554 cc. Daily supplements of 300 cc would bring that total to 854 cc, if she accepted them. When asked if this resident's fluid or food intake had been discussed in daily or monthly meetings in March 2012, or prior to hospitalization on [DATE], Employee #44 checked with the Employee #46 (director of dietary services). Employee #44 then reported Resident #33's fluid and/or food intake was not discussed in daily or monthly meetings in March 2012, or prior to hospitalization on [DATE]. She stated the resident was offered food and fluid frequently, but would often refuse. During an interview with Employee #46 on 04/23/12, at approximately 2:00 p.m., she said residents who triggered for weight loss received follow-ups. Since Resident #33 did not trigger for weight loss in March 2012 and April 2012, there was no follow-up by dietary in those two (2) months. This resulted in a failure to to monitor the resident's fluid intake to identify potential risks for dehydration. Review of dietary notes found the last entry for this resident, prior to her final discharge to the hospital on [DATE], was dated 02/28/12. There was nothing in the notes related to the assessment and/or monitoring of the resident's fluid intake.

Based on medical record review, observations and staff interview, the facility failed to provide care and services to prevent infections related to catheter usage, failed to assess for and implement interventions to restore bladder continence to the extent possible, and/or failed to ensure there were valid medical justifications for the use of catheters for two (2) of 45 Stage II residents. Additionally, there was no evidence of ongoing assessment and/or implementation of individualized interventions in an effort to discontinue the catheter and/or to provide services to restore normal bladder function for these residents. There was no evidence the facility assessed the residents for causal factors for the incontinence, as urinary incontinence is a symptom of a condition which may be reversible. Additionally, there was no evidence the facility managed the Foley catheters in a manner which reduced complications, such as urinary tract infections (UTIs), which are a known complication related to catheter usage. Resident identifiers: #32 and #70. Facility census: 52 Findings include: a) Resident #32 Medical record review revealed a bladder assessment dated [DATE]. At that time restorative retraining was not recommended due to urge incontinence. There was no evidence that possible causal factors for the urge incontinence had been explored. According to the medical record, the resident had a Foley catheter inserted on 12/31/10, at the request of Hospice, for [MEDICAL CONDITION]. There was no evidence of [MEDICAL CONDITION] at the time of insertion of the catheter, and there was no evidence of a urology consultation before or since the Foley catheter was inserted. Additionally, there was no evidence of any attempts to remove the Foley catheter and initiate interventions in an effort to restore normal bladder functioning. An interview was conducted with a licensed practical nurse (LPN), Employee #45, at 10:20 a.m. on 07/18/12. She stated bladder training was tried and failed, during one of the times the resident was receiving hospice. The LPN stated the resident had been on and off hospice a few times. The director of nursing was asked to provide evidence of attempts to discontinue the Foley catheter, but was unable to provide that evidence. The resident was also diagnosed with [REDACTED]. Coli, proteus, and pseudomonas were identified. She had a UTI five (5) of six (6) months in 2012. At the time of the survey, the resident was receiving [MEDICATION NAME] 100 mg twice daily for the prevention of UTIs. The current care plan contained no goals, interventions, or any plan in an attempt to prevent the recurrent UTIs. Medical record review revealed the resident's average daily fluid intake was 857cc. An inadequate fluid intake is known to contribute to the development of UTIs. There was no evidence the resident's fluid intake was evaluated in relationship to the UTIs. An interview was conducted with Employee #54, a nursing assistant (NA), who was familiar with the resident. She stated the resident was assisted in toileting. The NA said when the resident had a bowel movement (BM), the BM got all over the Foley catheter. She also stated the resident's Foley catheter often had BM on it. This interview also revealed the resident often had stool leakage. Employee #54 stated BM got on the Foley catheter at those times. . . b) Resident # 70 Interview with Employee #62, a registered nurse, on 07/16/12 at 9:29 a.m., revealed this resident had a Foley catheter. Employee #62 stated the Foley catheter was in place due to [MEDICAL CONDITION]. Medical record review revealed no evidence of [MEDICAL CONDITION], or any other medical condition which necessitated the use of a Foley catheter. Additionally, there was no evidence of any trials without a catheter. During an observation, on 07/18/12 at 10:40 a.m., the resident's Foley catheter was lying on the floor, creating a potential for the introduction of bacteria and other infectious organisms into the catheter. On 07/18/12 at 2:05 p.m., catheter care was observed being performed by Employee #51, a nursing assistant. At that time, the catheter drainage bag was observed lying on the floor beside of the bed. This was verified with Employee #51. At 2:30 p.m. on 7/18/12, the resident was observed lying on his right side. The Foley catheter was lying on the floor on the left side of the bed. .

Based on medical record review, observations and staff interview, the facility failed to provide care and services to prevent infections related to catheter usage, failed to assess for and implement interventions to restore bladder continence to the extent possible, and/or failed to ensure there were valid medical justifications for the use of catheters for two (2) of 45 Stage II residents. Additionally, there was no evidence of ongoing assessment and/or implementation of individualized interventions in an effort to discontinue the catheter and/or to provide services to restore normal bladder function for these residents. There was no evidence the facility assessed the residents for causal factors for the incontinence, as urinary incontinence is a symptom of a condition which may be reversible. Additionally, there was no evidence the facility managed the Foley catheters in a manner which reduced complications, such as urinary tract infections (UTIs), which are a known complication related to catheter usage. Resident identifiers: #32 and #70. Facility census: 52 Findings include: a) Resident #32 Medical record review revealed a bladder assessment dated [DATE]. At that time restorative retraining was not recommended due to urge incontinence. There was no evidence that possible causal factors for the urge incontinence had been explored. According to the medical record, the resident had a Foley catheter inserted on 12/31/10, at the request of Hospice, for [MEDICAL CONDITION]. There was no evidence of [MEDICAL CONDITION] at the time of insertion of the catheter, and there was no evidence of a urology consultation before or since the Foley catheter was inserted. Additionally, there was no evidence of any attempts to remove the Foley catheter and initiate interventions in an effort to restore normal bladder functioning. An interview was conducted with a licensed practical nurse (LPN), Employee #45, at 10:20 a.m. on 07/18/12. She stated bladder training was tried and failed, during one of the times the resident was receiving hospice. The LPN stated the resident had been on and off hospice a few times. The director of nursing was asked to provide evidence of attempts to discontinue the Foley catheter, but was unable to provide that evidence. The resident was also diagnosed with [REDACTED]. Coli, proteus, and pseudomonas were identified. She had a UTI five (5) of six (6) months in 2012. At the time of the survey, the resident was receiving [MEDICATION NAME] 100 mg twice daily for the prevention of UTIs. The current care plan contained no goals, interventions, or any plan in an attempt to prevent the recurrent UTIs. Medical record review revealed the resident's average daily fluid intake was 857cc. An inadequate fluid intake is known to contribute to the development of UTIs. There was no evidence the resident's fluid intake was evaluated in relationship to the UTIs. An interview was conducted with Employee #54, a nursing assistant (NA), who was familiar with the resident. She stated the resident was assisted in toileting. The NA said when the resident had a bowel movement (BM), the BM got all over the Foley catheter. She also stated the resident's Foley catheter often had BM on it. This interview also revealed the resident often had stool leakage. Employee #54 stated BM got on the Foley catheter at those times. . b) Resident # 70 Interview with Employee #62, a registered nurse, on 07/16/12 at 9:29 a.m., revealed this resident had a Foley catheter. Employee #62 stated the Foley catheter was in place due to [MEDICAL CONDITION]. Medical record review revealed no evidence of [MEDICAL CONDITION], or any other medical condition which necessitated the use of a Foley catheter. Additionally, there was no evidence of any trials without a catheter. During an observation, on 07/18/12 at 10:40 a.m., the resident's Foley catheter was lying on the floor, creating a potential for the introduction of bacteria and other infectious organisms into the catheter. On 07/18/12 at 2:05 p.m., catheter care was observed being performed by Employee #51, a nursing assistant. At that time, the catheter drainage bag was observed lying on the floor beside of the bed. This was verified with Employee #51. At 2:30 p.m. on 7/18/12, the resident was observed lying on his right side. The Foley catheter was lying on the floor on the left side of the bed.

Based on staff interview and medical record review, the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care. The resident received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility policy. Resident identifier: #42. Facility Census: 49 Findings include: a) Resident #42 Review of this resident's medical record revealed she had end stage [MEDICAL CONDITION] and was receiving [MEDICAL TREATMENT] services. According to the care plan, nursing staff were instructed to check the fistula site prior to and after [MEDICAL TREATMENT] services. Additionally, the site was to be observed daily for signs and symptoms of infection. At 2:58 p.m. on 10/03/12 an interview was conducted with a licensed practical nurse (LPN), Employee #11, regarding what the facility did for the resident before and after she went to [MEDICAL TREATMENT]. Employee #11 said the resident's blood sugar was checked upon return from [MEDICAL TREATMENT]. She did not provide any information specific to the [MEDICAL TREATMENT] care plan, which described the facility's responsibilities before and after the resident went to [MEDICAL TREATMENT]. The LPN stated there was a form which had to be completed and sent with the resident when she went to [MEDICAL TREATMENT]. She said the forms were in the resident's medical record. This form (GSS #862) was located in the resident's medical record. It was entitled "[MEDICAL TREATMENT] Communication/Referral," and indicated it was for visits to [MEDICAL TREATMENT]. The resident's forms, dated 08/01/12 through 10/01/12, were reviewed. This review revealed no evidence staff were performing these assessments. The portion of the form on which bruit and thrill was supposed to be documented was blank on every form. Additionally, there was no evidence the fistula site was being monitored for signs and symptoms of infection. The facility's policy for residents who received [MEDICAL TREATMENT] was reviewed. It indicated form "GSS #863," a monitoring flow sheet for [MEDICAL TREATMENT], was supposed to be used daily to monitor the bruit and thrill of the fistula site. The resident's medical record contained only one (1) flow sheet, dated 09/13/12, and it was only partially completed. An interview was conducted with the individual who maintained medical records, Employee #46, at 2:30 p.m. on 10/04/12. At that time, Employee #46 attempted to locate completed flow sheets for August 2012 and September 2012. Upon being unable to locate these flow sheets, she stated, "I don't have any." .

Based on staff interview and medical record review, the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care. The resident received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility policy. Resident identifier: #42. Facility Census: 49 Findings include: a) Resident #42 Review of this resident's medical record revealed she had end stage [MEDICAL CONDITION] and was receiving [MEDICAL TREATMENT] services. According to the care plan, nursing staff were instructed to check the fistula site prior to and after [MEDICAL TREATMENT] services. Additionally, the site was to be observed daily for signs and symptoms of infection. At 2:58 p.m. on 10/03/12 an interview was conducted with a licensed practical nurse (LPN), Employee #11, regarding what the facility did for the resident before and after she went to [MEDICAL TREATMENT]. Employee #11 said the resident's blood sugar was checked upon return from [MEDICAL TREATMENT]. She did not provide any information specific to the [MEDICAL TREATMENT] care plan, which described the facility's responsibilities before and after the resident went to [MEDICAL TREATMENT]. The LPN stated there was a form which had to be completed and sent with the resident when she went to [MEDICAL TREATMENT]. She said the forms were in the resident's medical record. This form (GSS #862) was located in the resident's medical record. It was entitled "[MEDICAL TREATMENT] Communication/Referral," and indicated it was for visits to [MEDICAL TREATMENT]. The resident's forms, dated 08/01/12 through 10/01/12, were reviewed. This review revealed no evidence staff were performing these assessments. The portion of the form on which bruit and thrill was supposed to be documented was blank on every form. Additionally, there was no evidence the fistula site was being monitored for signs and symptoms of infection. The facility's policy for residents who received [MEDICAL TREATMENT] was reviewed. It indicated form "GSS #863," a monitoring flow sheet for [MEDICAL TREATMENT], was supposed to be used daily to monitor the bruit and thrill of the fistula site. The resident's medical record contained only one (1) flow sheet, dated 09/13/12, and it was only partially completed. An interview was conducted with the individual who maintained medical records, Employee #46, at 2:30 p.m. on 10/04/12. At that time, Employee #46 attempted to locate completed flow sheets for August 2012 and September 2012. Upon being unable to locate these flow sheets, she stated, "I don't have any." .

Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident receiving intravenous fluids. Additionally, the facility failed to ensure timely medical intervention when a resident experienced deterioration in health status. The facility ' s failure to provide the necessary care and services for this resident resulted in harm. This practice affected one (1) of 45 Stage II sample residents. Resident identifier: #33. Facility census: 53. Findings include: a) Resident #33 Medical record review revealed Resident #33 began receiving intravenous (IV) fluids with 20 MeQ (milliquivalents) of potassium at 75 cc per hour shortly after midnight on 04/20/12. Factors which placed her at higher risk for potential adverse reactions from receiving IV fluid therapy included a [DIAGNOSES REDACTED]. Despite the increased risk of adverse reactions, record review revealed that nursing staff were not consistently assessing lung sounds or early signs of fluid overload. Review of a hospice note, written by a registered nurse from hospice, found notation that the resident's lung sounds were clear when assessed on 04/20/12. Further medical record review found no evidence of lung sound assessments by facility staff on any of the three (3) shifts on 04/20/12, 04/21/12, or 04/22/12. The 04/23/12 nurse's notes for 3:00 a.m. noted the resident's respiratory rate had been 32 breaths per minute at 10:00 p.m., and lung sounds were diminished bilaterally in the lower lobes. Later, at 8:45 a.m. on 04/23/12, the hospice aide notified the nurse that the resident was coughing. The nurse assessed the resident ' s moist lung sounds and noted rhonchi present bilaterally. The nurse ' s note indicated the hospice nurse was called to come in and evaluate the resident. Upon her arrival to the facility at 10:30 a.m., the hospice nurse assessed the resident with slight expiratory wheezing. Neither the physician nor the responsible party was notified of the changes in the resident ' s respiratory status/lung sounds. It was not until 12:10 p.m., when a laboratory technician from the hospital called to report a critically elevated potassium blood level and a high creatinine blood level, that the intravenous infusion of fluids with potassium was stopped, and the physician and responsible party were notified. The resident was transported to the hospital, on 04/23/12 at 12:40 p.m., where she was admitted . Review of the hospital ' s admission history and physical, dated 04/23/12, revealed the documented admitting impression was the resident " ...seems to have volume in her lungs with bilateral pleural effusions and crackles." The physician noted she also had acute [MEDICAL CONDITION] and [MEDICAL CONDITION] that appeared to be systolic.. Comparatively, the facility ' s medical record review found a chest x-ray which had been completed on 04/16/12. This x-ray revealed no acute infiltrates or effusions were seen, and no acute cardiopulmonary process was noted at that time. Review of the hospital discharge summary, dated 04/26/12, found discharge [DIAGNOSES REDACTED]. During an interview with the director of nursing (DON), on 07/23/12 at approximately 11:00 a.m., she said it was her expectation that nurses do lung assessments on each shift when a resident was receiving IV fluids. The DON said she would have expected the nurses to have notified the physician regarding the lung sound assessment changes on 4/23/12. She said the facility had no policy about assessing lung sounds on residents who were receiving IV fluids. .

I. Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident receiving intravenous fluids. Additionally, the facility failed to ensure timely medical intervention when a resident experienced deterioration in health status. The facility ' s failure to provide the necessary care and services for this resident resulted in harm. This practice affected one (1) of 45 Stage II sample residents. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 Medical record review revealed Resident #33 began receiving intravenous (IV) fluids with 20 MeQ (milliquivalents) of potassium at 75 cc per hour shortly after midnight on 04/20/12. Factors which placed her at higher risk for potential adverse reactions from receiving IV fluid therapy included a [DIAGNOSES REDACTED]. Despite the increased risk of adverse reactions, record review revealed that nursing staff were not consistently assessing lung sounds or early signs of fluid overload. Review of a hospice note, written by a registered nurse from hospice, found notation that the resident's lung sounds were clear when assessed on 04/20/12. Further medical record review found no evidence of lung sound assessments by facility staff on any of the three (3) shifts on 04/20/12, 04/21/12, or 04/22/12. The 04/23/12 nurse's notes for 3:00 a.m. noted the resident's respiratory rate had been 32 breaths per minute at 10:00 p.m., and lung sounds were diminished bilaterally in the lower lobes. Later, at 8:45 a.m. on 04/23/12, the hospice aide notified the nurse that the resident was coughing. The nurse assessed the resident ' s moist lung sounds and noted rhonchi present bilaterally. The nurse ' s note indicated the hospice nurse was called to come in and evaluate the resident. Upon her arrival to the facility at 10:30 a.m., the hospice nurse assessed the resident with slight expiratory wheezing. Neither the physician nor the responsible party was notified of the changes in the resident ' s respiratory status/lung sounds. It was not until 12:10 p.m., when a laboratory technician from the hospital called to report a critically elevated potassium blood level and a high creatinine blood level, that the intravenous infusion of fluids with potassium was stopped, and the physician and responsible party were notified. The resident was transported to the hospital, on 04/23/12 at 12:40 p.m., where she was admitted . Review of the hospital ' s admission history and physical, dated 04/23/12, revealed the documented admitting impression was the resident " ...seems to have volume in her lungs with bilateral pleural effusions and crackles." The physician noted she also had acute [MEDICAL CONDITION] and [MEDICAL CONDITION] that appeared to be systolic.. Comparatively, the facility ' s medical record review found a chest x-ray which had been completed on 04/16/12. This x-ray revealed no acute infiltrates or effusions were seen, and no acute cardiopulmonary process was noted at that time. Review of the hospital discharge summary, dated 04/26/12, found discharge [DIAGNOSES REDACTED]. During an interview with the director of nursing (DON), on 07/23/12 at approximately 11:00 a.m., she said it was her expectation that nurses do lung assessments on each shift when a resident was receiving IV fluids. The DON said she would have expected the nurses to have notified the physician regarding the lung sound assessment changes on 4/23/12. She said the facility had no policy about assessing lung sounds on residents who were receiving IV fluids. . . II. Based on medical record review and resident interview, the facility failed to ensure residents received services and care necessary to promote their highest level of well-being. The facility failed to ensure services were provided to promote comfort and relieve pain. Resident identifiers: #42 and #48. Facility census: 52 Findings include: a) Resident # 42 Medical record review of nurses' notes, dated 06/25/12 at 6:00 p.m., written by Employee #14, found, "Resident was sitting in solarium with husband. She is asking and hollering to be layed down. She was told that as soon as dinner is over she will be layed down due to pain in back and legs. She tells her husband 'just push me out of the chair and maybe then I will get layed down.'" The next entry was written on 06/26/12 at 3:25 a.m., by Employee #28, which described, " ... complains of leg and back pain and scheduled pain medication given per order with short term pain relief and Tylenol prn given for breakthrough pain as well as repositioning, massage and relaxation techniques. Each produced short term results with one (1) to two (2) hours of relief." There was no evidence the physician was notified of the increase in the resident's back and leg pain or that only short term relief was obtained from the prescribed medications. An entry in the nurse's notes, on 06/26/12 at 3:50 p.m., by Employee #14, noted a new order for [MEDICATION NAME] due to back and leg pain. The record contained nothing regarding the efficacy of this new medication and there was no evidence of continued assessment to determine whether the current medication regimen relieved the resident's pain. During an interview with the resident regarding her pain, in the afternoon of 07/25/12, the resident stated the facility gave her pain medications, but it only "sometimes" helped relieve her pain. . b) Resident #48 Review of the facility's policy for medication response revealed that ongoing pain and the use of as needed (PRN) pain medication was to be documented upon giving the medication, and completed again within a reasonable time. The Pain Policy also stated that PRN medications were to be followed up with a pain level assessment. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During this time period, PRN pain medication was given ten (10) times. .