Every finding on record at Wedgewood Manor

Based on observation and staff interviews, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 3 of 3 sampled residents (Residents #11, #12, and #14's) and 1 of 1 commons area (Hall B) with circulating fans. Failure to ensure the residents' environment and equipment (fans) are kept clean and sanitary does not promote a homelike living environment. Findings include: Observations on 07/07/26 showed the following: * At 1:59 p.m., the grates of a black pedestal fan coated with dust and debris next to an oxygen concentrator in Resident #14's room. * At 4:42 p.m., the grates of table fan coated with dust and debris located in the common area of Hall B. Observations on all days of survey showed the following:* Resident #11's fan with visible dust debris. * Resident #12's fan grate coated with dust debris and hanging fuzz. On 07/08/26 at 3:05 p.m., a nurse (#5) placed nebulizer equipment directly in front of the blowing fan to air dry. During an interview on 07/09/26 at 10:30 a.m., a housekeeping staff (#7) stated the certified nurse aides and housekeeping staff were expected to identify dirty fans and inform maintenance staff for cleaning and confirmed the fans in Hall B common area and in residents' rooms needed cleaning.

Based on record review, review of facility policy, and staff interviews, the facility failed to notify the resident's medical provider for 1 of 1 sampled resident (Resident #15) with high blood glucose readings. Failure to notify the provider of high blood glucose levels as ordered may result in adverse outcomes for the resident and delay in treatment.Findings include:Review of the facility policy titled Physician Notification occurred on 07/09/26. This policy, dated 05/29/24 stated, . The facility must timely notify the attending physician or practitioner on call of change in condition, lab results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per ordering physician's orders. Examples of timely Notification Orders: Blood glucose levels outside the individual resident parameters. Guidelines: . Immediate notifications . Document notification of result and condition .Review of Resident #15's medical record occurred on all days of survey and included a diagnosis of type 2 diabetes mellitus. A physician's order, dated 01/22/26 stated, Parameters for blood glucose-Call physician if BS [blood sugar] below 70 mg/dl [milligrams per deciliter] and above 400 mg/dl. Review of Resident #15's Blood Sugar Summary, dated April 10 - July 9, 2026, showed the following blood glucose readings:* 05/19/26 at 9:42 p.m. - 445.0 mg/dL* 06/12/26 at 4:45 p.m. - 412.0 mg/dL* 06/18/26 at 4:39 p.m.- 453.0 mg/dL The medical record lacked documentation the facility notified Resident #15's provider of the elevated blood glucose levels. During an interview on 07/09/26 at 11:30 a.m., an administrative nurse (#2) confirmed staff failed to notify the physician of Resident #15's high blood sugar levels on the above dates. During an interview on 07/09/26 at 11:46 a.m., an administrative nurse (#1) stated she expected staff to follow orders and notify the physician of Resident #15's high blood sugar levels.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 1 of 14 sampled residents (Resident #8). Failure to develop a comprehensive care plan that includes opioid medication use and pain may negatively impact the resident's quality of care.Findings include:Review of Resident #8's medical record occurred on all days of survey. Medications included hydrocodone-acetaminophen (an opioid) 5-325 milligrams (mg) every four hours as needed for pain and hydrocodone-acetaminophen 7.50-325 mg three times a day for pain.The admission Minimum Data Set (MDS) dated [DATE], identified Resident #8 received opioid medication, non-medication intervention for pain, and experienced pain almost constant during the assessment period.Resident #8's care plan lacked goals and interventions related to opioid use and pain.During an interview on 07/09/26 at 11:50 a.m., an administrative staff nurse (#1) confirmed staff failed to include opioid medication risks/side effects and interventions for pain management in Resident #8's care plan.

Based on observation, record review, and staff interview, the facility failed to ensure the safety of equipment for 1 of 2 sampled resident (Resident #12) observed with a nebulizer machine. Failure to maintain equipment in safe operating conditions may result in equipment short circuiting, fires, and injuries to the residents or staff. Findings include: The facility was unable to provide a policy on equipment maintenance. Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, . I self-administer my nebulizer after set up by nurse .Observation on all days of survey showed the power cord to Resident #12's nebulizer machine damaged and the insulated conductor wires exposed.During an interview on 07/09/2026 at 11:16 a.m., an administrative nurse (#1) stated she expected all equipment to be in proper working order and immediately removed the nebulizer machine from Resident #12's room.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to provide the necessary care and services for 1 of 1 sampled resident (Resident #11) receiving oxygen. Failure to administer oxygen according to the physician's order may result in complications and compromise the resident's respiratory status.Findings include:Review of the facility policy titled Oxygen Administration occurred on 07/09/26. This policy, dated March 2023, stated, . Oxygen is administered under orders of a physician . Equipment setting for the prescribed flow rates.Review of Resident #11's medical record occurred on all days of survey. Diagnoses included acute and chronic respiratory failure with hypoxia (inadequate oxygen reaching the body's tissues) and chronic obstructive pulmonary disease with acute exacerbation. A physician's order, dated 05/18/26, stated, Continuous oxygen via NC [nasal cannula] set at 3 LPM [liters per minute] in use. The current care plan stated, . observe for s/s [signs and symptoms] of sob [shortness of breath]. Oxygen at 3L/min via Nasal Cannula .Review of the nurse's progress notes from February 1 through July 7, 2026, identified 30 times Resident #11 complained of shortness of breath.Observations on all days of survey showed Resident #11's room oxygen concentrator setting at 2 LPM.During an interview on 07/09/26 at 8:35 a.m., Resident #11 stated the oxygen concentrator should be set at 3 LPM.During an interview on 07/09/26 at 8:47 a.m., a nurse (#5) confirmed the physician's order stated oxygen at 3 LPM.During an interview on 07/09/26 at 8:55 a.m., an administrative nurse (#1) stated she expected staff to administer oxygen at the rate ordered by the physician.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to utilize the assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #6) observed during a transfer. Failure to use a gait belt during transfers placed residents at risk for injuries and falls. Findings include: Review of the facility policy titled Use of Gait Belt occurred on 07/09/26. This policy, dated 03/16/23, stated, . Use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Review of Resident #6's medical record occurred on all days of survey. The care plan, stated, Assist of 1 with transfers with gait belt, toileting, dressing, bathing, and personal hygiene. Observation on 07/08/26 at 9:35 a.m. showed a certified nurse aide (CNA) (#4) assisted Resident #6 to the bathroom without using a gait belt. During an interview on 07/08/26 at 10:11 a.m., Resident #6 stated, Therapy uses the gait belt when they are working with me, but the CNA's typically do not. During an interview on 07/09/26 at 11:47 a.m., an administrative nurse (#1) stated she expected staff to use a gait belt during transfers.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 facility kitchen. Failure to ensure the sanitizer test strips used to measure the concentration of sanitizing solution are not expired has the potential for inadequate sanitization and may result in foodborne illness. Findings include: Observation in the kitchen on 06/03/25 at 1:35 p.m. showed a dietary staff member (#5) measured the concentration of a premixed bucket of sanitizing solution with expired test strips, dated 05/15/2021. During an interview on 06/03/25 at 4:25 p.m., a dietary staff member (#5) stated staff should not use expired test strips.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 3 sampled residents (Resident #14 and #32) observed during wound care. Failure to practice infection control standards related to enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/04/25. This policy, dated March 2023, stated, . Enhanced barrier precautions refer to the use of gown and gloves for high-contact resident care activities for residents known to be colonized or infected with a MDRO (multidrug resistant organism) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident care activities include: . Wound care: any skin opening requiring a dressing . - Review of Resident #14's medical record occurred on all days of survey and identified a pressure ulcer on the inner buttocks and dressing changes every three days and as needed. The resident's room failed to identify EBP. Observation on 06/03/25 at 9:08 a.m. showed a certified nurse aide (CNA) (#4) and a nurse (#3) applied gloves and assisted Resident #14 off the toilet. The nurse cleansed the pressure ulcer area and applied a dressing. The nurse (#3) and the CNA (#4) failed to wear a gown during high-contact resident care for toileting and wound care. - Review of Resident #32's medical record occurred on all days of survey. The record identified an indwelling urinary catheter, heel ulcers to both heels, and dressing changes to the heels two times a day. Observation on 06/03/25 at 12:27 p.m. showed Resident #32's room with signage for EBP and a supply cart located at the entrance of the room. Two nurses (#2 and #3) entered the room, applied gloves, removed the wound dressings, cleansed the wounds, and applied new dressings to both the right and left heels. The nurses failed to apply a gown during the high-contact resident care for wound treatment and dressing changes. During interviews on 06/04/25, an administrative staff member (#1) reported she expected Resident #14 to be in EBP and staff to wear gowns when providing wound cares. 2. Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 6 sampled residents (Resident #32) observed during medication pass. Failure to practice infection control standards during medication pass has the potential to spread infection to residents. Findings include: Review of the facility policy titled Medication Administration- General Guidelines occurred on 06/04/25. This policy, dated October 2022, stated, . If the integrity or sanitation of a medication is in question (e.g. [for example] . inadvertently touched by a staff member . The compromised medication shall be destroyed per facility policies . Observation on 06/03/25 at 1:06 p.m. showed a nurse (#3) prepared Resident #32's medications for administration. The nurse dropped the Vitamin B complex capsule on the medication cart and, with a bare hand, picked up the capsule and placed it into the medication cup for administration. During an interview on 06/04/25 at 10:00 a.m., an administrative nurse (#1) reported she expected staff to discard a medication dropped on the medication cart.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #19 and #31). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTIONS N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, page N-6 to N-8, stated, . Code all high-risk drug class medications according to their pharmacological classification . N0415: High-Risk Drug Classes . Coding Instructions: . N0415B1. Antianxiety: Check if an anxiolytic [antianxiety] medication was taken by the resident at any time during the 7-day look-back period . - Review of Resident #19's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], showed facility staff coded an antianxiety medication during the seven-day look back period. The medical record failed to identify an antianxiety medication administered in the look-back period. During an interview on the afternoon of 06/03/25, an administrative nurse (#1) confirmed staff failed to code the MDS correctly. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages P1-P5, stated, . PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. P0100: Physical Restraints . Coding Instructions: . After determining whether or not an item . is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. - Review of Resident #31's medical record occurred on all days of survey. An admission MDS, dated [DATE], showed facility staff coded section P0100A, bed rail as 2 used daily. Observation showed no bed rails present. During an interview on 06/02/25 at 5:00 p.m., an administrative nurse (#1) confirmed Resident #31 does not have bed rails and staff failed to code the admission MDS correctly.

Based on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to immediately implement safeguards for all residents after suspected sexual abuse occurred for 1 of 1 sampled resident (Resident #1). Failure to immediately protect all residents from the potential of sexual abuse placed them at risk for mental and emotional distress, and/or physical injury. During the on-site FRI survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. The interview confirmed the results of a urinalysis sample, collected 09/30/24, from Resident #1, an [AGE] year old female who was not sexually active, contained non-motile sperm, confirmed by three laboratorians and a Medical Doctor (MD). The interview also confirmed the facility had not provided adequate protection from all potential perpetrators. This finding placed all residents at risk for mental and emotional distress, and/or physical injury. *10/08/24 at 11:08 a.m. The survey team notified the Chief Executive Officer and Director of Nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *10/08/24 at 2:30 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: - No additional male travelers will be utilized for staffing until investigation is completed. - In addition, all male staff on duty or scheduled, including non direct care staff, certified nurse aides (CNAs), and licensed staff will have a female staff member with them while in a resident's room. - All staff meeting held on 10/08/24 at 2:00 p.m. informed staff of the changes in procedures for care provided by male caregivers and reviewed the abuse and neglect policy. Staff not present at the meeting will read, review, and sign the information provided prior to their next shift. *10/08/24 at 2:45 p.m. The survey team verified the implementation of the removal plan as of 10/08/24 and the IJ removal. The deficient practice remained at a G scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Resident Abuse & Neglect occurred on 10/08/24. This policy, revised 06/23/21, stated, . No resident shall be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident . Abuse: is defined as the willful infliction of injury . with resulting physical harm, pain or mental anguish. It includes . sexual abuse . Sexual Abuse: is defined as non-consensual sexual contact of any type with a resident. Ongoing education on abuse will be offered no less that [sic] yearly. Should it be necessary, it will be offered more frequently. Investigation of Alleged Abuse . Any employee who sees or suspects abuse will report immediately to the charge nurse . The charge nurse will assure immediate safety and mental well-being of the resident; investigate the extent of harm to the resident; and provide facts through the investigation. The charge nurse will contact the DON . The . DON . will contact the Administrator . ND [North Dakota] Dept. [Department] of Health . Physician . Responsible Party . Police Department . No attempt is made to disturb the area in anyway. If it is an employee who is being suspected for abuse, the employee is informed and suspended while the investigation is conducted by the DON . Local authorities will direct further follow-up and investigations . Written Report Identify person sending report and/or contact person, facility sending report, all information listed above in initial report, describe measures taken to protect the resident during investigation, describe measures taken to prevent re-occurrence of the incident . Review of the facility's final investigation occurred on 10/07/24 and identified facility staff collected a urine specimen on 09/30/24 at 12:20 p.m. The description of the event stated, . CNA [#6] stated, I heard [Resident #1] screaming for help and I went into the room to help her. [Resident #1] was trying to get out of bed and stated she had to go pee. I assisted [Resident #1] to the bathroom . I remembered she needed her urine collected. I took the hat that was in the room and placed it on the toilet. After she did the sample into the hat, I finished washing her up and assisted her to the nurse's station. I informed the nurse of the sample, and she went in and got the sample. Nurse [#9] . states the hat was full of urine and sitting in the toilet. I grabbed a clean new specimen cup and poured urine into the cup. The urine was transferred to the lab, and I received a call from the lab stating the specimen cup was not labeled. Nurse [#9] . went to the lab and labeled the specimen with [Resident #1's] name. Nurse [#9] reports, I then got a call from Laboratorian [#7] at the lab requesting another specimen because they had concerns with the first specimen. Administrative staff [#2] . contacted Laboratorian [#7] at the lab and Laboratorian [#7] reported that sperm was found in the urine specimen. Administrative staff [#2] . contacted [Resident #1's] PCP [primary care provider] and the PCP requested [Resident #1] be brought to the clinic for further evaluation. CNA [#6] was removed from service at this time. During an interview on 10/07/24 at approximately 9:55 p.m., three administrative staff members (#1, #2, and #5) and a staff nurse (#4) confirmed they terminated the male CNA (#6) who assisted Resident #1 to the toilet but continued to allow other male staff members to provide personal cares to all residents in the facility by themselves except for Resident #1, who required two staff members present. The facility failed to ensure all residents were protected from sexual abuse. When the facility received notification of sperm identified in Resident #1's urine sample, the facility failed to implement measures to protect residents from sexual abuse by all potential male perpetrators and follow established policies and procedures.

Based on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to report potential sexual abuse to law enforcement for 1 of 1 sampled resident (Resident #1) with cognitive impairment. Failure to report potential sexual abuse placed Resident #1 and all other residents at risk for possible abuse and/or injury. During the on-site survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. The interview confirmed the results of a urinalysis sample, collected 09/30/24, from Resident #1, an [AGE] year old female who was not sexually active, contained non-motile sperm, confirmed by three laboratorians and a Medical Doctor (MD). The interview confirmed the facility failed to notify law enforcement. These findings placed all residents in immediate danger for abuse, mental and emotional distress, and/or physical injury. *10/08/24 at 11:08 a.m. The survey team notified the Chief Executive Officer and Director of Nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *10/08/24 at 2:30 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: - Chief of Police notified via phone at 11:24 a.m. on 10/08/24 of potential sexual abuse of resident regarding potential improper contents of female urine specimen. - Facility will cooperate with reporting and investigation per law enforcement. - All staff meeting held on 10/08/24 at 2:00 p.m. informed staff of the changes in procedures for care provided by male caregivers and reviewed the abuse and neglect policy. Staff not present at the meeting will read, review, and sign the information provided prior to their next shift. *10/08/24 at 2:45 p.m. The survey team verified the implementation of the removal plan as of 10/08/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Resident Abuse & Neglect occurred on 10/08/24. This policy, revised 06/23/21, stated, . Investigation of Alleged Abuse/Neglect . The . DON . will contact . the . Police Department . No attempt is made to disturb the area in anyway. Local authorities will direct further follow-up and investigations . Review of the facility's final investigation occurred on 10/07/24. A progress note, dated 09/30/24, stated . An order from MD [#12] was obtained for a urinalysis Sunday night, 9/29. A urine sample was brought to the lab, without a name on it. Nurse [#9] . had poured the urine from the hat, to the collection cup, and forgot to place a label on it. The nurses' aide had gotten the urine from [Resident #1] . The urine sample showed bacteria, and sperm, which were non-motile, seen by all 4 personnel in the lab, and myself [MD #13]. During an interview on 10/07/24 at approximately 9:55 p.m., an administrative staff member (#5) confirmed the facility failed to notify law enforcement regarding the alleged sexual abuse.

Based on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to conduct a thorough investigation of potential sexual abuse for all residents after suspected sexual abuse for 1 of 1 sampled resident (Resident #1). Failure to investigate alleged violations of sexual abuse and ensure all residents were protected during the investigation, placed Resident #1 and all other residents at risk for possible abuse, mental and emotional distress, and/or physical injury. During the on-site survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. following the submission of the final investigation report. The report contained the results of a urinalysis sample, collected 09/30/24, from Resident #1, an [AGE] year old female who was not sexually active. The urinalysis sample contained non-motile sperm, confirmed by three laboratorians and a Medical Doctor (MD). The interview confirmed the following: - Male facility staff members continued to provide cares to all residents, except Resident #1, - Male residents, visitors, and non-resident care staff members were not included in the facility's investigation, and - Education had not been provided by the facility to all staff regarding sexual abuse. The facility failed to thoroughly investigate an incident of potential sexual abuse for Resident #1 which placed all residents at risk for abuse, mental and emotional distress, and/or physical injury. *10/08/24 at 11:08 a.m. The survey team notified the Chief Executive Officer and Director of Nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *10/08/24 at 2:30 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: - During investigation all male staff will be accompanied by another female at all times during cares and behind closed doors. - A camera was placed in Resident #1's room on 09/28/24 and is stationed at the nurses station. - All staff meeting held on 10/08/24 at 2:00 p.m. informed staff of the changes in procedures for care provided by male caregivers and reviewed the abuse and neglect policy. Staff not present at the meeting will read, review, and sign the information provided prior to their next shift. *10/08/24 at 2:45 p.m. The survey team verified the implementation of the removal plan as of 10/08/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Resident Abuse & Neglect occurred on 10/08/24. This policy, revised 06/23/21, stated, . Investigation of Alleged Abuse/Neglect . Any employee who sees or suspects abuse will report immediately to the charge nurse . The charge nurse will assure immediate safety and mental well-being of the resident; investigate the extent of harm to the resident; and provide facts through the investigation. No attempt is made to disturb the area in anyway. The charge nurse will complete a variance report. The report will be reviewed by the DON and Administrator to determine the direction of the investigation, and to identify occurrences for patterns, and trends that constitute abuse. The investigation will include interviews with the resident reported to have been abused . anyone witnessing the abuse, the individual suspected of committing the abuse, or other pertinent persons. A report of the investigation is written, including summaries of all interviews, and any other investigation activities . When the investigation is finished, the investigator will meet with Administrator, and a decision shall be made regarding the validity of the reported abuse or need for further investigation. Local authorities will direct further follow-up and investigations as needed. Written Report Identify person sending report and/or contact person, facility sending report, all information listed above in initial report, describe measures taken to protect the resident during investigation, describe measures taken to prevent re-occurrence of the incident, include a written statement clearly identifying the result of the investigation and actions taken, include copies of written and signed statements of CNA, witness(es), and resident, include copies of any other documents, or pictures . resulting from investigation. Review of the facility's final investigation occurred on 10/07/24. A progress note, dated 09/30/24, stated . An order from MD [#12] was obtained for a urinalysis Sunday night, 9/29. A urine sample was brought to the lab, without a name on it. Nurse [#9] . had poured the urine from the hat, to the collection cup, and forgot to place a label on it. The nurses' aide had gotten the urine from [Resident #1] . The urine sample showed bacteria, and sperm, which were non-motile, seen by all 4 personnel in the lab, and myself [MD #13]. During an interview on 10/07/24 at approximately 9:55 p.m., three administrative staff members (#1, #2, and #5) and a staff nurse (#4) confirmed male direct care staff performed cares alone on all residents with the exception of Resident #1. The staff members confirmed the investigation failed to include wandering male residents. The facility lacked evidence of investigations of all potential perpetrators of sexual abuse and failed to protect all residents during the investigation.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 12 sampled residents (#3, #10, #15, #28, and #30). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION J: FALLS The Long-Term Care Facility RAI Manual, revised October 2023, page J-37, states, . If this is not the first assessment . the review period is from the day after the ARD [assessment reference date] of the last MDS assessment to the ARD of the current assessment. Determine the number of falls that occurred since . prior assessment . and code the level of fall-related injury for each. - Review of Resident #30's medical record occurred all days of survey. The record identified a fall with injury (bruising) on 02/28/24 and falls without injury on 02/24/24, 03/18/24, and 03/23/24. Resident #30's annual MDS, dated [DATE], identified no falls since the previous assessment on 01/04/24. During an interview on 05/16/24 at 09:30 a.m., an administrative nurse (#1) agreed Resident #30's 04/04/24 MDS lacked documentation of his falls. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages P-9 through P-11, stated, An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Code 2, used daily: if the device was used daily during the look-back period [seven days]. Other alarm includes devices, such as alarms on the resident's bathroom and/or bedroom door, toilet seat alarms or seatbelt alarms. - Review of Resident #3's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other. - Record review for Resident #10 occurred on all days of survey. The quarterly MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other alarm during the MDS assessment. - Review of Resident #15's medical record occurred on all days of survey. The annual MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other during the look-back period. - Record review for Resident #28 occurred on all days of survey. The quarterly MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other alarm during the MDS assessment. 28398 - Review of Resident #30's medical record occurred all days of survey. The annual MDS, dated [DATE], showed the facility coded other alarm used daily. The record lacked evidence the resident used an alarm the RAI manual defined as other. During an interview on 05/16/24 at 09:49 a.m., an administrative nurse (#1) stated staff coded other alarm for the alarm triggered on an exit door when a resident with a wander guard got too close to the exit. The nurse (#1) agreed the exit alarm did not meet the definition of an other alarm. 47896

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 12 sampled residents (Resident #15 and #28). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled [NAME] Manor Comprehensive Care Plans occurred on 05/16/24. This policy, dated 10/05/22, stated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. 28398 - Observation throughout the survey showed Resident #15 with a wanderguard (roam alert device) on his leg and wheelchair frame and frequently wandering throughout the building. Review of Resident #15's medical record occurred on all days of survey. Diagnoses included dementia with behavior disturbance. Resident #15's Elopement Risk Assessment, dated 11/13/19, identified the resident at risk for elopement/wandering with interventions of personal safety alarms, frequent monitoring, music, personalization of room, staff aware of wander risk, and initiation of roam alert. Resident #15's nurses' notes included episodes of exit seeking and/or elopement on at least nine occasions from 01/27/24 to 05/16/24. The facility failed to update the care plan to include interventions to address wandering/elopement. During an interview on 05/16/24 at 10:06 a.m., an administrative nurse (#2) agreed Resident #15's care plan lacked interventions related to wandering/elopement. - Review of Resident #28's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified the resident received anticoagulant and diuretic medications, and failed to identify the resident was in isolation for an active infection. The current care plan identified the resident was in isolation related to a communicable disease. The facility failed to update Resident #28's care plan to include side effects and/or interventions related to anticoagulant and diuretic medications and failed to remove isolation after the resident recovered from the disease in December 2023.

1. Based on record review, facility policy review, and staff interview, the facility failed to follow professional standards of care regarding physician orders for 1 of 5 sampled residents (Resident #17) selected for medication review. Failure to follow professional standards and contact the physician when blood glucose levels are higher than the practitioner's parameter has the potential to prevent the provider from altering medications to control residents blood sugar and/or result in adverse events. Findings include: Review of the facility policy title Notification of Changes occurred on 05/16/24. This policy, dated 12/11/23, stated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician . when there is a change requiring notification. Potential to require physician intervention. Circumstances that require a need to alter treatment. Record review for Resident #17 occurred on all days of survey. A physician's order, dated 04/09/24, stated, Accucheck [a test for blood sugar] - Obtain accucheck three times daily. Update physician if blood sugar is greater than 400 and if less than 70. Review of Resident #17's blood sugar levels from 05/01/24 to 05/15/24 showed the following: * 05/03/24 at 11:46 a.m. blood sugar 454 milligrams per deciliter (mg/dl) * 05/04/24 at 11:25 a.m. blood sugar 408 mg/dl * 05/04/24 at 4:39 p.m. blood sugar 501 mg/dl * 05/05/24 at 4:00 p.m. blood sugar 401 mg/dl * 05/07/24 at 12:00 p.m. blood sugar 412 mg/dl * 05/08/24 at 11:30 a.m. blood sugar 401 mg/dl * 05/08/24 at 4:38 p.m. blood sugar High * 05/11/24 at 5:04 p.m. blood sugar 430 mg/dl The medical record lacked documentation facility staff notified the provider of blood sugar results over 400 mg/dl. During an interview on the morning of 05/16/24, an administrative nurse (#1) identified the policy provided is the one the administrator expected nursing staff to follow regarding blood sugar levels outside the provider's parameters. 28398 2. Based on record review, review of facility policy, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 4 sampled residents (Resident #30) who experienced a fall. Failure to perform neurological assessments following a fall with actual or suspected head injury may result in delayed identification and treatment of a resident's medical condition. Findings include: Review of the facility policy titled Neurochecks occurred on 05/16/24. This policy, dated 05/29/14, stated, Neurochecks will be initiated in case of actual or suspected head injury to assess changes in vitals, level of consciousness, pupil response and motor function to help identify any nervous system damage. Neurological flow sheet will be completed . The attached Neurological Flow Sheet identified the timeframe for staff to complete vital signs and neurological checks as follows: - q [every] 15 min [minutes] X [times] (1) hr [hour] - q 30 min X (1) hr - q 1 hr X (4) hr - q 2 hr X (4) hr - q 4 hr X (4) hr - q 8 hr X (8) hr - 3 days after occ. [occurrence] Review of Resident #30's medical record occurred on all days of survey. Diagnoses included dementia, other abnormalities of gait and mobility, and repeated falls. Resident #30's nurses' notes showed the following: * 02/28/24 at 8:12 p.m., Resident found on his back in his room. VS [vital signs] taken. Neuros [neurological checks] completed. States he did remember if he hit his head. On left upper buttock a red area had formed with a bruise starting . * 03/01/24 at 7:11 p.m., Resident is alert and orient to person. Able to follow commands. Neuros WNL [within normal limits]. Able to move all extremities. The record lacked documentation of the results of the initial [02/28/24] and subsequent neurological checks except the entry on 03/01/24 above. * 03/20/24 at 4:40 a.m., Fall notes 3/19/24 [03/18/24 per the incident report]: Resident was found in the bathroom of another resident. Suspected head trauma from position after fall. Resident also claims to have hit his head. The neurological flow sheet, started 03/18/24 at 8:30 p.m., identified staff failed to complete eight of the required neurological checks. During an interview on 05/16/24 at 10:05 a.m., an administrative nurse (#2) stated Resident #30's record lacked a neurological flow sheet for the resident's fall on 02/28/24. The nurse verified staff failed to complete all the required neurological checks for the resident's fall on 03/18/24.

Based on review of facility policy, and staff interview, the facility failed to include the required elements intended to mitigate the transmission and spread of Covid-19 for all staff who are not fully vaccinated for Covid-19. Failure to implement additional precautions for staff who are not fully vaccinated may lead to increased transmission and spread of Covid-19 among residents, staff, and visitors. Findings include: Review of the policy titled Covid-19 Vaccination occurred on 04/13/23. This policy, dated 09/29/22, stated, . It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from Covid-19 (SARS-CoV-2) by educating and offering our residents and staff the Covid-19 vaccine . This policy lacked the required elements to mitigate the transmission, spread, and additional precautions of Covid-19, for staff who are not fully vaccinated. During an interview on 04/13/23 at 3:20 p.m., an administrative staff member (#5) confirmed the policy for Covid-19 vaccination lacked the mitigation strategies for transmission, spread, and additional precautions of unvaccinated staff.

Based on observation, record review, and staff interview, the facility failed to provide care in a manner and environment that maintained, enhanced, and respected the resident's dignity for 1 of 2 sampled residents (Resident #17) who used a urinal. Failure to provide privacy when using a urinal does not preserve the residents' dignity or enhance their quality of life. Findings include: Review of Resident #17's medical record occurred on all days of survey. The current care plan stated, Uses urinal independently. likes [sic] to stay in nightgown or has his pants around ankles. Provide privacy. pull [sic] curtain or close door halfway. Observation on 04/10/23 at 3:33 p.m. showed a certified nurse aide (CNA) (#1) transferred Resident #17 with a mechanical lift from the wheelchair to the resident's recliner. Prior to lowering the resident into the recliner, the CNA pulled the resident's pants down to the ankles exposing the resident's lower half of the body. The CNA failed to close the resident's door or pull the privacy curtain upon exiting the resident's room. Observation on 04/11/23 at 3:28 p.m. showed two CNAs (#1 and #2) transferring Resident #17 with a mechanical lift from the wheelchair to the resident's recliner. Prior to lowering the resident into the recliner, both CNAs pulled the resident's pants down to the ankles exposing the resident's lower half of the body. The CNAs failed to close the resident's door or pull the privacy curtain upon exiting the resident's room. When asked if it is the resident's preference to have the resident's pants pulled down to the ankles while sitting in the recliner, the CNA (#2) reported the resident prefers it that way for using the urinal. Observation on 04/11/23 at 3:58 p.m. showed Resident #17 sitting in the recliner with the resident's pants down to the ankles. Staff failed to close the door half ways or pull the privacy curtain. During an interview on the evening of 04/12/23 two administrative staff members (#4 and #5) confirmed there was an issue with the privacy of the resident during urinal use and reported they have been working on implementing new measures to ensure the privacy of the resident during urinal use.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 5 sampled residents (Resident #2 and #8) observed during personal care. Failure to perform hand hygiene and remove gloves after perineal care and follow enhanced barrier precautions guidelines may result in the spread of infection to other residents. Findings include:Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/12/23. This policy, dated 03/20/23, stated, . Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi-drug resistant organism] as well as those at increased risk of MDRO acquisition . High-contact resident care activities include: . providing hygiene . changing briefs or assisting with toileting . - Observation on 04/11/23 at 10:48 a.m. identified enhanced barrier precautions for Resident #8, including the use of gowns and gloves during high-contact resident care activities. Observation showed two certified nurse aides (CNAs) (#1 and #3) donned gloves but failed to put on gowns. A CNA (#3) changed Resident #8's brief and performed perineal care while the resident was in bed. Without removing her gloves, the CNA (#3) placed a new brief, pulled up the resident's pants, placed a mechanical lift sling under the resident, and transferred the resident into the wheelchair. The CNA (#3) then combed the resident's hair, made the bed, and placed the resident's call light and overbed table within reach before removing her gloves and performing hand hygiene. - Observation on 04/11/23 at 11:07 a.m. identified enhanced barrier precautions for Resident #2, including the use of gowns and gloves during high-contact resident care activities. Observation showed two CNAs (#1 and #3) donned gloves but failed to put on gowns. A CNA (#3) changed Resident #2's brief and performed perineal care while the resident was in bed. Without removing her gloves, the CNA (#3) placed a new brief, pulled up the resident's pants, placed a mechanical lift sling under the resident, and transferred the resident into the wheelchair. The CNA (#3) then placed a pillow between the resident's knees, combed the resident's hair, and assisted her with applying lipstick before removing her gloves and performing hand hygiene. During an interview on 04/12/23 at 4:39 p.m., an infection control nurse (#4) stated she expected staff to wear gowns when providing care to Resident #2 and #8 and remove their gloves after perineal care, use hand sanitizer, and put on new gloves.

Based on review of facility policy, resident and staff interviews, and review of the Resident Council minutes, the facility failed to ensure the prompt resolution of grievance from 6 of 6 confidential Residents (Residents A, B, C, D, E, F) attending the resident council interview, and one supplemental resident (Resident G) interview. Failure to address the Residents' concerns in a timely manner resulted in continued dissatisfaction regarding water passes and evening (HS) snacks. Findings include: Review of the facility policy titled Meal Times and Frequency occurred on 11/18/21. This policy, dated 09/01/21, stated, . HS snack: 7:30 pm or as resident desires . Adequacy of snack will be determined both by individuals in the group (resident council) and evaluating the overall nutritional status of those in the facility. Review of Resident Council meeting minutes from September 13, 2021 to November 8, 2021 showed two of three meetings included concerns related to the evening water and snack pass with issues unresolved. The meeting minutes identified residents voiced the following concerns: * September, . the evening snack cart only goes around once every third night, and often there's no cold-water pass at night. Weekends are especially bad for this. * October, . Water is not being passed at night, and PM snacks are also inconsistent. * November, the concerns were not addressed. During the Resident Council interview on 11/17/21 at 11:00 a.m. the resident's made the following statements regarding the evening water and snack pass: * Resident A, I do not receive a snack or water every night. * Resident B, We only get snacks a few times a week and I have to ask for them to fill my water. * Resident C, This has been an issue since I got here and it still is, why can't they just fix it? * Resident D, agreed with the statements from the other residents. * Resident E, I agree with [Resident C], they just don't have the staff. They are busy getting everyone ready for bed. * Resident F, We don't get a snack often and I have to ask for water in the evening or I don't get it. During an interview on 11/16/21 at 11:16 a.m., Resident G stated, The staffing is terrible, there is always someone quitting. They don't even ask us if we want a [evening] snack and if I don't ask them to fill my water, it doesn't happen until the morning. During an interview on 11/18/21 at 08:20 a.m., a nurse (#3) and a medication aide (#4) stated, The evening water and snack pass is at 7:00 p.m., the CNAs [certified nurse aides] are supposed to fill every resident's water mug and offer them a snack. During an interview on 11/18/21 at 8:57 a.m., an administrative nurse (#5) confirmed staff are expected to pass ice waters in the morning, between 2:00-3:00 p.m., and after supper. During an interview on 11/18/21 at 10:07 a.m., a social services staff stated, I bring concerns from the resident council meetings to the DON [director of nursing] and Administrator, and I notified both after the September and October meetings. During an interview on 11/18/21 at 2:10 p.m., an administrative nurse (#5) stated, This has been an issue since May [2021] but I thought it had gotten better.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and resident and staff interview, the facility failed to complete Minimum Data Sets (MDSs) that accurately reflected the residents' status for 4 of 12 sampled residents (Resident #5, #10, #28, and #33). Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: Section H: Bladder and Bowel The Long-Term Care Facility RAI Manual, revised October 2019, page H-8 - H-11, stated, . H0300: Urinary Continence . Steps for Assessment . Review the medical record for bladder or incontinence records or flow sheets, nursing assessments and progress notes, physician history, and physical examination. Interview the resident . Ask direct care staff who routinely work with the resident on all shifts about incontinence episodes. H0400: Bowel Continence . Steps for Assessment . Review the medical record for bowel records and incontinence flow sheets, nursing assessments and progress notes, physician history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Ask direct care staff who routinely work with the resident . - Review of Resident #33's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified the resident as occasionally incontinent of urine and frequently incontinent of bowel. A Bowel Assessment, dated 10/07/21, identified Resident #33 as continent of stool. The care plan identified Resident #33 continent of bowel and bladder. Review of the Routine Toileting Schedule documentation for October 7-13, 2021, showed the resident had no incontinent episodes of bowel or bladder. During an interview on 11/17/21 at 3:52 p.m., Resident #33 stated, I don't have those problems yet. I wore a pull-up one time when I didn't have any underwear back from the laundry. During an interview on 11/17/21 at 4:08 p.m., a certified nursing assistant (CNA) (#9) stated Resident #33 has had no episodes of incontinence. During an interview on 11/18/21 at 9:30 a.m., an administrative nurse (#1) confirmed the staff inaccurately coded the MDS. Section I: Active Diagnosis The Long-Term Care Facility RAI Manual, revised October 2019, page I-8, stated, . I: Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - Review of Resident #28's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note, dated 08/31/21, stated, . skin intact, has 3 scabs from history of cellulitus [skin infection] to left leg below knee cap, scabs intact. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Exam . Left lower leg eschars [dead tissue], no redness, or warmth, left lower leg . Integumentary: negative for skin [CONDITION(S)] or rashes . During an interview on 11/17/21 at 3:30 p.m., an administrative nurse (#1) confirmed Resident #28's infection was not active and staff inaccurately coded the MDS. Section K: Nutrition - The Long-Term Care Facility RAI Manual, revised October 2019, page K-3, stated, Steps for Assessment for K0200B, Weight . If the resident's weight was taken more than once during the preceding month, record the most recent weight. Review of Resident #5's medical record occurred on all days of survey. Review of weights identified the following: * 07/26/21 of 134 pounds * 08/02/21 of 133 pounds * 08/16/21 of 130 pounds Review of the quarterly MDS, dated [DATE], showed section K0200B weight as 136 pounds. The facility failed to use the most current on the quarterly MDS. - The Long-Term Care Facility RAI Manual revised October 2019, page K-5, stated, . K0300: Weight Loss . From the medical record, compare the resident's weight in the current observation period to . weight in the observation period 30 days ago. If the weight is less than the weight in the observation period . calculate the percentage of weight loss. compare the resident's weight in the current observation period to . weight in the observation period 180 days ago. If the current weight is less than the weight in the observation period . calculate the percentage of weight loss. Review of Resident #10's medical record occurred on all days of survey. Review of weights identified the following: * 02/22/21 87 pounds * 07/22/21 98 pounds * 08/23/21 94 pounds (a weight loss of 4% in 30 days or a weight gain of 8% in 180 days). A quarterly MDS dated [DATE] identified weight loss of greater than 5% in 30 days or 10% in 180 days. During an interview on 11/17/21 at 2:49 p.m., two dietary management staff (#7 and #8) verified facility staff incorrectly coded weight loss for Resident #10.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from physical restraints not required to treat the resident's medical symptoms for 1 of 1 closed record resident (Resident #7), identified as having been physically restrained. Failure to assess and manage Resident #7's pain during cares/wound treatments, resulted in Resident #7 being held down against his will in an attempt to control his behavior during those cares/treatments. Due to the resident's severe resistance to cares, the process of wrapping this resident in a blanket caused avoidable psychosocial harm. Findings include: Review of the facility policy "Restraint" occurred on 05/07/14. The policy, revised July 2009, stated, ". . . The resident has the right to be free from any physical . . . restraints that are not required to treat the resident's medical symptoms. Physical restraints are defined as any manual method or . . . material . . . adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. . . . (Facility) believes that any form of physical . . . restraint is an assault on the resident's dignity, physical and emotional well being. . . . Interdisciplinary team will evaluate all restraint issues . . . If restraints are used a physician order must be obtained. . . ." Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], indicated no use of physical restraints. Resident #7's care plan, dated 02/25/14, stated, ". . . I need assist with my daily cares: . . . dementia, [MEDICAL CONDITION] . . . physically aggressive, Has injured staff . . . Skin: . . . pain with treatment . . . physical aggression with treatment . . . wrap in blanket during treatment to decrease hitting/injuries . . . Comfort: express discomfort nonverbally . . ." A progress note, dated 02/07/14, indicated, "Resident has been very combative with changing throughout the night. Resident would attempt to punch staff x (times) 3, kick legs, squeeze hands. Resident's hand held to chest to prevent resident from striking staff. . . . Resident has been screaming in pain when changed. . . ." A provider progress note, dated 02/18/14, indicated, ". . . With his twice daily perirectal abscess dressing changes, he needs to be secured with blankets so he does not strike out at nursing staff. He has been physically aggressive . . . and he is now on [MEDICATION NAME] for that. . . . his nursing cares (are) very difficult because of his discomfort and his dementia and his propensity to strike out at staff. . . ." Resident #7's medical record failed to include a physician's order for the use of [REDACTED] During an interview on the morning of 05/07/14, two administrative staff members (#2 and #10) indicated they began securing Resident #7 with a blanket during toileting cares/wound treatments to protect the staff. The facility failed to evaluate the necessity of using manual force or material adjacent to Resident #7's body to restrain him during cares/wound treatments, failed to obtain a physician's order prior to restraining him, and failed to adequately assess and manage his pain during cares/treatments. These failures resulted in the use of physical restraints for staff convenience and placed Resident #7 at risk of injury and decreased function/well-being. See F309 Care and Services, Base #1.

1. Based on information provided by the complainant, medical record review, review of facility policy, and staff interview, the facility failed to assess and treat a skin condition in a timely manner and provide the necessary care and services to promote optimal well-being for 1 of 1 closed record resident (Resident #7) who experienced continued uncontrolled pain after developing a wound on his buttocks. Failure to identify the wound when it first appeared, inform the attending physician of his continued uncontrolled pain as a result of his deteriorating skin condition, resulted in Resident #7 experiencing avoidable pain and required hospitalization for wound debridement. Failure to notify the attending physician of the resident's continued uncontrolled pain did not allow the physician the opportunity to prescribe treatment for [REDACTED].#7 experiencing avoidable pain. Findings include: Review of the facility policy "Skin Care Protocol/Prevention" occurred on [DATE]. The policy, revised [DATE], stated, ". . . Early intervention/prevention is our primary focus. . . . Resident assistant will do a thorough skin inspection . . . on a daily basis. . . . Skin will be cleaned at the time of soiling and at routine intervals. . . ." Review of the facility policy "Pain Management" occurred on [DATE]. The policy, dated [DATE], stated, ". . . Pain in residents will be assessed and treated promptly and consistently to assure the highest level of pain relief possible. . . . Assess for possible nonpharmacological interventions . . . Assess for possible pharmacological interventions . . . Enter pain problem and interventions on the care plan . . . Assessment and interventions should continue until pain is resolved or at the acceptable level for the resident. . . ." Information provided by the complainant indicated the facility failed to assess Resident #7's skin and/or treat his buttock wound, which resulted in the progression of his wound. The complainant also indicated the facility failed to provide non-pharmacological interventions and/or medications in an effort to manage Resident #7's pain, which resulted in his experiencing uncontrolled pain. Resident #7's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The resident's significant change Minimum Data Set (MDS), dated [DATE], identified problems with memory, severely impaired daily decision making skills, decreased level of activity, moisture associated skin damage, surgical wound, daily pain, and use of scheduled and as needed (prn) pain medications. The MDS further identified Resident #7 expressed pain both non-verbally (through body/posture) and verbally. The care plan, dated [DATE], identified, ". . . Skin . . . systemic skin check weekly, Reposition at least every ,[DATE] hours - up in chair for meals only, Encourage to shift positions in w/c (wheelchair) as able frequently, Commercial moisture barrier as ordered, ,[DATE] Treatments as ordered - See ETar (electronic treatment administration record). . . . Pressure reduction mattress in place, Treatment as ordered - see etar, Nutritional supplements as needed, Monitor skin condition with cares, report any redness or other problems to nurse for further evaluation . . . Follow P (pressure) ulcer risk intervention guide, ,[DATE] air mattress roho cusion (sic) in wc roho or get in recliner, ,[DATE] (sic) Refers to LRD (licensed registered dietitian) for further interventions, wrap with blanket during treatment to decrease hitting/injuries." The care plan also identified, ". . . Comfort . . . Assess for pain, Please try other non-medication measures for comfort like: soft music, turning/repositioning, massage . . . Medications as ordered . . . Monitor effectivenes (sic) document update doctor . . . (prn), Interdisciplinary team will assess/reassess (prn) . . . ." The physician's orders identified the following pain medications: [REDACTED] * [DATE], Tylenol two 325 milligram (mg) caplets every four hours (hr) prn for general discomfort * [DATE], [MEDICATION NAME] 12.5 mg tablet every four hrs prn for agitation, increased to 25 mg every four hrs prn on [DATE] * [DATE], [MEDICATION NAME] two 200 mg tablets every four hrs prn for pain * [DATE], [MEDICATION NAME] ,[DATE] mg tablet every four hrs prn for pain * [DATE], [MEDICATION NAME] 25 micrograms per hr (mcg/hr) patch for pain The "ADL (Activites of Daily Living) Roster" identified staff toileted Resident #7 three times on [DATE], and four times on [DATE]. They also assisted him with bathing on [DATE]. The progress notes identified the following: * [DATE] at 4:54 a.m., ". . . Resident would not sit on toilet," and at 9:27 p.m., ". . . only gets agitated with toileting . . ." * [DATE] at 10:22 a.m., "Noted with bathroom cares: area on left inner coccyx/left side of crease with full tissue loss. Approx (approximately) 4 cm (centimeters) (length) x 2.5 cm (width) - unable to measure depth at this time d/t thick yellow sloth (sic) covering: no eschar noted. No drainage at this time. Edges are asymmetrical, dark pink/red in color. Duoderm applied to wound area alone. Approx (approximately) ,[DATE] inches above new wound area, mid-Left gluteal area noted a hard, unblanchable area beneath tissue. Resembles the shape of an egg. appox (sic) x 5 cm (length) x 5 cm (width) calmo (calmoseptamine) cream applied with egg cart (sic) cusion (sic) applied to wc for extra protection to prevent further skin break down. . . ." * At 11:34 a.m., "Family care conference . . . Reported to (family) the concern over skin condition that has been addressed." * At 3:00 p.m., "Assessed skin areas. Noted that general mid left gluteal is reddened, blanchable, firm to touch. No s/sx (signs/symptoms) of discomfort with palpation. No increased warmth noted. Open area on inner buttock is in close approximation to anus . . . This writer does not feel this is pressure related. Barrier cream applied. Call made to wound specialist for direction." * At 6:02 p.m., "Reviewed with (physican) change in skin condition as previously noted. No other orders, will proceed with skin specialist recommendation. Also with the area of redness/firmness on buttock to just monitor." * [DATE] at 2:43 p.m., "Wound to left buttock near anus . . . remains sloughy appearance. Resident has discomfort during cleansing. Provided Tylenol 650 mg which was effective. Area of possible [MEDICAL CONDITION] to left glute is hard with blanchable redness. No increased warmth observed at this site during a.m. assessment. Resident easily aggitated (sic) . . ." The prn Medication Administration Record [REDACTED] * [MEDICATION NAME] due to the resident being "agitated" and having "increased behaviors" on two occasions. * Tylenol on one occasion. There was no clear indication for use identified on the MAR. The progress notes identified the following: * [DATE] at 5:10 a.m., identified, ". . . CRA (certified resident assistant) reported that when they had resident up to bathroom, he barely missed punching her in the jaw . . . " * At 9:34 a.m., "During tx (treatment) to inner buttock it was observed that the area of yellow slough has become (sic) to darken. Updated (administrative staff member #2) who stated that she would make contact to the wound nurse." * At 1:04 p.m., ". . . When returning to facility resident began to cry out in pain that his butt hurt. Contacted (physician) to obtain medication other than otc (over the counter) Tylenol. Order given was [MEDICATION NAME] . . . prn for pain. Resident took along with Tylenol . . ." The physician ordered [MEDICATION NAME], another OTC pain medication. * At 2:00 p.m., "Observed wound on [DATE]. area measurements are approximates only due to resident guarding, clenching of buttocks and constant attempts to strike staff and nurse. on [DATE] area was yellow slough. during this a.m. tx area was darkened and dry. . . . medicating prior moderately effective," at 2:02 p.m., ". . . hardened area is egg shaped and causes resident discomfort. . . ." * At 2:02 p.m., "Area of possible [MEDICAL CONDITION] observed [DATE] during A.M. cares. area does not have warmth greater than right buttock. hardened area is egg shaped and causes resident discomfort. red but blanchable." * At 5:58 p.m., "(late entry) Did contact (clinical nurse wound specialist). Discussed current status of wound and she recommended to continue with current treatment and continue to monitor." * At 10:20 p.m., "8:30 p.m. Treatment to anal wound as ordered. Resident screams with pain when the area is touched. Has an egg-shaped Hard, warm, (and) bright red area on the left buttock that could be abscessed. Wound is dark black, hard to observe, but feels to be quarter-sized. Other open area is also hard to observe, but feels nickel-sized. Areas cleansed with saline (and) calmoseptamine cream applied." The wound assessment report, dated [DATE], identified, ". . . Treatments: . . . ([DATE]) If need to fully cleanse area on left inner buttock, use minerol (sic) oil to remove [MEDICATION NAME], then cleanse with normal saline. . . . [MEDICATION NAME] - apply heavy layer of (sic) to wound on inner left buttock near anus, with cleansing after toileting do not attempt to remove all of ung (sic). Cleanse away any soiled ung (sic) without attempting to remove all. Reapply to keep area protected. . . . ([DATE]) [MEDICATION NAME] . . . wound healing. . . . Pain with wound/treatment: Yes. Pain Intensity: Moaning, Grimacing, Crying, Guarding. Pain Management: Effective. . . ." This conflicts with documentation that indicated Resident #7 experienced significant pain during the dressing changes. The prn MAR, dated [DATE], identified staff administered: * [MEDICATION NAME] due to the resident having "struck (the) nurse twice," on one occasion. * Tylenol due to the resident having "pain to buttock . . . with no relief," on two occasions. * [MEDICATION NAME] due to the resident having "pain to buttock . . . with no relief," on one occasion. The progress notes identified the following: * On [DATE] at 5:42 a.m., "Resident has been very combative with changing throughout the night. Resident would attempt to punch staff x 3. kick legs, squeeze hands. Resident's hand held to chest to prevent resident from striking staff. . . . Resident has been screaming in pain when changed. Treatment applied as resident would allow." * At 1:39 p.m., "Wound has had significant deterioration since this nurse assessed yesterday a.m. Brought (administrative staff member #2) and (nurse practioner) to observe wound progression. Yesterday when this nurse assessed wound bed was hardened and dark. Resident had increased pain causing increased difficulty with assessment. Attempted to obtain increased pain management from (physician) ([DATE]). During assessment this shift (administrative staff member #2) and (nurse practioner) agreed that wound progression needs to be seen by (medical doctor) . . . transferred to ER (emergency room ) to immediate observation. Further intervention will be taken from (medical doctor) discretion." * At 6:24 p.m., ". . . he was transported to ER (emergency room ) . . . (and returned to facility [DATE] at 12:47 p.m.)" * [DATE] at 8:49 p.m., ". . . Becomes very restless and agitated at times. Grabs at staff members arms, wrists and fingers and twists them. . . . 3 staff members assisted to keep resident turned to right side for inspection of rectal area. . . . Open area of approximately 7 cm x 6 cm with depth difficult to determine . . . Reasonable guess would be ,[DATE] cm depth with 4 cm tunneling . . . Inner flesh was beefy red. . . . Resident incontinent . . . Assisted with peri cares. Resident was tearful at end of dressing change . . . did try to bite CNA . . . When asked if his butt hurt, he responded yes. . . ." Throughout the above referenced period of time, the record lacked any indication of treatment changes/medications changes despite the lack of improvement, and the worsening of the abscess. The wound assessment report, dated [DATE], identified, ". . . Pain with wound/treatment: Yes. Pain Intensity: Crying. Pain Management: Effective. . . ." This conflicts with the above documentation that indicated Resident #7 experienced significant pain during the dressing changes. The prn MAR, dated [DATE]-[DATE], identified staff administered: * Tylenol due to the resident having "pain to buttock" on two occasions. * [MEDICATION NAME] due to the resident having "pain to left buttock" on one occasion. * [MEDICATION NAME] on one occasion. There was no clear indication for use identified on the MAR. The progress notes identified the following: * [DATE] at 3:59 a.m., identified, "Resident aggressive during cares. Swinging at staff and trying to twist fingers. . . . PRN [MEDICATION NAME] and Seoquel (sic) given . . . for aggitation (sic)/aggressiveness . . ." * At 11:24 a.m., "Resident incontinent of large BM (bowel movement). PRN pain med given for peri and wound cares, only 15 min (minutes) prior to dressing change. Assistance of two aides, three RNs (registered nurses) and . . . staff nurse in room for this procedure. . . . superior edge of wound (at tunneling site) significant raise from tissue area, creating a 'flap like' structure . . . Peri wound area dark reddish/purple . . . Resident did not tolerate well with this dressing change. Grabbing at staff with attempt of hitting while yelling and moaning . . ." * At 9:24 p.m., "Res given pain med (medication) 1 hr prior to dressing change with 3 people . . . wound greenish in color . . . Res clinching buttock tight and resistive hitting out at staff . . ." The wound assessment report, dated [DATE], identified, ". . . Pain with wound/treatment: Yes, Pain Intensity: Crying, Pain Management: Effective. . . ." This conflicts with the above documentation that indicated Resident #7 experienced significant pain during the dressing changes. The prn MAR, dated [DATE], identified staff administered: * [MEDICATION NAME] "before dressing change for pain" and due to the resident having "agitation" on two occasions. The progress notes identified the following: * [DATE] at 4:57 a.m., "Resident has been very combative and agressive (sic) with staff when changing/repositioning. Resident has squeezed and twisted CRAs hands . . . Has struck one CRA in chest and the other CRA in stomach. Resident has also tried to kick staff. . . . Uncooperative during changing," and at 10:45 a.m., "(Physician) called due to increase in behaviors. Orders recieved (sic) to increase [MEDICATION NAME] (an anti-psychotic)," and at 10:50 p.m., ". . . Medicated for pain 1 hr prior to dressing change. Buttock wound is bright red granulation tissue with loose white-colored slough that loosened with irrigation . . ." * [DATE] at 10:43 a.m., ". . . Pain noted and prn medication given 1 hour before dressing change. . . . Wound bed was cleaned it is beefy red . . ." * [DATE] at 9:13 a.m., ". . . Resident was very combative this a.m. so we left (him) in a safe way in his room and checked on him often. Pain medications given at 7:30 a.m. and dressing done at 9:00 a.m., and he was more cooperative at this time," and at 1:54 p.m., ". . . (Family) felt that pain management was inadequate. Call placed to (physician) and updated on condition over past few weeks while she was gone on vacation. Orders for [MEDICATION NAME] . . . Patch placed on resident. He is resting comfortably. . . ." * [DATE] at 3:00 p.m., "Dressing change complete during this shift with assist of staff x 4. . . . Resident showed signs of improved toleration to procedure with new orders for pain management . . . min (minimal) moaning with no attempt to hit or yell at this time. Resident rested well through this shift. . . ." The prn MAR, dated [DATE]-[DATE], identified staff administered: * [MEDICATION NAME] due to the resident having "pain" and "hitting with repositioning" on eight occasions. A provider progress note, dated [DATE], identified, ". . . This past week, (Resident #7) had an irrigation and debridement of a rectal abscess by (physician) . . . (Resident #7) was admitted on [DATE], and discharged on [DATE]. . . ." The wound assessment report, dated [DATE], identified, ". . . Wound Type: open debriedment (sic). Wound Location: Coccyx; left buttock near rectum. . . . Measurements: Length - 5.50 cm, Width - 5.7 cm, Depth 2.1 cm . . ." A progress note, dated [DATE], indicated Resident #7 expired while in the facility. The death certificate, dated [DATE], indicated his rectal abscess was a significant condition contributing to his death. During an interview on the morning of [DATE], two administrative staff members (#2 and #10) stated they had contacted Resident #7's physician on [DATE], and confirmed they failed to contact her again regarding Resident #7's continued uncontrolled buttock pain. The facility failed to: * Identify Resident #7's buttock wound until it had progressed to 4 cm x 2.5 cm in size with necrotic tissue. * Notify physician of Resident #7's deteriorating condition until he required hospitalization and wound debridement. * Although the facility contacted the physician on [DATE], they failed to inform him/her of Resident #7's continued uncontrolled buttock pain during toileting cares as evidenced by: * his increasing anxiety * his increasing agitatation/combativeness: attempts to bite, grab, squeeze or twist fingers, hands, wrists, and arms, hit, punch or swing at staff, and kick staff * his nonverbal indications of discomfort: grimacing and clenching his buttocks * his verbal indications of discomfort: moaning, crying, and yelling or screaming in pain when the area was touched, and his confirming he was in pain when asked by staff Documentation indicated staff were aware he was not tolerating his dressing changes well, and his medications were ineffective. They increased the numberof staff to provide cares to six, and held his hands to his chest to prevent him from striking out at staff during cares. The facility's failure to notify the attending physician of Resident #7's continued uncontrolled pain, did not allow him the opportunity to prescribe treatment and resulted in Resident #7 experiencing avoidable pain. 2. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to manage behavioral and/or pain symptoms for 1 of 1 closed record resident (Resident #7) who received as needed (PRN) medications for behaviors and/or pain prior to attempting non-pharmacological interventions. Failure to identify target behaviors, assess the reason/causative factor(s) for behaviors, and establish accurate on-going monitoring of the behaviors had prevented the resident from obtaining his highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the facility policy "[MEDICAL CONDITION] medications" occurred on [DATE]. The undated policy stated, ". . . [MEDICAL CONDITION] medications will not be used unless behavioral programming and/or environmental changes have failed to sufficiently modify a resident's behavioral disturbances (ie: target behaviors). Resident will not receive [MEDICAL CONDITION] medications unless such medication is needed to treat a specific condition and each [MEDICAL CONDITION] medication will be given to treat clearly defined target behaviors. . . . Antianxiety (medications) . . . are to be monitored for effectiveness and continued need for the medication. . . ." Resident #7's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The resident's significant change Minimum Data Set (MDS), dated [DATE], identified problems with memory, severely impaired daily decision making skills, altered level of consciousness, decreased level of activity, and use of scheduled and prn pain medications. The care plan, dated [DATE], identified, ". . . Mood/sleep: . . . Medications as ordered, monitor for effectiveness and adverse effects . . . Take time to visit with and listen to concerns, Use family as a resource, like to have familiar objects brought from home, Encourage participation in activities . . . aroamatherapy (sic) as needed, music therapy. . ." The physician's orders identified the following [MEDICAL CONDITION] and pain medications: [REDACTED] * [DATE], [MEDICATION NAME] 1 milligram (mg) every four hours prn for aggression/agitation, decreased to .5 mg every four hours prn on [DATE], and discontinued on [DATE] * [DATE], [MEDICATION NAME] 12.5 mg tablet every four hours prn for agitation, increased to 25 mg every four hours prn on [DATE] * [DATE], [MEDICATION NAME] ,[DATE] mg tablet every four hours prn for pain * [DATE], [MEDICATION NAME] 25 micrograms per hour (mcg/hr) patch for pain The Medication Administration Record [REDACTED] * [DATE], ". . . Became resistive when CRA (certified resident assistant) wanted to do cares. PRN [MEDICATION NAME] given task completed 45 minutes later. . . ." * [DATE], ". . . he was pinching, hitting, and twisting CRA's arms when ever (sic) toileted. PRN [MEDICATION NAME] given, no relief noted. . . ." * [DATE], ". . . [MEDICATION NAME] . . . prn administered. Agitated. . . ." * [DATE], ". . . When staff was assisting, was trying to kick staff with his feet. . . . Resident given prn [MEDICATION NAME] at 11:20 p.m. . . ." * [DATE], "PRN Seroquil 12.5 mg given (at) 11:25 p.m. for aggitation. . . . Has been sleeping in recliner since. . . ." * [DATE], ". . . [MEDICATION NAME] . . . PRN administered. Profolactic (sic) due to frequency of increased behaviors after noon meal. . . ." * [DATE], ". . . During transfer resident struck nurse x (times) 2. Once in clavicle and once in face. After transfer [MEDICATION NAME] 12.5 mg was administered to resident. . . ." * [DATE], ". . . [MEDICATION NAME] . . . PRN administered. . . ." * [DATE], "Resident aggressive during cares. Swinging at staff and trying to twist fingers. . . . PRN [MEDICATION NAME] and Seoquel (sic) given 3:50 a.m. for agitation/aggressiveness." * [DATE], ". . . [MEDICATION NAME] . . . PRN administered. For aggression. . . ." * [DATE], ". . . [MEDICATION NAME] . . . PRN administered. . . ." * [DATE], ". . . Pain med and [MEDICATION NAME] given an hour before his tx (treatment) to minimize pain/agitation. Resident tolerated well . . ." * [DATE], ". . . PRN [MEDICATION NAME] and [MEDICATION NAME] given 1 hour before dressing change. Resident cooperative with dressing change. No resistance. . . ." During an interview on the morning of [DATE], two administrative staff members (#2 and #10) confirmed staff failed to: * identify the non-pharmacological interventions they attempted prior to administering Resident #7's prn [MEDICATION NAME] and [MEDICATION NAME]. * assess Resident #7's signs/symptoms of pain, resulting in the concurrent administration of [MEDICATION NAME] and [MEDICATION NAME]. Failure to attempt non-pharmacological interventions, administer one medication at a time, and monitor the effectiveness of those interventions/medications prior to administering an anti-anxiety/anti-psychotic medication did not allow staff to evaluate what interventions were most effective to manage Resident #7's behavior. 3. Based on information provided by the complainant, record review, review of professional literature, review of facility policy and procedure, and staff interview, the facility failed to provide interventions to promote regular bowel elimination for 1 of 1 closed record resident (Resident #7) who required as needed (PRN) interventions for constipation. The facility failed to schedule and administer stool softeners/laxatives to Resident #7 in a manner that stimulated bowel activity and prevented constipation and hemorrhoids. Findings include: Review of the facility policy "Bowel Protocol" occurred on [DATE]. The undated policy stated, ". . . All residents will have bowel movements monitored and recorded for the purpose of evaluating bowel habits and the need for possible nursing interventions. . . . Complications such as . . . hemorrhoids are prevented. . . . Nurse will: . . . Review the BM (bowel movement) record daily. . . . Determine which residents need intervention. . . . Prune juice and/or prune mixture may be given as often as necessary to promote . . . stools . . . If prune juice and/or Prune mixture is unsuccessful . . . the Dietitian recommends nursing incorporates [MEDICATION NAME] . . . If all of the above are unsuccessful, Standing orders for bowel management will be followed on the evening of the second day without a BM. . . . If standing orders is (sic) unsuccessful, the night nurse will insert a suppository rectally on the early morning of the third day . . . Stool softening medications on residents who are receiving narcotics or who are felt to be high risk of constipation. . . ." Information provided by the complainant indicated the facility failed to provide interventions to promote regular bowel elimination, which resulted in Resident #7 experiencing constipation. Resident #7's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The resident's significant change Minimum Data Set (MDS), dated [DATE], identified problems with memory, severely impaired daily decision making skills, extensive assistance of two persons for toileting, bowel incontinence, no constipation present, and use of scheduled and prn pain medications. The care plan, dated [DATE], identified, "Elimination: . . . Meds (medications) as ordered . . . Nutrition: . . . [DATE] prune juice 4 oz (ounces) . . . stewed prunes at dinner . . ." The physician's orders identified the following constipation medications: [REDACTED] * [DATE], Milk of Magnesia (MOM) 30 cubic centimeters (cc) every eight hours prn * [DATE], Senna S two tablets daily, Mirilax 17 grams (gm) twice daily (bid), and Hemmorrhoidal suppository twice daily prn * [DATE], Fleets enema daily prn * [DATE], [MEDICATION NAME] 10 milligram (mg) suppository daily prn The orders for Senna S, Fleets enemas, and [MEDICATION NAME], were obtained after the resident failed to have a bowel movement for three days, four days, and six days each on one occasion. A bowel assessment, dated [DATE], identified elimination occurred every three days. The progress notes identified the following: * [DATE], "Wife reports last BM was on Monday so PRN MOM given tonight." * [DATE], "Spoke with (physician) regarding current problems with bowels and hemorrhoids (after six days with no bm). Informed (physician) of last BM. Orders obtained to give Senna S 2 tabs orally daily. If no BM by Monday to give a full bottle of mag (magnesium) [MEDICATION NAME]. . . . Resident straining to pass bowel movement. . . . Fleet emema (sic) provided with no results. Observed large external hemorrhoids with bright red bleeding. Provided [MEDICATION NAME] suppository. Resident started on Mirilax 17 gms BID. Dietary notified to start resident on pureed prunes with meals and prune juice with nourishments. . . . He is anxious at times and stops being anxious after toileting. Resident is constipated. Warm prune juice and MOM given to resident. He stated he liked that very much. CNA (certified nursing assistant) noted scant amount of blood in brief. Nurse summoned and there are hemmoroids (sic) present. Hemmoroid (sic) supp prn given to help reduce inflamation of hemmoroids (sic). Then an enema was given after supp to see if this will help him have a BM. Resident does pass a lot of gas when toileted but no BM. . . . Dietary notified of trouble with having BM's (after six days with no bm). They are going to look at his diet and see if we can add dietary things to help resident have BM naturally without medications. . . ." Dietary was only contacted after the resident failed to have a bowel movement for three days on one occasion, four days on one occasion, and six days on one occasion. * [DATE], ". . . (Family) felt that pain management was inadequate. Call placed to (physician) . . . Orders for [MEDICATION NAME] 25 mcg/hr (micrograms per hour) (pain medication) . . ." * [DATE], ". . . Increase to [MEDICATION NAME] 50 mcg/hr . . ." * [DATE], "BS (bowel sounds) heard x 4 HYPERactive, however, no BM larger than a small since [DATE]. No results from suppository this AM. Given another one. . . . Residents eyes appeared glazed and out of focus when not ingaged (sic). Thick dry mucus in mouth with dry membranes note(d), mouth swabs put in room with staff informed of s/s (signs/symptoms) of dehydration and need for oral cares and increased fluid intake. . . ." * [DATE], ". . . Educated direct care staff to increase fluids . . ." A bowel assessment, dated [DATE], identified daily elimination, presence of fecal/oozing/straining, rectal abscess affecting bowel function, use of narcotic [MEDICATION NAME], and current bowel regime: laxative. Documentation of Resident #7's eliminations ("BM Roster"), dated [DATE]-[DATE], identified the resident failed to have a bowel movement for three days, four days, five days, seven days, and eight days each on one occasion. During an interview on the morning of [DATE], two administrative staff members (#2 and #10) confirmed staff failed to administer stool softeners/laxatives in a manner that stimulated bowel activity. The facility failed to assess and implement an individualized/specific plan of care for managment of Resident #7's problem with constipation, including any revisions (ie: nutritional, fluids, physician directed changes to the resident's pain medications, etc.) following the episodes of constipation, and lacked evidence of monitoring the effectiveness of the established plan to promote normal bowel patterns/habits for Resident #7.