Every finding on record at Westgate Health and Rehabilitation Center

Based on administrative and clinical record review and interviews, the facility failed to ensure that all allegations involving abuse, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, as evidenced by the staff failure to inform the appropriate administrative staff of a reported allegation of abuse in a timely manner affecting 1 of 3 sampled residents reviewed (Resident # 1), who apparently made multiple contacts with staff informing them of the alleged abuse before the facility made an attempt to act upon this allegation days later. The findings included:An interview was conducted on 12/15/25 beginning at approximately 2:30 PM with Resident #1 via a visual sign language interpretation line. Resident # 1 is a deaf mute who was admitted to the facility on [DATE] with diagnoses which included Discitis, Collapsed Vertebra, Radiculopathy, Type 2 Diabetes, Hypertension, Hyperlipidemia, Hypothyroidism, Insomnia, and Unspecified Hearing Loss. The resident's Brief Interview for Mental Status scored 14, which indicate that the resident is cognitively intact and healthy. The resident reported that she was admitted to the facility on [DATE] at night. After she was left at the facility by the paramedics, she stated she was in so much pain and she asked for help, but no one would help her. She stated she asked for pain medications and later 2 nurses came in. She needed to be changed also, but she couldn't open her legs, and the staff began to hit her on her stomach and back (motioning to these areas). She further stated she told the nurse, but nobody helped her. She also said she called 911, and the police came out but they said it was nothing they could do. She expressed that she had surgery in November and she came here and they did all this to me. She further stated some of the nurses are mean, some are good. She was asked if she could describe the nurses. She gave a general description at this time (almost three weeks later) but further stated it was hard for her to remember their faces. She also showed the surveyor some pictures of her abdomen and back that were dated December 3rd. The picture showed her suture sites from her back surgery and multiple dark bruises on her abdomen (it should be noted that the resident does receive anticoagulation drug injections daily). However, it was not totally clear who took the pictures which were on the resident's personal phone.An interview was conducted on 12/15/25 at approximately 3:30 PM with the Unit Manager. She confirmed she was not aware of any allegations of abuse with Resident # 1 until 12/03/25. When she learned of this allegation, she and another nurse performed a skin assessment on the resident on 12/03/25, when the Administrator was informed of the allegation. She stated she documented the skin assessment. The surveyor then showed her pictures of the resident, which were obtained from the resident's phone to confirm the condition of the resident's skin. She stated that the pictures confirmed the majority of what she observed on 12/03/25 except there was an additional bruise on the resident lower abdomen near the right hip area that she did not recall seeing nor did she document this area on the resident's skin assessment. The surveyor then reviewed with the Unit Manager, previous skin assessments on the resident from admission and the second skin check done after admission. She confirmed they did not document the same or similar bruising noted on her 12/03/25 skin assessment. We further reviewed the hospital records to determine if a skin assessment was completed and sent with the resident. The 3008 does not note any concerns regarding the resident's skin. However, it should be noted that the resident was receiving anticoagulation drug injections in the hospital as well.Review of the facility's administrative records did not reveal a report of an allegation of abuse associated with Resident # 1. There was a noted grievance on 12/03/25 regarding communication needs for the resident.Multiple interviews were conducted on 12/15/25 in the morning and afternoon with the Administrator, who reported that she was informed of an occurrence with Resident # 1 on 12/03/25 when the Therapist Assistant reported what the resident told her about being hit by staff. She stated she also called the police and reported the incident to the state agency but withdrew the report when told by her corporate staff that it was a grievance instead because they felt it was a communication issue. She stated when she called the police, she was informed that the police had received multiple calls from the resident and came out to the facility on [DATE] but nothing was done.The administrator provided a handwritten note from the resident, when she inquired about the incident from the resident on 12/03/25. The resident documented, The ambulance took me to the facility Friday night from the hospital. When I arrived there, two nurses and 1 secretary were there. Two nurses looked at me looking mean! They showed their ugly faces to me and then abused my abdomen, thigh and back, then tried to pull my diapers. I cried!!! I tried to call 911 and police. But they said they could not do anything for me. My daughter came here Saturday afternoon, and she and my son got so angry!!Another interview with the Administrator was conducted on 12/15/25 in the afternoon, who stated she got information from the daughter about interpreter's service and she was able to secure the resident an electronic device to view the app on.An interview was conducted on 12/16/25 at 8:15 AM with the 11-7 Registered Nurse, who reported that the resident was actually admitted to the facility on 3-11 shift and the resident's initial complaints were regarding her pain. She administered what she had prescribed but she did not have a script for the other pain medications. She confirmed that the resident reported to her about the staff hitting her on the evening she came into the facility, but she thought it was taken care of by the 3-11 shift and that the resident was just frustrated about her pain management. She further stated that the police did come to the facility, but they didn't do anything. The surveyor then inquired about who she reported this to and when it was reported. She stated she told the incoming 7-3 nurse. She confirmed the resident reported to her in a handwritten note. She also admitted that she did not report the incident to the Administrator or another supervisor. Again, she repeated that she thought the 3-11 nurse would have reported it. She also stated on 12/03/25 she was contacted about the incident and was told she was on suspension, but they called her right back and said she was no longer suspended because the incident was withdrawn.An interview was conducted on 12/16/25 at approximately 10:00 AM with the Administrator, who then reported that she interviewed the resident via the interpreter's service on 12/15/25 and confirmed the resident continued to make the allegation of abuse, so she called in a report to the agency on 12/15/25, almost three weeks after the initial occurrence. On 12/16/25 at approximately 10:30 AM, the surveyor again had an interview with Resident # 1 via the interpreter's line. The surveyor asked Resident # 1 about writing a note to the staff about the incident. In going through her notebook of handwritten notes, a note was located that was documented by the resident, Do you know two nurses who abused me Friday night. They made ugly faces at me. Under that note was another note in another person's handwriting that responded, I'm sorry about that. Additional notes on the paper by the resident documented, I want to know who the 2 nurses are. Ask an old lady who worked Friday night.An interview was conducted on 12/16/25 at approximately 11:30 AM with the Physical Therapist Assistant who reported the incident on 12/03/25. The staff reported that she was doing therapy with the resident, and the resident informed her that that two staff members entered her room to change her, and when she was unable to open her legs, the staff began making contact with her abdomen. She stated the resident wrote a note and she also made gestures for her to know what she was saying. She then reported it to her supervisor and the administrator. The surveyor then showed her a copy of the note in the resident's notebook to determine if this was the note that the resident wrote to her. She denied that this was the note.

Based on facility policy, observation, record review and interviews, the facility failed to ensure that 2 of 5 sampled residents with indwelling Foley catheters (urinary drainage device) received proper care and assessment as evidenced by failure to assess Resident #117 for removal of the Foley catheter in a timely manner and ensure the Foley catheter was secured with a statlock (device to prevent dislodgement); and failure to assess Resident #123 for removal of the Foley catheter in a timely manner. The findings included:The finding included: Review of the facility policy review, titled, Standards and Guidelines: Catheter Care-quality of Care, revised 01/2004, documented in part: .Standard: The facility will maintain infection guidelines related to catheter use and catheter care to minimize catheter associated infections. Procedure: 5. Changing indwelling catheters or drainage bags routinely and at fixed intervals is not recommended. Rather it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised at the discretion of the medical provider. 1.Record review revealed Resident #117 was admitted to facility on 07/30/25. The comprehensive assessment was still in progress, but there was a documented Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scale, indicating no cognitive impairment. Further review revealed the resident was admitted to the facility with an indwelling Foley catheter. During an interview on 08/04/25 at 11:42 AM, Resident # 117 stated, I have a Foley, but they don't even empty it or know that I have one. During an interview on 08/05/25 at 10:50 AM, Resident #117 was asked if she had a catheter, and stated, Yes I do, but the staff don't seem to know, because they always pull on it. When asked if she had a device that holds it in place, the resident showed me her left leg and an undated statlock was noted on her left thigh, but the Foley catheter was not secured to the device. During an observation on 08/06/25, Resident #117 was in her bed laying on her right side and a statlock was noted on her left thigh, but the Foley catheter was not secured to it. When asked if the Foley catheter been secured to the device, the resident stated No. Record review revealed an order dated 07/31/25 instructing staff on every shift (7AM-3PM, 3PM-11PM, 11PM-7AM) to use or apply a catheter tube securing device and the device may be replaced and location changed as needed. Review of the time stamped Medication Administration Record (MAR) revealed that the staff acknowledged, by signing on 08/05/25 and 08/06/25 for every shift, the use of or application of the catheter securing device for Resident #117 to secure her foley catheter. Review of the care plan documented Resident #117 was at risk for Urinary tract infection (UTI) related to history of or actual catheter use, incontinence of bowel with a goal that the resident will remain free from signs and symptoms of UTI . Secondly, the care plan documented that the resident was at risk for injury/infection related to the presence of the catheter with a goal that the resident will be free of complications related to catheter use and intervention to review with the doctor appropriateness for removal of the catheter. Review of the progress notes for Resident #117 did not reveal any documentation by staff indicating the resident was assessed for possible removal of the Foley catheter prior to 08/07/25. 2. Record review revealed Resident #123 was admitted to the facility on [DATE] with a urinary drainage device (urinary catheter). Further review of the record lacked any attempt to discontinue the urinary drainage device. Review of a progress note dated 07/29/25 by Staff B, Nurse Practitioner, documented the plan to remove the urinary drainage device and complete a voiding trial, pending the results of a urinalysis. Review of the urinalysis completed on 07/29/25 revealed the result was reported to the facility as negative, meaning no Urinary Tract Infection (UTI), on 07/30/25. The urinary drainage device was not discontinued until 08/06/25, one week after obtaining the results of the urinalysis. The record lacked any rationale for the delay. During an interview on 08/05/25 at 10:33 AM, the spouse of Resident #123 stated she had mentioned removing the urinary catheter to a nurse a couple of days earlier and was told the nurse would speak with the physician. The wife stated she thought it might be a good thing to get rid of the urinary catheter. During an interview on 08/07/25 at 9:50 AM, when asked the process for discontinuing the urinary drainage device for a resident who was admitted with one, Staff D, Unit Manager, stated they try to discontinue them timely depending upon the resident's history and orders. When asked the delay in discontinuing the urinary catheter for Resident #123, the Unit Manager stated she would have to look into it. During a subsequent interview on 08/07/25 at 12:54 PM, the Unit Manager referred to the progress note of Staff B, Nurse Practitioner, and urinalysis, both dated 07/29/25. When asked if that indicated a delay in services, the Unit Manager agreed. When asked if she spoke with the Nurse Practitioner about the delayed catheter removal, the Unit Manager stated she had, and the Nurse Practitioner had no comment.

Based on observation, interview, record review, policy review and professional standards, the facility failed to ensure respiratory services were adequately provided for 2 of 2 sampled residents as evidenced by the failure to provide oxygen as per physician order for Resident #91 and failure to assess Resident #105 during a nebulizer treatment.The findings included: 1.Review of the facility's Policy for Oxygen Administration, revised 12/2023, included instructions to review the physician's order for oxygen administration, and to adjust the oxygen delivery device so that the flow of oxygen administered met the resident's needs. Record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses that included Chronic Respiratory Failure, unspecified whether with Hypoxia or Hypercapnia, and Tracheostomy Status. The resident's documented Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE], was 8, indicating the resident had moderate cognitive impairment. Review of the MDS assessment showed that Resident #91 received oxygen during the 14-day lookback period. Review of Resident #91's care plan documented to administer oxygen as ordered. Record review documented Resident #91's physician order for oxygen dated 07/25/25, specified that the oxygen was to be administered to via trach collar at 3 liters (per minute). During an observation on 08/04/25, Resident #91 was observed lying in bed, with the oxygen concentrator tubing attached to the trach collar. The concentration of the oxygen that was delivered was set at approximately 5.8 liters per minute. Observations on 08/05/25 at 9:48 AM, 08/05/25 at 11:22 AM, and 08/06/25 at 8:25 AM revealed that the oxygen was delivered at approximately 5.8 liters per minute. Photographic Evidence Obtained. During an interview with Staff A, Registered Nurse (RN), on 08/06/25 at 8:35 AM, Staff A was asked how many liters of oxygen per minute were specified in Resident #91's physician order for oxygen administration. Staff A replied, 3 liters. Staff A went to Resident #91's room, viewed the oxygen concentrator, and stated the oxygen was set on 6 liters per minute. According to the doctor's order for oxygen, the oxygen concentrator should have been set on 3 liters per minute. 2. Review of the policy for Nebulizer revised 12/2023 documented, in part, to report information in accordance with facility policy and professional standards of practice. The facility managers were asked to provide the professional standards followed by the nursing staff. The facility provided a three-page document, titled, Nebulizer, that described what a nebulizer was and how to administer the medication. This process documented, in part, 9. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. A medication pass observation with Staff D, Licensed Practical Nurse (LPN)/Unit Manager, was made on 08/06/25 beginning at 12:02 PM for Resident #105. The nurse obtained the aerosol medication, ipratropium bromide 0.2 MG (milligrams)/ML (milliliter), to administer to Resident #105. Lunch was served at this time, so the nebulizer was not administered. At 1:08 PM, Resident #105 had finished lunch, so Staff D obtained the nebulizer medication to administer to the resident. The LPN checked the resident's pulse and oxygen saturation. The nebulizer treatment was completed at 1:27 PM and Staff D obtained the pulse and oxygen saturation level again for Resident #105. During an interview on 08/07/25 at 12:54 PM, when asked about an assessment during a nebulizer treatment, Staff D, LPN and Unit Manager, was unaware of the need to assess the resident's pulse during a nebulizer treatment.

Based on observation, record review and interview, the facility failed to provide treatment to promote wound healing for 1 of 2 sampled residents as evidenced by not changing the dressing as ordered for Resident #11's pressure ulcer.The findings included:Record review revealed Resident #11 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0-15 scale, indicating no cognitive impairment. Review of a wound care note documented by the wound care doctor on 07/30/25, indicated Resident #11 had a non-healed, stage 3 pressure ulcer on her sacrum (bone below the spine above the tailbone) that measured 3cm length x 2.5cm width x 0.6 cm depth.Review of the current care plan dated 07/07/25 documented Resident #11 was at risk for skin breakdown due to weakness and incontinence, with a goal that the resident will have no further skin impairment with an intervention to perform preventative skin treatments as ordered. The care plan documented that the resident was recently treated with intravenous (IV) antibiotic treatment due to ESBL (Extended-Spectrum Beta-Lactamase, contagious bacterial infection) in the urine.Review of a physician order active as of 08/02/25 for Resident #11, instructed the staff to cleanse the sacrum wound with wound cleanser, pat dry, apply skin prep to peri-wound (skin surround wound) then apply Silvadene (cream to prevent infection) and calcium alginate to the wound bed then cover with silicone super absorbent dressing daily and as needed.Review of a physician order written on 08/06/25 at 11:30 AM for Resident #11, instructed staff to cleanse sacrum wound with normal saline (salt solution), apply Silvadene cream to the wound and leave uncovered daily and as needed.During observation of wound care for Resident #11, on 08/06/25 at 12:30 PM, the Wound Care (WC) Nurse was asked if there was a change to the wound care order for the sacrum wound, she stated, Yes, the wound to the sacrum is to be left open to air after applying the Silvadene cream. The Regional Nurse was at bedside to assist with turning the resident while the WC nurse performed the care. When Resident #11 was turned on her left side and the brief was removed, no dressing was covering the sacrum wound. When the WC nurse was asked if she removed a dressing from the wound she stated, No When asked did you see the resident on 8/5/25 for wound care, the WC nurse stated, Yes, I did. When asked did she apply a dressing to the sacrum wound, she stated, No. The sacrum wound was noted to have an opening approximately the size of a quarter with depth, edges appeared white, eschar (brown tissue) to the wound bed and slight redness was noted to the buttocks area but the skin was intact. When asked do you know why the order was changed, the WC nurse stated, I requested an order from the wound care doctor this morning to leave the sacrum wound uncovered, because I noticed that the buttocks area was red due to moisture and I wanted to try to dry the area out. When asked if the wound care doctor saw Resident #11 today, she stated No. When asked why she didn't wait until after the wound care doctor saw the resident before requesting the order to be changed, the WC nurse stated, I can always call him to come back to see her. The Regional Nurse observed Resident #11's sacrum wound and stated, The wound needs to have a dressing over it. I will call the wound care doctor now to get him to change the order. The Regional Nurse left the room and came back with a verbal order to cleanse the sacrum wound with normal saline, apply Silvadene cream to the wound and pack with calcium alginate, then cover with a foam dressing every other day. During an interview on 08/07/25 at 1:45PM, the WC nurse was asked if she documented the wound care provided to Resident #11 on 08/05/25, she stated, Yes. She was then asked to show documentation of her care on 08/05/25. After looking through the record, the WC nurse was unable to find any documentation. The WC nurse was asked why she didn't perform the ordered wound care for Resident #11 when she saw her on 08/05/25, and she stated I didn't see any wound care orders for the resident in the record.

Based on interview and record review, the facility failed to ensure appropriate care and services for 2 of 27 sampled residents, as evidenced by the failure to administer medications timely for Residents #27 and #117, both of whom voiced complaints.The findings included:1. Review of the record revealed Resident #27 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. During a phone interview on 08/05/25 at 5:44 PM, a family member of Resident #27 voiced concerns that the nurses at the facility were not administering medication timely. The family member stated the medications were often administered late, and that at times the morning medications were late and then the evening medication were early. During an interview on 08/07/25 at 10:03 AM, when asked the expectation regarding the administration times for resident medication, Staff D, Licensed Practical Nurse (LPN)/Unit Manager, stated the nurses were to administer medications within an hour before or an hour after the physician ordered time. Review of the Medication Administration Record (MAR) for 07/01/25 through 07/24/25 documented the following occurrences for medications that were not administered as per the physician ordered times for Resident #27. For the 7 AM to 3 PM shift, the following was noted: a) On 07/01/25, the 10 AM medications were administered at 11:23 AM. b) On 07/03/25, the 10 AM medications were administered at 11:42 AM. c) On 07/04/25, the 10 AM medications were administered at 11:15 AM. d) On 07/05/25, the 10 AM medications were administered at 12:17 PM. e) On 07/06/25, the 10 AM medications were administered at 11:21 AM. f) On 07/09/25, the 10 AM medications were administered at 11:40 AM. g) On 07/10/25, the 10 AM medications were administered at 11:19 AM. h) On 07/11/25, the 10 AM medications were administered at 11:11 AM. i) On 07/13/25, the 10 AM medications were administered at 12:38 PM. j) On 07/15/25, the 10 AM medications were administered at 12:02 PM. k) On 07/17/25, the 10 AM medications were administered at 11:18 AM. l) On 07/22/25, the 10 AM medications were administered at 11:33 AM. m) On 07/24/25, the 10 AM medications were administered at 11:57 AM. n) On 07/25/25, the 10 AM medications were administered at 11:31 AM. For the 3 PM to 11 PM shift, the following was noted: o) On 07/02/25, the 6 PM medications were administered at 7:43 PM. p) On 07/03/25, the 6 PM medications were administered at 7:31 PM. q) On 07/04/25, the 6 PM medications were administered at 8:12 PM. r) On 07/05/25, the 6 PM medications were administered at 7:42 PM. s) On 07/07/25, the 6 PM medications were administered at 8:15 PM. t) On 07/09/25, the 6 PM medications were administered at 7:52 PM. u) On 07/11/25, the 6 PM medications were administered at 7:28 PM. v) On 07/12/25, the 6 PM medications were administered at 8:43 PM. w) On 07/14/25, the 6 PM medications were administered at 7:48 PM. The above represents 23 occurrences of late medication during the 24 day period. The medications were administered up to 1 and 1/2 hours late on the day shift, and up to 1 and 3/4 hours late on the evening shift. 2. Record review revealed Resident #117 was admitted to facility on 07/30/25. The comprehensive assessment was still in progress, but there was a documented Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scale, indicating no cognitive impairment. Review of the diagnosis revealed Resident #117 had a medical history of Essential Hypertension (an increase in blood pressure), Pain in left leg, Type 1 Diabetes Mellitus (increased blood sugar), and Gastro-Esophageal Reflux Disease (acid in stomach). An interview was conducted on 08/06/25 at 10:16 AM with the Regional Nurse who was asked where Staff F, Registered Nurse (RN) was, and stated, “She had to leave for an emergency.” An interview was conducted on 08/06/25 at 10:28 AM with Resident #117 who stated, “I need my medicine. I haven’t had my insulin. I need pain medication. When asked if Staff F, RN, had seen her this morning, she stated, “The nurse came into my room while I was eating breakfast, and she said she would be back with my medications.” During a follow up interview on 08/06/25 at 11:10 AM, when asked if she had received her morning medications yet, Resident #117 stated “No, no one has come yet.” During an observation on 08/06/25 at 11:10AM while standing in the hallway, Resident #117’s room was observed with the call light on. During an observation on 08/06/25 at 11:20AM, Staff G, Certified Nursing Assistant (CNA), was observed coming out of another resident’s room, and she saw that Resident #117 light was on, and she went into the resident’s room. During an interview on 08/06/25 at 11:21AM, the Director Of Nursing (DON) asked if everything was ok, and at that same time Staff G was walking down the hallway towards the DON. The DON asked what Resident 117 needed. Staff G stated, she needed her pain medication. I haven’t been able to find Staff F, RN, I’ve been looking for her.” The DON stated, she is outside on a phone call.” During an interview 08/06/25 at 11:30AM, the Assistant Director Of Nursing (ADON) was noted at the medication cart on the 100-112 unit, who was asked if she was administering medications in place of Staff F, RN. The ADON stated, “Yes, I’m getting medications for another resident, When asked if the medications were being given late, she stated, “I just received an order to administer the medications late.” The ADON was made aware of Resident #117 not receiving her morning medication, which included the scheduled insulin. She was told that Resident #117 was requesting pain medication. The ADON stated “I will give her medications next.” During an interview on 08/06/25 at 11:48 PM, Resident #117's call light was observed to be on, who when asked if she had received her medications, the resident stated, “No.” At that time, the resident was on the phone, and stated, “I've been here 10 days, and I can never reach anyone at the front desk on the phone. I'm having so much pain.” The Regional Nurse entered the resident's room and asked, “Is everything ok?” At that time, she was made aware of Resident #117's concern of not receiving her morning medication, had complained of pain and hadn’t received pain medication since 6:00 AM on 08/05/25. The Regional Nurse ran down the hallway to get the ADON. They went back to Resident #117 room with the medication cart. During an interview on 08/06/25 at 1:15 PM, when asked if she received her medications, Resident #117 stated, “Yes, finally if it wasn't for you, I would not have received them.” Review of the requested time stamped Medication Administration Record (MAR) for Resident #117 revealed the resident received her scheduled 10:00 AM medications between 12:09 PM and 2:19 PM on 08/06/25. The pain medication that was requested was documented as administered at 11:54 AM on 08/06/25. Further review of the time stamped MAR revealed the medications that were scheduled at 8:00 PM on 07/30/25 were documented as administered at 10:15 PM. During an interview on 08/07/25 at 9:10 AM, when asked why residents received medications so late on 08/06/25, the DON stated, “I wasn't aware that Staff F, RN was going to be off the unit for a long period of time. When asked when she knew the nurse would not be returning, the DON, stated “At 11:47 AM, I received a text from her that stated she was on a telephone case, and she couldn't get off the phone.” When asked if she was aware that the nurse had not administered medications to all of her assigned residents, the DON stated, “No, not when she left, I thought she was going to be on a thirty-minute call. Staff F, RN came in because the scheduled nurse called off.” When asked if Staff F, RN was the Unit Manager (UM), the DON stated, “She resigned from the UM position two weeks ago and she hadn’t been working here.”

Based on observation, record review and interview, the facility failed to treat 1 of 1 sampled resident with dignity as evidenced by not providing Resident #37 with a urinal.The findings included:Record review revealed Resident #37 was admitted to the facility on [DATE]. Review of quarterly assessment, dated 05/18/25, documented a Brief Mental Status (BIMS) score of 03 on a 0-15 scale, indicating severe cognitive impairment.During an observation on 08/04/25 at 10:29 AM, the resident was noted to have a medium size clear bowl under his bed with amber colored urine in it. When asked what was in the bowl underneath the bed, the resident stated, Pee. When the resident was asked why he was using a bowl to pee in, the resident stated, That's what I have to pee in. When asked why he was not using a urinal, the resident stated, I don't have one. Photographic Evidence Obtained.During an observation on 08/05/25 at 11:45 AM, Resident #37 was observed lying in his bed. An empty clear bowl, similar to the one observed on 08/04/25, was noted on the nightstand near his bed, There was no urinal was observed in his room.During an interview on 08/06/25 at 6:12PM, when asked if Resident #37 uses a urinal, Staff E, Certified Nursing Assistant (CNA), stated Sometimes, but most of the time he goes in his brief. When asked if she helps him with using the urinal, the CNA stated, Yes.Review of the care plan dated 05/28/25 documented Resident #37 had an ADL (activities of daily living) self-care deficit related to his disease process and chronic medical conditions.An interview was conducted on 08/07/25 at 9:02 AM with the Director of Nursing (DON), the Risk Manager and the Regional Nurse, who were made aware of the bowl of urine observed underneath Resident #37s bed. The DON asked, How did that get there? Why didn't he have a urinal? The DON immediately went to Resident #37's room. The Risk Manger asked, How did that get there, because the resident is not mobile enough to place that under the bed himself? The DON returned to the nurses' station and stated, I gave the resident a urinal.

Based on policy review, record review, observation and interviews, the facility failed to follow their weight assessment policy for 1of 4 sampled residents, as evidenced by not reweighing Resident #68 after a significant weight gain.The findings included:Review of the facility policy, titled, Weight Assessment revised on 08/2023, documented, in part, .Weight assessment: 2. Weight Variance changes that are undesired or unplanned since the last weight assessment will be retaken as soon as practical for confirmation. If the weight is verified, nursing will communicate with the Dietician and/or the physician. Record review revealed Resident #68 was admitted to the facility on [DATE]. Review of quarterly assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 on a 0-15 scale, indicating mild cognitive impairment. Review of the care plan dated 07/15/24 revealed Resident #68 was at risk for alteration in nutrition / hydration related to his diagnosis of Depression, MS (multiple sclerosis) with a goal that the resident will not have any complications or alterations in nutrition. During an interview with Resident #68 on 08/04/25 at 10:49 AM, when asked how the food was, the resident stated, It's good. When asked if eating well, he stated, yes. When he was asked if he had lost weight, Resident #68 stated, No, I have gained weight, I weigh 180 pounds. Review of the current documented weight revealed Resident #68 weighed 180 pounds while sitting as of 07/25/25. The documented weight on 07/07/25 was 150.5 pounds while sitting, which indicated a 30-pound weight gain. The weights were reviewed and input in the resident's record by the Registered Dietitian (RD). Review of a progress note dated 07/25/25, written by the RD, indicated a weight clarification was needed due to the significant weight gain, according to the documented weight on 07/25/25. She stated she had spoken to Resident #68, who stated his usual weight was 175-180 pounds. The RD stated in her note that the resident will be reweighed weekly. Further review of the weights on 08/06/25 did not indicate that Resident #68 was reweighed. Further review of the past documented weights for Resident #68 revealed that on 10/08/24, he weighed 173.2 pounds while sitting and on 11/08/24, there was a documented weight of 159.2 pounds while sitting, which indicated a 14-pound (8.08%) weight loss. Following this significant weight loss, the facility failed to reweigh the resident for confirmation of an actual weight loss. Resident #68 was not reweighed until 12/30/24, at that time the documented weight was 172.4 pounds, which indicated a significant weight gain of 13.2 pounds. During an interview on 08/06/25 at 1:59 PM, when asked for an explanation of why Resident #117's weight was documented as 180 pounds on 07/25/25 and his weight was documented as 150.5 pounds on 07/07/25, the RD stated, Nursing staff enters the weights on a sheet of paper, and the RD reviews the weights prior to the weight being entered into the record. During an interview on 08/07/25 at 9:20 AM, when asked who was responsible for weighing the residents, the Director Of Nursing (DON) stated, the Certified Nursing Assistant (CNA) that is assigned to the resident is responsible for weighing the resident. When asked who inputs the weights into the resident record, the DON stated the dietitian inputs them into the system after the CNA records them in the book. When asked if she was aware of the 30-pound weight gain documented for Resident #68, after viewing the resident's weight, she stated, I don't understand why the resident was not reweighted right away.During an interview on 08/07/25 at 10:06 AM, when asked weren't there any weights taken on Resident #68, between 11/08/24 and 12/30/24, the RD said that she would look into it, and she would get back to me. She also stated she was not physically working in the facility during those times.Review of the weight book revealed the documented July 2025 weight for Resident #68 was 180 pounds, with no further weight document for the resident.

Based on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 27 sampled residents, as evidenced by inaccurate medication documentation for Resident #2 and inaccurate fall documentation for Resident #57.The findings included:1. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident was being administered medications to include a hypoglycemic medication, which was used for diabetes or high blood sugar levels.Review of the corresponding Medication Administration Record (MAR) for the seven-day look-back period of 07/09/25 through 07/15/25 lacked any documented administration of a hypoglycemic medication.During a side-by-side record review and interview on 08/07/25 at 11:54 AM, Staff C, MDS Coordinator, agreed with the inaccuracy. 2. Review of the record revealed Resident #57 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS assessment documented the resident had had no falls since admission or last entry, reentry, or prior assessment, whichever was more recent. The most recent event for Resident #57 was the previous assessment of 04/05/25.During an interview on 08/05/25 at 9:29 AM, when asked if she had had any falls while at the facility, Resident #57 stated she had had multiple falls here.Further review of the record revealed two falls between the assessment dates of 04/05/25 and 05/08/25 as follows:a) On 05/01/25, Resident #57 was observed lying on the floor.b) On 04/18/25, Resident #57 stated she fell in her room while walking to get to her wheelchair and that she got herself up off the floor.During a side-by-side record review and interview on 08/07/25 at 11:58 AM, Staff C, MDS Coordinator, agreed with the inaccuracy.

Based on observation, clinical and administrative record review, and interview, the facility staff failed to ensure that 2 of 3 sampled residents, Resident # 1 and #2, received the necessary care and services as related to the resident's gastrostomy tube and site and skin assessments, as evidenced by the facility failure to provide evidence that care and services were provided for a resident with a gastrostomy tube, failed to properly assess and provide evidence of care and services for a gastrostomy tube site after removal, and failed to provide evidence that weekly skin assessments were completed for residents. The findings included: Review of the facility's policy and procedure for Administering Medications through an Enteral Tube, revised 01/2024, documented, in part, the following regarding Enteral Tube Care: 1. Cleanse enteral feeding site per the physician orders. Typically, one time per day with normal saline or soap and water. May leave enteral feeding site open to air or cover with a dry dressing as needed. 2. Change enteral feeding syringe per the physician orders. Typically, one time per day. Store in hygienic manner in the resident's room. 3. Check residual per the physician orders. Typically, every shift. Hold medications and enteral feeding if residual is greater than 60 ml and notify the physician. Review of the facility's policy regarding Standards and Guidelines: Prevention of Skin Impairments / Pressure Injury, revised 01/2024, documented, in part: Review the resident's care and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Procedure included for Risk Assessment: 1. Assess the resident on admission for existing wound risk factors. 2. Conduct a comprehensive assessment upon admission including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries. b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin wound (i.e. nonblanchable erythema/rashes). For darkly pigmented skin, inspect. for changes in skin tone, temperature, and consistency. b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). c. Wash the skin after episodes of incontinence d. Reposition resident as indicated on the care plan. 1. Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction affecting left non-dominant side, and Respiratory Failure. The admission assessments documented the resident had a PEG tube (percutaneous endoscopic gastrostomy) in her abdomen. Review of the physician orders revealed the physician prescribed for the resident to receive her medications via the PEG tube. Further review of the physician orders failed to provide evidence of orders prescribing for gastrostomy tube daily care being provided to the PEG tube, and there were no orders prescribing for checking residual or providing water flush to the tube. Review of the Medication and Treatment Administration Record (MAR, TAR) for February 2024 provided evidence that the nursing staff placed their initials in the appropriate boxes to indicate the medications were administered via the PEG tube, but the administration records failed to provide evidence that the staff provided care and services to the PEG tube site. On 03/02/24 at 3:01 AM, the nurse documented, Resident vomits x 1 and had a bowel movement - Resp(respirations) even and unlabored with no distress - VS (vital signs): B/P (blood pressure) 126/72, P (pulse) 82, R (respirations) 20, T (temperature) 97.9, 02 sat [oxygen saturation] 96% on room air - Head of bed elevated to prevent aspiration - ARNP [Advance Registered Nurse Practitioner] notify - Will continue to monitor. On 03/02/24 at 8:57 AM, the nurse documented, Upon observation this am, patient noted with projectile vomiting, green bile. Patient v/s taken and noted. Patient denied any pain. Bowel sounds absent. Patient md [physician] made aware orders given to send patient out to hospital, patient daughter made aware and requested a specific hospital, medics called awaiting arrival. The hospital gastroenterologist documented on 03/02/24, Impression - Nausea and vomiting secondary to migrated PEG tube distally into the jejunum causing partial obstruction. CT [computerized tomography] reports j-tube but actually this is a PEG tube placed January 2, 2024, which seems replaced with Foley Catheter and as Foley Catheter does not have external bumper migrated with her per status is into jejunum. Constipation Fecal Impaction. The Progress note further documented the physician removed the Foley Catheter and a 20 French PEG tube was placed instead and left eternal bumper at 5 cm. Another gastroenterologist progress note, addendum on 03/04/24 at 6:44 PM, documented the PEG tube was removed per patient and family request. The resident was discharged from the hospital and readmitted to the facility on [DATE]. The admission nursing note on 03/04/24 at 10:19 PM did not provide any assessment or documentation regarding the resident's PEG tube site. The Admission Summary, dated 03/05/24 at 11:31 PM, documented the following: a skin assessment was done, no skin issue noted, the exception of skin tag noted to left upper scapula and peg removal site, dressing is clean and dry, no drainage, no irritation nor swollen noted. Review of the twenty-one physician progress notes from 03/06/24 through 05/31/24 documented the same notation for skin - no rash or lesions abdominal dressing was C/D/I [clean, dry and intact]. Further review of the physician orders did not provide documentation of physician prescriptions prescribing for care, dressing changes and/or treatment to the site of the recently removed PEG tube. An interview was conducted on 08/27/24 at approximately at 3:15 PM with the Licensed Practical Nurse, Staff A. Staff A was the nurse who sent the resident to the hospital on 03/02/24 with nausea and vomiting. She stated when she came on duty, the resident was sitting in a wheelchair, and she noticed she had vomited and had the green bile on her clothing. She had assessed the resident and did not hear any bowel sounds. She called the physician, and he said to send the resident out to the hospital and then she called the resident's daughter, who requested to send the resident to a specific hospital. The surveyor asked Staff A regarding the care and services for the PEG tube. She stated the resident ate by mouth and medications (meds) were by the PEG tube. She stated the PEG tube dressing would have been done on the night shifts. She confirmed she did not see a physician order for the care and services for the PEG tube. The surveyor asked about what the PEG tube site looked like post hospitalization . She stated she doesn't specifically remember but confirmed the assessment did not provide a thorough picture of the site and did not verify whether the site was open or closed. She stated if the site was opened, it would usually close within 2 weeks. The surveyor explained that the documentation was misleading because the initial nursing note documented the dressing was clean and dry. The nurses were not completing the weekly skin checks; and the skin checks completed did not provide information on the PEG tube site. Review of the Nurse Practitioner's notes were the same and were documenting there was an abdominal dressing that was clean and dry for over 2 and 1/2 months after the resident returned to the facility. An interview was conducted on 08/27/24 beginning at approximately 3:45 PM with the Advance Registered Nurse Practitioner (ARNP) who stated she normally would check the G-tube dressings to ensure staff are performing the dressing changes. She stated she would prescribe the care and services of dressing changes, flushes, and to check residual for the G-tubes. She did not know what happened with Resident #1 and there not being orders regarding care and services for the resident during her stay in the facility. The surveyor asked the ARNP about the PEG tube site once it was removed because all her notes were the same and documented that the dressing was C/D/I [Clean, Dry, and Intact]. The surveyor inquired whether the site was open or closed upon admission and thereafter. The ARNP was unable to confirm the appearance of the PEG tube site upon admission and during the resident's 2nd admission to the facility. She again stated that she normally would have lifted the dressing to view the area. She stated that once a PEG tube is removed, the amount of time when the site closes varies but it will usually close within two weeks. She confirmed that the site, if open, would need a daily dressing change and need monitoring for signs of infection, etc. She further stated that she would normally prescribe for daily dressing changes until the area closed. She confirmed that this was not done for Resident #1, and she further confirmed that the skin assessment on progress notes were carried over and not changed. Further review of the clinical record for Resident #1 revealed the staff failed to complete the weekly skin assessments for the resident. Review of the plan of care revealed a concern as, The resident is at risk for skin impairment r/t (related to) diabetes, neuropathy, risk for malnutrition, use of anticoagulant/antiplatelet medications, weakness/decreased mobility, s/p (status post) tracheostomy. The interventions included: .Skin checks weekly and as indicated; Report any s/s of skin breakdown to MD/wound team as indicated. Review of the assessment completed for the resident revealed the facility completed an assessment on admission. There were no further weekly skin assessments until 03/06/24 (3 weeks later, the readmission to the facility after a 4-day hospitalization ). The next weekly skin assessment was completed on 04/14/24 (more than 5 weeks later). The next weekly assessment was completed on 05/03/24 (over 2 weeks later). An interview was conducted on 08/27/24 at approximately 3:15 PM with Staff A. She stated that when the admission assessments are completed it is placed in the computer and the computer will generate the task of performing the weekly assessments. She had no explanation why the assessments were not completed. 2. Review of the clinical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Osteomyelitis of the Vertebrae, Sacral and Sacrococcygeal region. The admission assessment documented a Stage IV pressure in the sacrum and left upper quadrant PEG tube. The 06/07/24 Wound Evaluation identified a Stage IV sacrum wound measuring 4.2 x 3 x 1.2 cm. Further review of the assessments for the resident revealed a 06/10/24, 06/17/24 and 06/24/24 weekly skin assessments. After the resident was readmitted to the facility on [DATE] after a brief hospitalization , a 07/06/24 weekly skin assessment documented the sacrum wound and noted ongoing treatment to her sacrum and left knee. There was no other acute skin alterations noted. Further review of the clinical record on 08/27/24 failed to provide evidence of additional weekly skin assessments completed for the resident after the date of 07/06/24 (over 7 weeks). Review of the 07/07/24 5-day Minimum Data Set Assessment (MDS) documented the resident is at risk for the development of pressure ulcers and the resident had 1 Stage IV unhealed pressure ulcer. A skin observation for Resident #2 was conducted on 08/27/24 at 2:05 PM with the Certified Nursing Assistants, Staff B and Staff C. The observation revealed a dressing on the sacrum dated 08/27/24. There were no further skin issues identified at this time.

Based on observation, interview, record review, and policy review, the facility failed to ensure proper disinfecting of glucometers (devices to obtain a blood sugar level) for 2 of 3 sampled residents observed (Residents #23 and #19); failed to properly disposing of a used lancet for 1 of 3 sampled residents (Resident #71); failed to ensure proper hand hygiene during the passing of meal trays for 1 of 2 floors (second floor); failed to implement enhanced barrier precautions (EBPs) for 2 of 11 sampled residents (Residents #18 and #359); and failed to ensure personal protective equipment (PPE), for use for with enhanced barrier precautions, was readily accessible for use with residents on 2 of 2 floors (first and second floor). At the time of the survey, there were 16 residents' rooms identified as needing PPE, to include gowns, for proper implementation of EBPs. The census at the time of survey was 110. The findings included: Review of the policy, titled, Blood Sampling - Capillary (Finger Sticks), revised September 2014, documented, in part, Steps in the Procedure: . 7. Discard lancet and platform into the sharps container. 8. following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. Review of the User's Guide for the EvenCare Blood Glucose Monitoring System, the glucometer used at the facility, documented, in part, The EvenCare G3 Meter should be cleaned and disinfected between each patient. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. The following products have been approved for cleaning and disinfectin the EvenCare G3 Meter: Dispatch Hospital Clean Disinfectant Towels with Bleach, Medline Micro-Kill Disinfecting, deordorizing Cleaning WIpes with Alcohol, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes and Medline Micro-Kill Bleach Germicidal Bleach Wipes . Review of the Sani-Cloth Germicidal Disposable Wipe instructions documented, in part, To disinfect and deodorize hard, nonporous surfaces: . Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry. 1. A medication observation pass for Resident #23, was made on 04/09/24 beginning at 3:49 PM, with Staff G, Licensed Practical Nurse (LPN). The LPN took the supplies into the resident's room, preformed the finger stick to obtain the blood for the blood sugar level, and returned to the medication cart. The LPN wiped the glucometer with an alcohol pad and set it on the top of the medication cart. At 4:09 PM, the LPN placed the glucometer into the medication cart, without disinfecting it with an approved product. During an interview on 04/09/24 at 4:40 PM, when asked how to disinfect a glucometer, Staff G, LPN stated, I either use the purple top (disinfectant) or an alcohol wipe. When asked why she did not use the purple top disinfectant, the LPN stated, Because I didn't have any on the cart. The LPN explained there was usually a container of disinfectant wipes on the side of the medication cart. An observation at that time revealed no container of disinfectant wipes on the medication cart. When asked if she had the individual Clorox Bleach Germicidal wipe, as that was used by another staff member, the LPN stated she had seen them before but didn't have any. During an interview on 04/09/24 at 4:51 PM, the Director of Nursing (DON) agreed with the improper glucometer disinfecting. 2. During the continued medication observation pass on 04/09/24 at 4:10 PM, Staff H, LPN, obtained supplies to do a finger stick for Resident #19. After completing the process of using the glucometer to test for blood sugar level, the LPN returned to the medication cart and wiped the glucometer with a disinfectant wipe, and then immediately wrapped it in a dry tissue. The LPN failed to ensure a proper wet time, as per the disinfectant instructions. During an interview on 04/09/24 at 4:51 PM, the Director of Nursing (DON) agreed with the improper glucometer disinfecting. 3. A medication observation pass for Resident #71 was made on 04/09/24 beginning at 4:21 PM with Staff I, Registered Nurse (RN). The RN gathered supplies to complete a finger stick, and upon completion, threw the used lancet into the resident's trash can in the resident's bathroom. During an interview on 04/09/24 at 4:51 PM, the Director of Nursing (DON) agreed with the improper disposal of the lancet. 4. The facility did not have a policy for Enhanced Barrier Precautions (EBP), but verbalized they were following CDC (Center's for Disease Control and Prevention) guidance. Review of current CDC guidance revealed the use of gowns and gloves were to be used by staff providing high-contact resident care activites, for residents designated as needing EBPs. CDC guidance for EBP also included the posting of signage that clearly indicated the high-contact resident care activities that require the use of gown and gloves. The CDC guidance also included the availability of PPE (Personal Protective Equipment) supplies, including glowns and gloves, be available immediately outside of the resident room. At the time of the survey, there were a total of 25 residents identified as needing the enhanced barrier precautions. Observations during the initial pool process on 04/08/24, identified numerous rooms with a sign on the door that documented, Enhanced Barrier Precautions. The signs lacked any indication of when or how to implement the precautions. During the room by room observations on 04/08/24, it was noted there were no gowns readily accessible in rooms, storage containers, or linen carts, for staff use. An observational tour of the first floor, on 04/10/24 at 1:13 PM, to ensure accessible PPE (specifically gowns, as gloves were in each room) for resident's on EBPs, including an observation of all linen carts, revealed the following (Photographic Evidence Obtained): a) Rooms 100 to 107 had three rooms identified as needing PPE for EBP. One room had a plastic, rollable drawer set with PPE in the room. The other two rooms, located at the other end of the hall, had no gowns readily accessible. The clean linen cart located part way down the hall lacked any gowns for PPE use. b) Rooms 108 - 115 had five rooms identified as needing PPE for EBP. None of the rooms had any gowns for PPE use. The linen cart had one package of gowns available. c) Rooms 116 to 130 had two rooms identified as needing PPE for EBP. None of the rooms had any gowns for PPE use. One linen cart had one package of gowns under a stack of linens, and the second cart had none. 39167 5. On 04/08/24 at 12:21 PM, dining observation was conducted at the upper 200s unit. Lunch trays were being passed by CNAs and the followings were observed: at 12:21 PM: Staff L brought the food tray in room [ROOM NUMBER], Staff L touched items in the room, exited the room, did not conduct hand hygiene, then Staff L removed another tray from the food cart, went in room [ROOM NUMBER]A (a transmission base precaution room) and provided the tray to the resident. At 12:24 PM, Staff L exited room [ROOM NUMBER]A, without conducting hand hygiene, removed another tray from the food cart and provided it to the resident in room [ROOM NUMBER]B. 6. Clinical record review revealed Resident #18 was admitted to the facility on [DATE], with diagnosis included: MDROS (Multidrug-Drug Resistant Organisms), a condition in which bacteria have become resistant to certain antibiotics. The admission Minimum Data Set (MDS) assessment, reference date 02/23/24, recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated Resident #18 was cognitively intact. This MDS recorded no mood or behavior issue. Review of physician order, dated 02/20/24, documented an order for Cefazolin Sodium (antibiotic) Intravenous Solution Reconstituted 2 GM, every 8 hours for Extended Spectrum Beta Lactamase (ESBL). ESBL is an enzyme or chemical produced by germs like certain bacteria, and ESBL enzymes make some antibiotics ineffective. Further review of clinical records revealed a physician order dated 02/20/24 for a Midline [a peripheral inserted central catheter] to the right arm. Additional physician orders, dated 04/01/24, documented for Cefazolin Sodium Intravenous Solution Reconstituted 2 GM, every 8 hours for ESBL until 04/06/24. Review of current and discontinued physician orders, care plans, and progress notes from February through April 2024 lacked documented evidence of transmission-based precaution being in place. On 04/08/24 at 10:58 AM, an observation was conducted of Resident #18, and there was an IV (intravenous) pole in the room, with an empty bag of antibiotic (Cefazolin 2gGM for ESBL) hanging on the pole. There was an IV site obseved to be located to Resident #18's right upper arm, and the dressing was falling apart. There was no transmission base precaution or EBPs noted in place. On 04/08/24 at 11:10 AM, Resident #18 was observed in the process of receiving incontinent care. The staff member was observed in the room changing the resident's incontninent adult brief. The staff member was not wearing a gown. On 04/09/24 at 12:35 PM, the resident was observed lying in bed, and the IV was located to the residnet's right arm. There were no transmission base precautions or EBPs noted in place. On 04/10/24 at 11:57 AM, a subsequent observation was conducted on Resident #18. The IV was noted to her right arm, and there was no dressing on the IV site. There were no transmission base precautions or EBPs in place. 7. Resident #359 was admitted to the facility on [DATE], with diagnosis that included: Septicemia (blood poisoning by bacteria). Review of Physician order, dated 04/03/24, documented an order for Cefazolin Sodium Injection Solution Reconstituted 2 GM, three times a day for sepsis until 04/29/24. Review of current and discontinued orders, care plans and progress notes revealed no documented evidence of transmission base precautions or EBPs in place. On 04/08/24 at 1:25 PM, an observation and interview were conducted with Resident #359, who revealed that she had an order in place to receive IV antibiotic therapy. During this time, an observation was conducted of the IV site to the right upper arm. There were no transmission base precautions or EBPs in place. On 04/09/24 at 12:16 PM, an observation was conducted on Resident #359. There were no transmission base precautions or EBPs in place. On 04/10/24 at 11:32 AM, an observation was conducted on Resident #359. There was an IV pole in room with an empty antibiotic bag hanging on the pole. There were no transmission base precautions or EBPs in place. On 04/11/24 at 10:49 AM, an interview was conducted with the Director Of Nursing (DON), who was made aware of concerns related to lack of documented evidence of transmission base precautions, EBPs, and lack of hand hygiene by staff during passing of meal trays. 8. On 4/10/24 at 1:39 PM, six rooms on the second floor were identified for Enhanced Barrier Precaution (EBP). Upon close inspection, it was noted that while gloves were readily available, protective gowns were not observed to be readily available as required. The room numbers identified were #207, #220, #232, #233, #234, and #235.

Based on observation, record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 34 sampled residents, related to the Brief Interview for Mental Status (BIMS) score for Resident #43, antibiotic use for Resident #3, and discharge location for Resident #108. The findings included: 1. Review of the record revealed Resident #43 was admitted to the facility on [DATE]. Review of the Annual MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6. The BIMS score is determined in part by asking the resident to repeat a pattern of words. During observations and attempted interviews on 04/08/24 at 11:06 AM and on 04/09/24 at 9:24 AM, Resident #43 did not verbally respond. During an interview in the morning of 04/08/24, Staff K, Certified Nursing Assistant (CNA), confirmed Resident #43 could not speak or move, but would only blink her eyes for yes and no questions. During an interview on 04/11/24 at 11:32 AM, when asked about conducting an interview for BIMS status, the Social Services Director (SSD) confirmed the resident would need to be verbal or able to utilize cue cards developed for assessing the BIMS status. When asked specifically about Resident #43 and the documented BIMS score of 6, the SSD confirmed that was an error. 2. Review of the record revealed Resident #3 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] documented the resident was receiving an antibiotic. Review of the corresponding orders and Medication Administration Record (MAR) lacked any documented antibiotic use. During an interview on 04/11/24 at 11:42 AM, the MDS Director agreed with the error. 39142 3. Review of the closed record for Resident #108 for hospitalization revealed in the progress notes that Resident #108 was discharged home and not transferred to the hospital. The two general notes found were dated 1/27/24 at 13:55 (1:55 PM) and 13:59 (1:59 PM). The 13:55 note text was as follows: Patient discharge summary reviewed copy given to patient. Patient education provided for diabetic teaching and oxygen. Patient given all medications reviewed. Patient safety and comfort maintained. The 13:59 note text was as follows: patient exiting with all belongings at this time. Review of the record for Resident #108 documented there were two discharge orders identified for Resident #108. The first discharge order was written on 01/26/24 at 10:02 AM and was written as follows: Discharge Home on 1/26/2024 with Home Health-RN/PT/OT eval. treat. Home Health Aide for ADLs. DME to include O2 concentrator and portable tank for O2, 2L via nasal canula and acc check machine for blood sugar monitoring. The second discharge order was written on 01/26/24 at 21:13 [9:13 PM] and was written as follows: [Resident] Home with family. Family/Son will pick-up at 11am. Patient already has new portable oxygen tank to go home with in her room. (Please be sure patient is ready). On 04/11/24 at 4:04 PM, an interview was conducted with Staff E, the MDS Coordinator with the MD Director present. Staff E reviewed Resident #108's records and he verified the findings of the surveyor. Staff E located a discharge assessment, with the date of 01/26/24, that indicated the discharge was to the resident's home. Staff E admitted to his error and surmised he accidentally selected the wrong entry on the MDS Discharge assessment. Staff E explained the most likely reason for the incorrect discharge on the MDS was because of a miss-click of the mouse. When Staff E was asked how he could miss-click on option 4 instead of option 1, he stated he could have been scrolling quickly and accidentally clicked on hospitalization , option 4, instead of home, option 1.

Based on observation, interview, and record review, the facility failed to ensure timely smoking privileges as per resident choice and schedule for 2 of 5 sampled residents who smoke, Residents #159 and #259. At the time of the survey, there were five residents residing in the facility who smoked. The findings included: Upon entrance to the facility, an observation at the first-floor nurses' station revealed a sign that documented, Smoking Times: 10 AM, 2 PM, 4 PM, and 6:30 PM. Review of the record revealed Resident #159 was admitted to the facility on [DATE]. Although the Brief Interview for Mental Status (BIMS) score had not yet been completed, review of the progress notes documented the resident was alert and oriented. During an interview on 04/09/24 at 9:03 AM, Resident #159 stated there were different Certified Nursing Assistants (CNAs) assigned to the smoking area at different times throughout the day, and they were never on time. During an observation at the first-floor nurses' station on 04/09/24 at 10:05 AM, the Director of Nursing (DON) and Unit Manager were unable to find Staff C, CNA, who was assigned to the smoking area, as documented on the staff assignment written on the white board. The DON asked the Unit Manager to cover the smoking area, STAT (immediately) as it's 5 after [the scheduled time]. The Unit Manager walked down the hall looking for Staff C and was unable to find her. The Unit Manager then went to get the smoking box (a small container that held the resident's cigarettes and lighters), and went out to the smoking area at 10:06 AM. Residents #159 and #259 were waiting outside. A third resident arrived at 10:11 AM. Staff C, CNA, arrived to the area on 04/09/24 at 10:12 AM. An observation of the smoking area on 04/10/24 at 4:06 PM revealed Resident #159 in the smoking area with Resident #259. Staff D, CNA, was attending to the two residents. When asked how the smoking area staff were scheduled, Staff D explained for the 3 PM to 11 PM shift, the first floor staff was responsible for the 4 PM smoking time and the second floor staff was responsible for the 6:30 PM time. Resident #159 stated Staff D was always on time, but was the only CNA who was timely. Staff D stated, It's the last smoke time that is the problem and pointed up to the second floor. Staff D stated it could be as late as 7:30 or 8 PM before the second-floor staff come down. Resident #159 agreed it could be as late as 7:30 or 8 PM before the second-floor staff come down. Staff D stated, Sometimes I just come out to give them their smoke break. They (the residents) deserve it. It's their right. On 04/11/24 at 10:01 AM, the smoking area was being attended to by the Unit Manager with four residents who smoke, even though it was assigned to a CNA. During an interview on 04/11/24 at 11:17 AM, when asked about the timeliness of staff for the smoking area, Resident #259 stated the day shift was ok, but staff for the last one (scheduled for 6:30 PM) were usually 30 minutes or more late. Resident #259 had a Brief Interview for Mental Stats (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 04/11/24 at 2:45 PM, when asked how the smoking area staff were assigned, the Assistant Director of Nursing (ADON) explained the first floor was responsible for the 10 AM and 4 PM times, and the second floor for the 2 PM and 6:30 PM times. The ADON stated they all get busy, so they all pitch in and help each other out. When told there were voiced concerns about the 6:30 PM staff being 30 to 60 minutes late, the ADON stated maybe 10 or 15 minutes, but she doubted it was more than that as she was often at the facility during that time. The ADON stated, they call me the Smoking Police as I know how important it is for the residents. The ADON stated she was not there on the weekends. When told there were complaints from 2 smokers and one staff, the ADON stated, Oh.

Based on record review, observation, and interview, the facility failed to provide the appropriate treatment and services related to a clinically justified indwelling urinary catheter for 1 of 6 sampled residents, Resident #42. The findings included: Review of the record revealed Resident #42 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and had memory problems. This MDS also documented Resident #42 had an indwelling urinary catheter and was totally dependent upon staff for all care. Further review of the record revealed orders dated 03/01/24 for staff to provide indwelling catheter care every shift as needed, and to irrigate the catheter using 60 ml (milliliters) of normal saline every eight hours as needed for blockage, leakage, increased sediment, or decreased output. An additional order dated 03/02/24 had instructions to change and date the catheter securement (anchoring) device every week. Review of the April 2024 Treatment Administration Record (TAR) documented the indwelling urinary catheter had been changed on 04/06/24. An observation on 04/08/24 at 9:00 AM revealed Resident #42 lying in bed. An indwelling urinary catheter bag was noted hanging from the resident's bed. The urine in the tubing was red tinged. A yellow paper tag attached to the indwelling catheter tubing was dated 03/31/24. Photographic Evidence Obtained. During an observation on 04/09/24 at 3:19 PM, Staff J, Certified Nursing Assistant (CNA), uncovered Resident #42. The red tinged urinary catheter tubing was freely hanging in between the resident's thighs, without any type of an anchoring device. During an observation on 04/11/24 at 9:04 AM, Staff A, CNA, confirmed she provided the morning care for Resident #42 earlier that day. An observation of the resident's thighs lacked any type of anchoring device. When asked about the use of an anchor for the indwelling urinary catheter tubing, Staff A confirmed they were used at the facility, and agreed there should be one in use for Resident #42. Observation of the tubing revealed the urine was now clear. During an interview and side-by-side review of the April 2024 TAR on 04/11/24 at 9:59 AM, the Unit Manager agreed the TAR documented the indwelling urinary catheter was changed on 04/06/24, yet the date on the observed catheter was 03/31/24. The Unit Manager was shown the photograph of the red tinged urinary catheter tubing from 04/08/24 and agreed the catheter should have been irrigated or changed as of the 04/09/24 observation in the afternoon.

Based on record review, observation, and interview, the facility failed to implement physician ordered blood pressure monitoring parameters for 1 of 6 sampled residents, Resident #78, as evidenced by lack of BP documentation and to ensure adequate monitoring. The findings included: Review of the record revealed Resident #78 was admitted to the facility on [DATE], with a diagnosis that included Essential Primary Hypertension (high blood pressure). Further review of the record revealed an order dated 09/26/23 to give Lisinopril 20 mg (milligrams) by mouth one time a day for Hypertension. The order also included a monitoring parameter to hold the medication for a systolic blood pressure (SBP) reading of less than 130. Review of the January 2024, February 2024, March 2024, and the current April 2024 Medication Administration Record (MAR) revealed Resident #78's blood pressure results were not documented. Review of the vital signs section of the electronic record revealed the following: a. Blood pressure (BP) results were documented on 01/13/24, 01/16/24, 01/21/24, 01/22,24 and 01/23/24, which was only 5 of the 31 days in January 2024. b. BP results were documented on 02/04/24 and 02/17/24, which were only 2 days in February 2024. c. BP results were documented on 03/04/24 and 03/23/24, which were only 2 days in March 2024. d. There were no documented BP results for the month of April 2024, until after surveyor intervention on 04/10/24. Additional review revealed that on 12/11/23, and 12/18/23, Lisinopril BP medications were given even when the documented systolic BP were below 130. During an interview on 04/10/24 at 11:15 AM, the Unit Manager stated the APRN (Advanced Practice Registered Nurse) wrote the order and that she herself confirmed it. The Unit Manager confirmed the BP should be recorded on the MAR, when physician ordered parameters are in place.

Based on observation, interview, record review, and policy review, the facility failed to ensure care and services for oxygen use for 2 of 3 sampled residents, Residents #59 and #55. The findings included: Review of the policy, titled, Oxygen Administration, revised 12/2023, documented, in part, General Guidelines: . 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physicians' orders and/or facility protocol. 4. Store oxygen tubing in a hygienic manner (i.e. labeling bag with date tubing was changed). 1. Review of the record revealed Resident #59 was admitted to the facility on [DATE], and moved to her current room on 04/15/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented oxygen was in use. Review of the vital sign record revealed oxygen saturations on 04/08/24 and on 04/09/24 were taken those mornings while the resident was on oxygen. Review of the record revealed an order dated 10/15/23 for the use of continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. Review of the care plan revised on 10/17/23 documented Resident #59 was at risk for altered respiratory status / difficulty breathing related to shortness of breath. The interventions included administering the oxygen as ordered. An observation on 04/08/24 at 11:37 AM, revealed Resident #59 in bed, wearing the nasal cannula, and the oxygen concentrator running at 2 liters per minute. Further observation revealed the oxygen tubing, dated with a piece of tape labeled 4/7/24, was not attached to the concentrator. Photographic Evidence Obtained. Resident #59 denied shortness of breath at that time. An observation on 04/09/24 at 11:25 AM revealed Resident #59 in bed. The oxygen concentrator was running at 2 liters, but the same oxygen tubing as observed the previous day, was lying on the bed and not hooked to the concentrator. Photographic Evidence Obtained. On 04/10/24 at 9:39 AM, Resident #59 put on the call light. A random staff member entered the room, and the resident requested that her head of the bed be adjusted. The staff assisted the resident and left the room. Upon entering the room after the staff left, the oxygen concentrator was running. The same tubing dated 04/07/24 was lying over the concentrator, with the nasal cannula on the floor, and was not hooked to the concentrator. Photographic Evidence Obtained. On 04/10/24 at 2:40 PM, the same oxygen tubing that had been observed throughout the survey, not attached to the oxygen concentrator and/or on the floor, was now in the resident's nose, but still not hooked to the concentrator. Staff B, Licensed Practical Nurse (LPN), and Staff F, Certified Nursing Assistant (CNA), both direct caregivers for Resident #59, denied picking up the oxygen tubing from the floor and putting it on Resident #59. Staff F, CNA, stated she found the tubing on the bed and put it on the resident. 2. Review of the record revealed Resident #55 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the use of oxygen by the resident. Further review of the record revealed the following three orders related to the use of a nebulizer (machine used for the administration of a medication by inhalation): An order dated 06/11/23 documented staff were to change the nebulizer treatment tubing weekly and place the mask in a bag. An order dated 11/07/23 documented Ipratropium-Albuterol Solution, a respiratory medication, was administered every four hours for COPD (Chronic Obstructive Pulmonary Disease, a lung and breathing disorder). An order dated 12/15/23 documented Yupelri Solution, a respiratory medication, was to be given daily at bedtime. An observation on 04/08/24 at 12:35 PM revealed the nebulizer mask, used to administer the respiratory medication, was lying on top of the nebulizer machine, and the plastic storage bag was noted to the left of the machine on the bedside nightstand. Further observation of the machine revealed the machine was dirty with debris in the cavity of the machine. Photographic Evidence Obtained. An observation on 04/09/24 at 11:23 AM revealed the nebulizer mask was lying on top of the nightstand, but again not in the storage bag. An observation on 04/10/24 at 10:22 AM revealed the same nebulizer and improper storage method of the mask. During an interview on 04/11/24 at 9:57 AM, Staff B, LPN, agreed the nebulizer machine needed to be either cleaned or replaced, and the tubing replaced and stored properly.

Based on observation, interview and record review, the facility failed to ensure an intravenous peripherally inserted central catheter (PICC) line dressing was changed as ordered for 1 of 1 sampled resident, Resident #362. The findings included: Record review revealed that Resident #362 was admitted to the facility on [DATE], with diagnosis that included Septicemia (blood poisoning by bacteria). The admission Minimum Data Set (MDS) assessment, reference date 03/29/24 (which was completed and ready to export), recorded a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #362 was cognitively intact. This MDS recorded no mood or behavior issue. Subsequent review of the clinical record evidenced a physician order dated 03/24/24 of Ceftolozane-Tazobactam (an antibiotic) Intravenous Solution Reconstituted 1.5 (1-0.5) GM to use 1.5 gram intravenously every 8 hours for wound infection until 04/22/2024. An additional physician order dated 03/24/24 documented for the PICC line dressing to be changed every 7 day(s). A subsequent order dated 03/25/24 documented for the 'PICC Line left arm, change dressing within 24 hours of admission, insertion, or reinsertion and every 7 days and as needed thereafter using sterile technique. Measure arm circumference and external length of catheter.' Review of the March 2024 and April 2024 medication administration records (MARs) and treatment administration records (TARs) indicated the PICC line dressing had been changed on 03/24/24, 03/26/24, 04/02/24, and 04/07/24. On 04/08/24 at 11:59 AM, an observation was made of Resident#362, who was verbally responsive, alert, oriented, and calm, with no behaviors noted. During the observation, the resident's intravenous (IV) site dressing to the left upper arm was observed and had a date of 3/23. Resident #362 confirmed the IV had been inserted since being at the hospital. When asked whether the IV dressing was changed by the facility staff, Resident #362 stated no. On 04/11/24 at 11:01 AM, an interview was held with the Director Of Nursing (DON), who was made aware of the finding and concern related to the IV dressing not being changed as ordered and that staff had documented the IV dressing was changed only on four occasions. A side-by-side review of Resident #362's record was conducted with the DON, who acknowledged the finding.

Based on clinical and administrative record review and staff interview, the facility failed to ensure that clinical records were complete and accurately documented the implementation of prescribed medications and treatments for 1 of 3 sampled residents reviewed, Resident #1, as evidenced by staff failure to ensure all telephone orders were accurately recorded in the clinical record and the nurses' initial placed in the appropriate box to depict the medication and treatment orders were documented and implemented for Resident #1. The findings included: The facility's policy, titled, Administrating Medications, documented, in part, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site ( if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnosis that included Fusion of spine - cervical region, Pneumonia and Diabetes Mellitus, type II. A late entry Nursing progress note by the Registered Nurse Supervisor, Staff A, documented on 08/26/23 at 6:53 PM, Writer educated resident on hypoglycemic / hyperglycemic sign and symptoms (s/s). Writer had assigned nurse notify resident physician and family. Nursing teaching provided, Resident verbalized understanding. The Licensed Practical Nurse (LPN) assigned to the resident, Staff B, documented on 08/26/23 at 11:15 PM, Resident complained of (c/o) dizziness, frequent urination,and nausea. Glucose checked results 360, 8 units of Humalog given via sliding scale. Resident still c/o dizziness, and nausea. glucose checked again results 550. Doctor [name] notified via text. Instructed to give an additional 10 units of Humalog. Continued to monitor residents glucose every 30 min. Glucose decreased to 280 by 2030. Resident demanded another 10 units of insulin. I informed the resident that he has a routine dose of long acting insulin at bedtime. 2045: paramedics came up to the unit saying the resident in [room #] called 911. I was not aware of the resident calling 911. Went with EMS [Emergency Medical Services] to resident room. Resident stated 'I told her my blood sugar was high and she ignored me and she did nothing for me'. EMS checked resident's vitals and everything was in normal range. Resident was not transferred to hospital. Resident family notified. No distress noted at this time. Call light within reach. Further review of the Medication Administration Record (MAR) failed to document the blood sugars noted nor did the electronic record document the additional insulin dosage of Humalog 10 units prescribed by the physician. An interview was conducted on 10/30/23 at 3:41 PM with the Licensed Practical Nurse, Staff B. She did recall the incident noted above regarding the resident's elevated blood sugars. She recalled giving the initial 8 units which was documented. She stated she did not give the 10 units. The surveyor also informed the nurse the clinical record did not document the additional order prescribed for the resident for the elevated blood sugar of 550 [mg/dl] as noted in her progress note. She further stated the nursing supervisor was assisting her that evening and she thought she put the order in and carried out the order. The nurse stated we were really busy that night and she jotted down some notes in her personal notebook and proceeded to show the surveyor the handwritten notes she had. The surveyor again inquired about the resident receiving the 10 units of insulin. She confirmed she did not give the additional insulin coverage prescribed. She further showed the surveyor the text she stated she received from the Nursing Supervisor who texted the physician, which noted [Resident #1's] blood sugar at 4:00 PM was 360 [mg/dl] coverage of 8 units was given. We checked now because he complained of nausea and urination frequency and his accucheck was 550 [mg/dl]. I gave him 10 more units of the Humalog. Ok. Thank you. A telephone interview was conducted on 10/30/23 at approximately 4:30 PM with the Nursing Supervisor, Staff A, who reported she did recall the incident. When asked about giving the Resident #1 insulin, she stated she would not have given the additional unit unless she was on the medication cart, otherwise it would have been given by the nurse giving medications. The surveyor then relayed the text message, Staff B showed the surveyor regarding the text conversation she sent to the physician, which indicated she gave the resident Humalog 10 units for the accucheck of 550 [mg/dl]. She stated she does not recall giving the resident the 10 units but she too, will jot down personal notes because they were busy. She stated she wasn't home but she would check her notes when she got home and contact the surveyor. A telephone call was received on 10/30/23 at 6:35 PM from Staff A, who stated her notes indicate that she gave the Humalog 10 units. The surveyor requested that she email her the note. The note documented that Resident #1 complained of feeling nausea and frequent urination. Accucheck at 4:00 PM, 360 [mg/dl], coverage of 8 units given. Checked again at 5:56-6:00 PM, accucheck 550 [mg/dl], 10 more units of the Humalog given as ordered by the physician. It should be noted that Staff A took the time to write a late entry progress note about educating Resident #1 regarding the signs and symptoms of hypo/hyperglycemia and took the time to document personal notation of her alleged administration of said medication, but failed to document a telephone order from the physician and implementation of this order in the electronic clinical record.

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 2 Units (100 & 200 Units) that included residents' rooms, storage areas, and common areas. The findings included: During the initial resident screenings conducted by the surveyors on 01/09/23 and the Environment Tour conducted on 01/11/23 at 10 AM accompanied with the Director of Maintenance, the following were noted: First Floor (100 Unit): a. First Floor Dining Room: Two of two ceiling vents were noted to be heavily soiled and black type mold matter. b. Physical Therapy room [ROOM NUMBER]: Room floor perimeter was heavily soiled and not being cleaned on a regular basis. Room windows noted to be covered with a white film. c. Physical Therapy room [ROOM NUMBER]: Two of two ceiling vents were noted to be heavily soiled and dust laden. Main Hallways: the hallways near the nurses' stations and south hallway were heavily soiled and stained. d. Clean Utility room [ROOM NUMBER]: Three IV poles were located with room were noted to have large amounts of dried brown matter. e. First Floor Community Shower: Stall #1 had broken floor tiles, stall #2 had stained tiles, and ceiling vent was dust laden. f. room [ROOM NUMBER]: Wardrobe closet had missing doorknob. g. room [ROOM NUMBER]: Toilet seat was loose and falling off. h. room [ROOM NUMBER]: Room wallpaper was torn and falling off walls, toilet required recaulking to the floor, and wardrobe closet was missing doorknob. i. room [ROOM NUMBER]: Wardrobe closet was missing doorknob. j. room [ROOM NUMBER]: Toilet required recaulking to the floor. k. room [ROOM NUMBER]: Wardrobe closet was missing doorknob. l. room [ROOM NUMBER]: The portable toilet seat was noted to be rust laden. m. room [ROOM NUMBER]: Room wallpaper was in disrepair and peeling away from walls, toilet required recaulking to the bathroom floor, the portable toilet seat was rust laden, and wardrobe closet was missing doorknob. n. room [ROOM NUMBER]: Room wallpaper was in disrepair and peeling away from walls. o. room [ROOM NUMBER]: Room wallpaper was in disrepair and peeling away from walls and wardrobe closet missing doorknob. Second Floor (200 Unit): a. Second Floor Dining Room: Room walls required repainting. b. room [ROOM NUMBER]: Portable toilet seat was rust laden, room chair exterior was heavily worn, and nightstand drawers were not shutting properly. c. room [ROOM NUMBER]: Nightstand drawers did not close properly, over-bed table exterior was in disrepair, portable toilet seat was rust laden, and toilet seat was loose. d. room [ROOM NUMBER]: Exterior damage noted to closet door, peeling wallpaper in bathroom, window blinds were falling off, and bathroom call cord was wrapped around wall handrail. e. room [ROOM NUMBER]: Large black scuff marks noted to room walls, portable toilet seat and toilet were covered in dried brown matter, and toilet required recaulking to bathroom floor. f. room [ROOM NUMBER]: Toilet required recaulking to the bathroom floor, and portable toilet seat was rust laden. Following the 01/11/23 tour, the findings were again confirmed with the Director of Maintenance and Administration. It was noted that the facility has a computerized TELS system for staff to document housekeeping and maintenance issue, bu it was revealed that staff were not utilizing the system.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included failure to ensure proper temperature and chemical sanitizing levels in the dish machine and 3-compartment sink, failure to store food to prevent contamination / food borne illness, failure to ensure hot and cold foods are held at regulatory temperatures, and failure to ensure silverware is handled in a sanitary manner. The findings included: 1. During the initial food service / kitchen sanitation tour conducted on 01/09/23 at 9:00 AM, accompanied with the Food Service Director (FSD), the following was noted: (a) Observation noted the high temperature dish machine was in use by staff. At the request of the surveyor, the final rinse temperature was taken and noted to be 175 degrees F (Fahrenheit). The surveyor informed the Food Service Director (FSD) the regulatory minimum final rinse temperature was 180 degrees F. At the FSD's request, 3 more attempts were conducted to check the final rinse temperature and all were recorded at below 175 degrees F. The surveyor informed the FSD that the dish machine should not be used until the final rinse temperature of a minimum 180 degrees F was obtained. On 01/09/23, a representative for the dish machine / chemical company was in the facility to evaluate the dish machine's final rinse temperature. The technician approached the surveyor and informed that a new final rinse temperature gauge was needed and had been replaced. A test of the dish machine final rinse temperature on 01/10/23 at 8:00 AM noted the final rinse to be recorded by the surveyor at 185 degrees F. (b) Observation of the walk-in refrigerator noted a food storage rack to contain a large pan of raw chicken (30 portions). Further observation noted the storage shelf below the pan of raw chicken contained a pan of cooked ground chicken and a pan of cooked chicken pieces. The surveyor immediately informed the FSD that there was a potential for food contamination from raw chicken being stored over / above cooked chicken and to recommend to the FSD to discard the pans of cooked chicken. It was also discussed the regulatory requirement of storage of cooked and raw foods. The FSD stated it is the facility policy to never store raw foods (chicken) over cooked foods and that all raw foods be placed on the bottom shelf at all times to prevent food contamination / food borne illness. During the observation of the 01/09/23 lunch meal, it was noted the cooked chicken that had been located in the walk-in refrigerator was served to the facility's residents. (c) During the observation of the 3-compartment sink, the surveyor requested the FSD to test the sanitizing sink to ensure regulatory level of the chemical sanitizer. The FSD informed the surveyor that a new sanitizing chemical was installed recently and the FSD was unsure what the chemical was. The FSD tested that sanitizing sink with the appropriate test strip. It was noted an insufficient level of chemical was present. It was noted that the test strip tuned blue, but the test information documented that the test strip should turn green in color. The surveyor informed that the 3-compartment sink should not be utilized until the regulatory chemical levels were present. On 01/09/23 at approximately 9:00 AM, the technician for the chemical company was in the kitchen to test the chemical level of the 3-compartment sink. Interview with the technician noted that the chemicals triturated into the sink were insufficient to meet regulatory chemical level requirements. (d) During the tour, it was noted that a staff's personal phone was located directly on a food preparation / serving counter. The surveyor informed the FSD that the counter was contaminated from the phone and requested that phone be removed and the counter be chemically re-sanitized. (e) During the tour, it was noted that the clean silverware was not being handled in a sanitary manner. Specifically, staff were noted to be wiping the clean silverware with a cloth prior to rolling the silverware in a paper napkin and continued using the same cloth. The surveyor informed the FSD that the cloth used for wiping can become soiled and contaminate the silverware. The surveyor requested that the silverware be rewashed / sanitized prior to meal service. 2. During the observation of the food assembly line in the main kitchen on 01/09/23 at 11:30 AM, food temperatures were taken by the FSD utilizing the facility's calibrated food thermometer. The findings of the temperature tests indicated that hot and cold food were not being held at 135 degrees F or greater or 41 degrees F or below, as evidenced by the following: * Chicken Jambalaya (large pan) = 130 F * Ground Jambalaya (1/2 pan ) = 114 F * Pumpkin Pie (slices) = 50 degrees F * Pureed Pumpkin Pie = 56 degrees F * Turkey Sandwiches (10 each) = 56 degrees F The surveyor informed the FSD that the foods could no be served to residents until regulatory temperature were obtained and held at proper temperatures.

Based on interviews and record review, the facility failed to ensure an accurate assessment, reflective of the resident's status at the time of the assessment for 2 of 29 sampled residents (Resident #10 and #109), as evidenced by Resident #10 did not a smoking assessment completed after a significant change and Resident #109 had an inaccurant assessment completed related to disharge. The findings included: A review of the facility's policy, titled, Smoking Guidelines, revealed, in part, Evaluate patients / residents that smoke utilizing the Smoking Evaluation tool either (a) upon admission/move-in; (b) when a previous non-smoking patient/resident takes up smoking; (c) if unsafe smoking practices are observed in a current smoker; or, (d) when a patient/resident that smokes has a significant change in medical condition. 1. Record review revealed Resident #10 was initially admitted to the facility on [DATE] for rehabilitation with a history of Chronic Kidney Disease, Osteomyelitis of the left foot, Hyperthyroidism, Hyperlipidemia, Diabetes and Hypertension. Further review of the electronic medical record (EMR) revealed the resident was discharged to the hospital for a below the knee amputation on 03/06/22.The resident was readmitted on [DATE] post below knee amputation. Record review revealed Resident #10 was smoking prior to his hospitalization and upon readmission to the facility. On 01/10/23, the EMR revealed that the last smoking evaluation was dated 02/14/20. A review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/21/22 revealed under section J, Other Health Conditions, the response to the question Current Tobacco Use was answered 'no'. The resident's Brief Interview for Mental Status (BIMS) was 15, which indicated he was cognitively intact. An interview that was conducted with Resident #10 on 01/09/23 at 11:18 AM revealed he smoked before and after he went to the hospital in March 2022. An interview with the Director of Nurses on 01/11/23 at 10:30 AM revealed they realized yesterday (01/10/23) that a smoking assessment was not done when he had a significant change and it should have been done at that time. This was confirmed with Staff A, MDS coordinator, on 01/11/23 at 3:02 PM. During the interview conducted with Staff A, MDS coordinator, Staff A who confirmed that the question of current tobacco use should have been a 'yes' answer. 2. Resident #109's EMR was reviewed for hospitalization . She was admitted to the facility on [DATE] post dislocation of the left hip and was discharged home on 10/31/22. A review of the discharge MDS with an ARD of 10/31/22 revealed the resident was discharged to an acute hospital. An interview was conducted with Staff A, MDS coordinator, on 01/11/23 at 3:05 PM, who confirmed it was mistake that it was coded as a discharge to hospital and confirmed the resident was discharged home.

Based on observation, record review and interview, the facility failed to develop comprehensive care plans for 8 of 24 sampled residents, as follows: 1) Resident #93, for additional avoidable pain inflicted during accuchecks, who is also diagnosed with [REDACTED].#109, for positioning while in her wheelchair; 3) Resident #38 for specific behaviors, with the use of [MEDICATION NAME] and [MEDICATION NAME]; and for an injury to the facial area; 4) Resident #119, for dental services, as documented by the dentist; 5) Resident #295, for back pain due to the resident sitting in his wheelchair for an extended amount of time; 6) Resident #41 for specific behaviors, with the use of [MEDICATION NAME] ; 7) Resident #26, for urinary incontinence and; 8). Resident #170, for positioning with an identified foot drop. The findings include: 1). During interview with Resident #93, conducted on 07/23/2015 beginning at 10:00 AM, he stated he has repeatedly asked the nurses that draw blood from his fingers, on the 11-7 shift, on a daily basis, why they will not obtain an adapter, so blood does not have to be taken from his painful fingers. Resident #93 stated the nurses just respond by saying they don ' t have the equipment and cannot get it. He stated his fingers have to be iced down prior to the finger sticks (accu-checks) due to the level of pain that this causes. He stated his eyes tear up every time he has his fingers stuck to obtain blood. During further interview, Resident #93 acknowledged that due to his [MEDICAL CONDITION], he is always in pain. He stated that his fingers and feet are where the pain is the worst, and to have to be stuck with a needle every day in the fingers that have pain anyway is not excusable. During subsequent interview with the DON (Director of Nursing), on 07/23/2015 at 10:10 AM, she was informed of Resident #93 ' s concerns and request for an adapter. She stated this was the first she had heard of this and that she would obtain the piece of equipment (adapter), today. The DON provided a copy of a grievance form that had been completed on 07/23/2015 at 12:45 PM, that noted Resident #93 ' s concern and attached to this form was information related to this requested piece of equipment. The DON stated this equipment will be utilized during the next accu-check for this resident (Resident #93). Review of Resident #93's medical record revealed a current admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident ' s annual MDS (Minimum Data Set) assessment dated [DATE], documented he was noted to have a BIMs (Brief Interview of Mental Status) score of 15, indicating he is cognitively intact. The MDS documented the resident was assessed for pain management and indicated the resident experienced pain, was on a scheduled pain medication regimen as well as PRN (as needed) pain medication. The nurse's note, dated 07/23/2015, reflected Resident #93 is alert and oriented to person, place and time. This note also indicated he is able to make his needs known. The care plan for Endocrine System, dated 07/21/2015, indicated the facility is to obtain glucometer readings and report abnormalities, as ordered. The care plan for pain related to [MEDICAL CONDITION] and chronic back pain, initiated on 03/21/2013 with a revision date of 01/14/2015, documented as Goal: Pain or [MEDICATION NAME] will not affect participation in activities of choice or daily care; target date 10/29/2015; and Interventions: Administer pain medication per physician orders; encourage/assist to reposition frequently to position of comfort; notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective; and therapy evaluation and treatment per orders. Further review revealed the care plans were not addressed and revised regarding pain to address the fact that the resident's fingers are iced down prior to the finger sticks (accu-checks) due to the level of pain that this causes, and the request for alternative equipment (adapter) for accuchecks, after the resident requested from staff to prevent avoidable pain. During a subsequent interview with Resident #93, conducted on 07/24/2015 at 10:30 AM, he confirmed that the 11 P.M. to 7 A.M. nurse utilized the new equipment to conduct the accu-check. He stated, God bless you . He said he did not know why it took him talking to the surveyor to get a $10.00 piece of equipment (adapter). He was asked if it helped with the pain. He stated there was no pain caused from the use of this new equipment and that there was no excuse for not getting it sooner. During an interview, conducted on 07/24/2015 at 3:40 PM, the Administrator stated Resident #93 is always in pain so she was surprised this was cited at a harm level. She was informed that it was cited at a harm level because the additional pain inflicted by the accu-checks was avoidable. She replied that neither she nor the DON knew anything about Resident #93's desire to have the adapter. She was informed that Resident #93 repeatedly informed the 11 P.M.-7 A.M. nurses of his desire to have the adapter. During a telephone interview, conducted with Staff R, an 11 P.M.-7 A.M. Licensed Practical Nurse (LPN) on the 2nd floor, on 07/27/2015 at 9:45 AM, she was asked if she recalls Resident #93 complaining of pain with accu-checks. She replied that he always complains of pain with the accu-checks and that he does not like them. She acknowledged that he applies ice to his fingers prior to the accu-checks. She also acknowledged that Resident #93 has repeatedly discussed with her that he would like to have the adapter for the accu-checks, so he does not have to have his fingers stuck with a needle. She stated that she just reminds him that the facility does not have the equipment. She acknowledged that she had not told anyone else about this resident ' s complaints of pain with accu-checks or of his request for the adapter for the accu-checks so he does not have to receive the finger sticks. 2) Observation on 7/21/15 at 11:15 AM revealed Resident #109 sleeping in her wheelchair; she was leaning forward. A nurse was made aware of the observation. Further observations on 7/23/15, throughout the day, revealed Resident #109 in bed and asleep. Observation on 7/24/15 at 10:20 AM revealed the resident in her wheelchair, leaning forward. Further observation at that time revealed that the resident had side bolsters on her wheelchair, but no seat cushion. The resident's Certified Nursing Assistant (CNA), Staff P, acknowledged the observation at that time and stated that the previous shift staff had placed the resident in the wheelchair. Review of Resident #109's clinical record on 7/23/15 revealed that the resident was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. was severely impaired; she needed extensive assistance for bed mobility and transfers. Further review of the resident's clinical record on 7/23/15 revealed that the resident had a current care plan in place for activities of daily living self-care deficit; however, the care plan failed to address positioning. The resident had a current care plan for risk for falls, initiated on 5/12/10, that included anti-thrust cushion as an intervention to prevent falls. The clinical record revealed no evidence that the facility had addressed positioning in any of the resident's other care plans, including the aide care plan. Review on 7/23/15 of the resident's interdisciplinary notes from 3/13/15 to date revealed no documentation of any positioning concerns until 7/21/15 and again on 7/22/15. According to the notes of 7/22/15, the facility informed the resident's physician that the resident was leaning forward in her wheelchair and the physician ordered Physical and Occupational therapy evaluations. In an interview conducted on 7/24/15 at 10:37 AM with the resident's Licensed Practical Nurse, Staff M, the nurse stated that she was not noted any concerns with the resident's positioning. She acknowledged that the resident had bolsters in her wheelchair, but was not aware of the cushion. In an interview conducted on 7/24/15 at 10:46 AM with the Second Wing Manager, the Manager reported that staff had observed the resident leaning in her wheelchair on Tuesday (7/21/15) and obtained an order for [REDACTED]. She stated that the resident had lateral supports on her wheelchair for positioning, but was not aware of the cushion. In an interview, conducted on 7/24/15 at 10:57 AM with the MDS Coordinator, the Coordinator reviewed resident #109's clinical record, including the current care plans and reported that he did not see anything specific for positioning. He added that the resident has not had any falls in the last 6 months. In an interview conducted on 7/24/15 at 11:51 AM with the Nurse Consultant, the Consultant reported that she had not been able to find any physician orders [REDACTED]. Observation on 7/24/15 at 11:54 AM with the MDS Coordinator revealed Resident #109 in her room, in bed. The resident's wheelchair was observed by the bedside. The wheelchair included side support/bolsters for the resident, but no anti-thrust cushion. The MDS Coordinator acknowledged the findings. 3) In an interview, conducted with Resident #38 on 7/23/15 at 11:58 AM, the resident reported that she recently had a fall. The resident was observed at that time with sutures to her left eyebrow and a bruise under her left eye. Review of Resident #38's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Interview Mental Status score was 15, which indicated no cognitive impairments. The MDS assessment indicated that the resident did not have any behaviors; however, the resident's current medications included a physician's orders [REDACTED]. The clinical record revealed a Psychiatric Medication Follow-up Note dated 7/08/15 in which the Psychiatrist noted that the resident was tearful and anxious and had increased depression. The clinical record included a Psychotherapy note dated 6/26/15, in which the Psychologist noted that the resident received services for goals that included decreased experience of/report of sadness/crying. Further review of the resident's clinical record revealed that the resident was transferred to the hospital on [DATE] after she had a fall. The nursing notes from 5/30/15 to 7/23/15 revealed numerous instances when the resident received [MEDICATION NAME] and [MEDICATION NAME]; however, no behaviors were documented for the use of the medications. Review of the resident's clinical record on 7/24/15 revealed a current care plan, initiated on 5/18/15 for changes in mood r/t (related to) anxiety and depression. The resident's specific behaviors were not specified. The clinical record failed to include a care plan for the treatment of [REDACTED]. In an interview conducted on 7/24/15 at 9:19 AM with the Director of Nursing (DON), the DON reported that staff should document the resident's behaviors, including in the resident's care plan, and the Unit Manager made monthly notes on the resident's behaviors. In an interview, conducted with the First Wing Unit Manager on 7/24/15 at 9:38 AM and 9:52 AM, the Unit Manager acknowledged the lack of notes related to the resident's specific behaviors, but stated that the resident had a care plan for mood and behaviors. The Manager acknowledged that the resident's clinical record failed to contain a care plan that addressed interventions for the injuries to the left side of the resident's face. 4) During interview and record review for Resident #119, conducted with the SSD (Social Services Director) on 07/23/2015 beginning at approximately 12:50 PM, she acknowledged that a care plan was not developed related to this resident's dental concerns. The dental visit report, dated 05/01/2015, noted an oral exam was conducted and [MEDICATION NAME] (cleaning) as well. This note indicated that the treatments needed are as follows: a) Extractions 18, 19, 21 b) Full upper denture c) Cast partial lower denture d) Impressions taken for upper and lower dentures e) Will contact responsible party f) Will submit for pre-authorization 5) An interview was conducted on 07/22/2015 at 11:15 AM with Resident # 295. The resident expressed that the staff are leaving him in the wheelchair too long and he is experiencing severe pain in his back. He stated that when he is out of bed in the wheelchair, he has pain in his back from two bones rubbing together and he cannot tolerate being up in the chair for longer than 45 minutes to an hour. He stated they are forcing me to stay up in the chair 2-3 hours and it's too much. He further stated he has told two to three people. He stated he told the person who got him up and the nurse who gave him his medicine, but they are still making me stay in the wheelchair for hours. He also reports that he is experiencing pain in his back and legs and the current pain medication only takes the edge off. Review of the resident's 07/07/2015 Plan of care regarding Pain reveal that the staff identified a concern regarding pain related to disease process [MEDICAL CONDITIONS] and [MEDICAL CONDITION] Fibrillation. The goal is that the resident will express that pain management is within acceptable limits and the interventions include administer pain medication per physician orders. No other interventions are listed. There is no indication regarding the resident's increased pain while out of bed in the wheelchair and the facility interventions to manage the resident's pain. An interview was conducted with Staff D on 7/22/2015 at 2:00 PM, Licensed Practical Nurse, who reports she does not routinely work with the resident and is not too familiar with him. She stated she gave him some pain medication earlier with his morning medication. An interview was conducted on 07/23/2015 at 3:22 PM with Staff H, Certified Nursing Assistant, who reports that she has worked with the resident and the resident complains of pain in his back especially when he is up in the wheelchair. She reports that we will typically get him up before lunch and sometimes he wants to go back to bed immediately. He doesn't want to stay up too long. She states she informs the nurse when the resident complains of pain. 6) Record review reveals Resident #41 was ordered [MEDICATION NAME] 50 mg (milligrams) at bedtime for [MEDICAL CONDITION], as of 06/24/15. Further review of the record reveals two care plans related to mood disorders and risk for adverse effects related to the use of antipsychotic medications. Neither of these care plans document what behaviors are being exhibited by Resident #41 related to the use of the [MEDICATION NAME]. During an interview on 07/24/15 at 10:31 AM Staff J, an MDS (Minimum Data Set/Assessment) Coordinator was asked what behaviors are being monitored for Resident #41, and was unable to locate any. Staff J stated the behaviors may or may not be on the care plans, but should be on the assessment; Staff J was unable to locate documentation of the behaviors. 7) Review of the Admission MDS (Minimum Data Set) assessment dated [DATE] documents Resident #26 is occasionally incontinent of urine. Review of the most current Quarterly MDS dated [DATE] documents Resident #26 is frequently incontinent of urine. Further review of the current care plans revealed no documentation related to urinary incontinence. During an interview on 07/24/15 at 10:27 AM, Staff J, an MDS Coordinator, was unable to locate any care plan related to incontinence for Resident #26. 8). Observation of Resident # 170 on 07/22/2015 at 10:30 AM revealed the resident was out of bed in her wheelchair. The resident was noted to have both of her feet angled in a downward position (foot drop). Further observations revealed the resident's wheelchair foot rest does not provide support for the resident's foot drop. An interview was conducted with Resident #170 at the time of the observation. She stated that the wheelchair is so uncomfortable. She further stated she also has to put a pillow in the wheelchair seat and has a pain that just stabs her at the top of the crack of her butt. She also extends her legs out when seated in the wheelchair. She demonstrated that she cannot rest her feet on the foot rest. Additionally, she stated she used to get therapy for her foot drop and they were doing an exercise with a rubber band but it stopped months ago. Review of the clinical record reveals Resident #170 was readmitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented for functional limitation in Range of Motion, no impairment in the upper extremity and lower extremity. The 06/26/2015 Quarterly MDS Assessment, identified functional limitation of the resident ' s lower extremity and impairment on both sides. Review of the plan of care which identified a concern for Activities of Daily Living failed to identify concerns regarding the resident's foot drop. An interview was conducted on 07/24/2015 at 10:23 AM with Staff S, a Licensed Practical Nurse/MDS Coordinator. The surveyor questioned the MDS Coordinator regarding the resident's identified impairment in her lower extremity and the resident's care plan. The MDS Coordinator indicated that the foot drop identification would be noted on the ADL deficit care plan. Review of the care plan was conducted at this time with the MDS Coordinator, who acknowledged that the current care plan does not specifically address the resident's foot drop positioning. She did indicate that the care plan notes that the resident's arm rests are to be removed to assist in mobility.

Based on interview and record review, it was determined that the facility failed to provide necessary care and services to meet each residents highest practicable, physical, mental, and psychosocial well-being, in accordance with their comprehensive assessment and plan of care, specifically related to avoidable pain for 2 of 4 sampled residents (Resident #93 and Resident #295); and the facility failed to provide the necessary care and services related to positioning for a resident with an identified foot drop (Resident # 170). The findings include: 1). During interview with Resident #93, conducted on 07/23/2015 beginning at 10:00 AM, he stated he has repeatedly asked the nurses that draw blood from his fingers, on the 11-7 shift, on a daily basis, why they will not obtain an adapter, so blood does not have to be taken from his painful fingers. Resident #93 stated the nurses just respond by saying they don ' t have the equipment and cannot get it. He stated his fingers have to be iced down prior to the finger sticks (accu-checks) due to the level of pain that this causes. He stated his eyes tear up every time he has his fingers stuck to obtain blood. During further interview, Resident #93 acknowledged that due to his [MEDICAL CONDITION], he is always in pain. He stated that his fingers and feet are where the pain is the worst, and to have to be stuck with a needle every day in the fingers that have pain anyway is not excusable. During subsequent interview with the DON (Director of Nursing), on 07/23/2015 at 10:10 AM, she was informed of Resident #93 ' s concerns and request for an adapter. She stated this was the first she had heard of this and that she would obtain the piece of equipment (adapter), today. The DON provided a copy of a grievance form that had been completed on 07/23/2015 at 12:45 PM, that noted Resident #93 ' s concern and attached to this form was information related to this requested piece of equipment. The DON stated this equipment will be utilized during the next accu-check for this resident (Resident #93). Review of Resident #93's medical record revealed a current admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident ' s annual MDS (Minimum Data Set) assessment dated [DATE], documented he was noted to have a BIMs (Brief Interview of Mental Status) score of 15, indicating he is cognitively intact. The MDS documented the resident was assessed for pain management and indicated the resident experienced pain, was on a scheduled pain medication regimen as well as PRN (as needed) pain medication. The nurse's note, dated 07/23/2015, reflected Resident #93 is alert and oriented to person, place and time. This note also indicated he is able to make his needs known. The care plan for Endocrine System, dated 07/21/2015, indicated the facility is to obtain glucometer readings and report abnormalities, as ordered. The care plan for pain related to [MEDICAL CONDITION] and chronic back pain, initiated on 03/21/2013 with a revision date of 01/14/2015, included, Goal: Pain or [MEDICATION NAME] will not affect participation in activities of choice or daily care (target date 10/29/2015); and Interventions: Administer pain medication per physician orders; encourage/assist to reposition frequently to position of comfort; notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective; and therapy evaluation and treatment per orders. Further review revealed the care plans were not addressed and revised regarding pain to address the fact that the resident's fingers are iced down prior to the finger sticks (accu-checks) due to the level of pain that this causes, and the request for alternative equipment (adapter) for accuchecks, after the resident requested from staff to prevent avoidable pain. During a subsequent interview with Resident #93, conducted on 07/24/2015 at 10:30 AM, he confirmed that the 11 P.M. to 7 A.M. nurse utilized the new equipment to conduct the accu-check. He stated, God bless you . He said he did not know why it took him talking to the surveyor to get a $10.00 piece of equipment (adapter). He was asked if it helped with the pain. He stated there was no pain caused from the use of this new equipment and that there was no excuse for not getting it sooner. During an interview, conducted on 07/24/2015 at 3:40 PM, the Administrator stated Resident #93 is always in pain so she was surprised this was cited at a harm level. She was informed that it was cited at a harm level because the additional pain inflicted by the accu-checks was avoidable. She replied that neither she nor the DON knew anything about Resident #93's desire to have the adapter. She was informed that Resident #93 repeatedly informed the 11 P.M.-7 A.M. nurses of his desire to have the adapter. During a telephone interview, conducted with Staff R, an 11 P.M.-7 A.M. Licensed Practical Nurse (LPN) on the 2nd floor, on 07/27/2015 at 9:45 AM, she was asked if she recalls Resident #93 complaining of pain with accu-checks. She replied that he always complains of pain with the accu-checks and that he does not like them. She acknowledged that he applies ice to his fingers prior to the accu-checks. She also acknowledged that Resident #93 has repeatedly discussed with her that he would like to have the adapter for the accu-checks, so he does not have to have his fingers stuck with a needle. She stated that she just reminds him that the facility does not have the equipment. She acknowledged that she had not told anyone else about this resident ' s complaints of pain with accu-checks or of his request for the adapter for the accu-checks so he does not have to receive the finger sticks. 2) An interview was conducted on 07/22/2015 at 11:19 AM with Resident # 295 who expressed that the staff are getting him up early in the morning; are leaving him in the wheelchair too long and he is experiencing severe back pain. He stated that when he is out of bed in the wheelchair, he has pain from two bones rubbing together from an old injury and he cannot tolerate being up in the chair for longer than 45 minutes to an hour. He stated they are forcing me to stay up in the chair 2-3 hours and its too much. He further stated he has told two to three people (staff members). He stated he told the person who got him up and the nurse who gave him his medicine, but they are still making me stay in the wheelchair for hours and won't do anything about it . He also reports that he is experiencing pain in his back and legs and the current pain medication only takes the edge off. A further interview was conducted with Resident #295 on 07/23/2015 at approximately 1:45 PM, who was out of bed in the wheelchair. The resident was noted to have a grimace on his face and was also attempting to adjust himself in the wheelchair. The resident summoned the surveyor and stated, see I told them I wanted to go back to bed because I am hurting and they haven't done anything. I have been in this chair for over 2 hours. An interview was conducted with Staff F, a Certified Nursing Assistant assigned to the resident, on 7/23/2015 at 1:50 PM. The aide reported that she had gotten the resident up at approximately 11:00 AM. She further confirmed that the resident had expressed to her that he wanted to go back to bed. An interview was conducted on 07/23/2015 at 3:22 PM with Staff H, a Certified Nursing Assistant, who reported that she has worked with Resident #295 previously and the resident complains of pain in his back, especially when he is up in the wheelchair. She reported that we will typically get him up before lunch and sometimes he wants to go back to bed immediately. He doesn't want to stay up too long. She stated she informs the nurse when the resident complains of pain. An interview was conducted with Staff D, a Licensed Practical Nurse on 7/22/2015 at 2:00 PM, who reported she does not routinely work with Resident #295 and is not too familiar with him. She stated she gave him some pain medication earlier with his morning medications. Review of the clinical record for Resident # 295, reveals that the facility failed to thoroughly identify concerns associated with the resident ' s pain; failed to address the resident ' s pain concerns on his plan of care or identify the facility/staff interventions to reduce the resident ' s pain. Review of the resident's 07/07/2015 plan of care regarding pain reveals that the staff identified a concern regarding pain related to disease process [MEDICAL CONDITIONS] and [MEDICAL CONDITION] Fibrillation. The goal includes that the resident will express that pain management is within acceptable limits. The interventions include administer pain medication per physician orders. No other interventions are listed. There is no notation regarding the resident's increased pain while out of bed in the wheelchair or facility interventions to manage the resident's pain. Review of the physician prescription and the MAR (Medication Administration Record) revealed the facility documents an assessment of the Resident #295's pain once daily, on the day shift. The resident was prescribed Tylenol 325 mg; give 2 tablets by mouth every 4 hours. The MAR indicated [REDACTED]. Further review revealed the MAR indicated [REDACTED]. On 07/16/2015, the resident was prescribed [MEDICATION NAME] tablets 50 mg give one tablet by mouth every 6 hours for pain. The resident received 4 doses of the [MEDICATION NAME] before it was discontinued on 07/17/2015. The nurse administered the medication on 7/16/2015 at 1800 and documented a pain score of 0; 7/17/2015 at 12 midnight, the nurse documented a pain score of 8; 7/17/2015 at 6:00 AM, the nurse documented a pain score of 7 and a 12:00 Noon and documented a pain score of 0. On 07/18/2015, the physician prescribed [MEDICATION NAME] tablet 800 mg one tablet by mouth every 6 hours as needed for pain. The MAR indicated [REDACTED]. Review of the corresponding nursing progress notes associated with the above as needed pain medications did not provide information regarding a thorough assessment of the resident's pain (location and characteristic of the resident's pain). The progress notes document the pain medication was administered and its effectiveness. Further review of the clinical record for Resident # 295 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 07/18/2015 Minimum Data Set (MDS) assessment identified that the resident was not on scheduled pain medication, received as needed pain medication and a pain assessment interview was conducted. Further review of the pain evaluation, completed on 07/06/2015, documents that the resident experiences generalized pain, and did not identify further concerns regarding the resident's pain. A 7/23/2015 pain evaluation documents that the resident experiences lower back pain (chronic); pain is generalized. Numeric descriptor of the resident's pain at its best is 3 on a pain scale of 1 - 10 with 10 being the worst and the numeric descriptor of pain at its worst is 10. The relieving factors identified were repositioning or change in position and medication. 3) Observation of Resident # 170 on 07/22/2015 at 10:30 AM revealed the resident was out of bed in her wheelchair. The resident was noted to have both of her feet angled in a downward position (foot drop). Further observations revealed the resident's wheelchair foot rest does not provide support for the resident's foot drop. An interview was conducted with Resident #170 at the time of the observation. She stated that the wheelchair is so uncomfortable. She further stated she also has to put a pillow in the wheelchair seat and has a pain that just stabs her at the top of the crack of her butt. She also extends her legs out when seated in the wheelchair. She demonstrated that she cannot rest her feet on the foot rest. Additionally, she stated she used to get therapy for her foot drop and they were doing an exercise with a rubber band but it stopped months ago. Review of the clinical record reveals Resident #170 was readmitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented for functional limitation in Range of Motion, no impairment in the upper extremity and lower extremity. The 06/26/2015 Quarterly MDS Assessment, identified functional limitation of the resident ' s lower extremity and impairment on both sides. Review of the plan of care which identified a concern for Activities of Daily Living failed to identify concerns regarding the resident's foot drop. An interview was conducted on 07/24/2015 at 10:23 AM with Staff S, a Licensed Practical Nurse/MDS Coordinator. The surveyor questioned the MDS Coordinator regarding the resident's identified impairment in her lower extremity and the resident's care plan. The MDS Coordinator indicated that the foot drop identification would be noted on the ADL deficit care plan. Review of the care plan was conducted at this time with the MDS Coordinator, who acknowledged that the current care plan does not specifically address the resident's foot drop positioning. She did indicate that the care plan notes that the resident's arm rests are to be removed to assist in mobility. An interview was conducted on 07/23/2015 at 4:30 PM with Staff T, an Occupational Therapist, who confirmed that Resident #170 is not on the current case load for therapy. If additional therapy is needed or issues with the wheelchair develop, then therapy would need a referral to evaluate. She acknowledged observing the resident with her legs extended and her foot extended out when propelling herself in the wheelchair. She further acknowledged that the resident will need a referral from the nurse to reassess the resident. An interview was conducted on 07/24/2015 at 9:15 AM with Staff B, a Licensed Practical Nurse. A discussion regarding the resident's complaint of being uncomfortable in the wheelchair and the resident's foot drop was conducted at this time. Staff B denied awareness of the resident's complaint of being uncomfortable in her wheelchair. She acknowledged that she is aware of the resident's foot drop and stated that the resident arranged and was evaluated by a physician for the foot drop. She also stated she has observed the resident in the wheelchair and noticed that the resident's feet are not supported in the wheelchair. She explained that the resident oftentimes extends her legs outward when propelling herself in the wheelchair. She further stated that as soon as the staff observes the resident has issues with positioning, the staff can refer the resident to therapy to evaluate. However, she confirmed that this was not done for Resident # 170. An interview was conducted on 07/24/2015 at 11:00 AM with the Director of Rehabilitation. The therapist initially stated that the reason Resident #170 was discontinued from therapy was because the insurance stop paying and she became private pay. The resident's family was willing to pay but this did not happen. The resident received therapy 03/19 - 04/19/2015. The Director later approached the surveyor and stated that the resident's therapy was not stopped secondary to the payer source but that the resident had reached her goal. She further stated that if the resident requires additional therapy, then she would need to be referred.