Every finding on record at Wilson Care and Rehab

The facility identified a census of 34 residents, with 12 included in the sample. Based on observation, record review, and interview, the facility failed to ensure nursing staff donned (put on) the appropriate required Enhance Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) before providing direct cares to Resident (R) 5 and ensure staff did not set R5's catheter bag (medical device that collects urine) directly on the resident's floor. The facility failed to ensure nursing staff donned the required EBP and performed hand hygiene prior to and during the wound dressing change for R15. Findings included:- On 12/10/25 at 11:23 AM, Licensed Nurse (LN) G gathered and prepared wound care supplies (placed gauze pads into a clean plastic cup and placed zinc ointment into a clean cup) on the treatment cart outside of R15's room. LN G gathered the wound care supplies in her hands as she knocked on R15's door to announce herself and explained she was going to change the dressing for his pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, a result of pressure, or pressure in combination with shear and/or friction) on his right buttock. LN G then placed the cups and wound supplies directly onto R15's bedside table, as well as the sealed dressing package. LN G failed to don (put on) a clean gown, as required, due to R15's Enhanced Barrier Precaution (EBP) status. LN G failed to wash her hands or perform hand hygiene before she donned clean gloves and removed the old bandage from R15's bottom. LN G removed her gloves and placed them in the trash and donned a clean pair of gloves, without performing hand hygiene. LN G then grabbed the wound cleanser bottle to spray the wound area and wiped the area with a clean gauze pad from the cup on the bedside table. LN G removed the dirty gloves and disposed of them in the trash. LN G did not perform hand hygiene before she donned clean gloves. LN G applied the zinc to the wound bed. LN G opened the new dressing bandage, wrote the date on the bandage, removed the adhesive tab covers, and applied the dressing to the wound area. LN G rolled R15 back over to his back and refastened his brief. LN G disposed of the dressing supplies in the trash, removed her gloves, and exited the room. LN G did not wash or sanitize her hands after exiting R15's room. On 12/11/25 at 12:02 PM, LN G stated she should have put on a gown as she entered R15's room and she had not realized she did not put one on or that she did not perform hand hygiene. On 12/11/25 at 12:35 PM, Administrative Nurse D stated she expected her nursing staff to put on all the appropriate EBP when performing direct cares on residents, including putting on a gown. Administrative Nurse D stated she expected staff to perform appropriate hand washing and hand hygiene during any cares. The facility's Infection Prevention and Control Program policy, dated 01/2024, documented the community Infection Prevention and Control Program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The community program would follow accepted national standards. Components of the program would include (see appropriate Policy and Guidelines): Surveillance system; reporting requirements; use of standard and transmission-based precautions; employee health; hand hygiene; environmental cleaning; occupational health; antibiotic stewardship; recording system; and annual review. - During an observation on 12/10/25 at 03:50 PM, Certified Nurse Aide (CNA) M entered R5's room and retrieved gloves from the Enhanced Barrier Precaution (EBP) supply hanger on the door, but did not don a gown. CNA M asked R5 if she had permission to empty the catheter bag. R5 agreed to have his catheter bag drained. CNA M proceeded to don gloves, retrieve a measuring device from the bathroom, and empty the catheter drainage bag. CNA M placed the catheter drainage bag on the floor under R5's wheelchair while she obtained a privacy bag to hook under the wheelchair, after which CNA M washed her hands. CNA M lacked the use of an EBP gown during caring for the catheter drainage bag. On 12/11/25 at 11:19 AM, Administrative Nurse F verified staff should wear gloves and gowns while caring for R5's catheter, and the drainage bag should not lie on the floor. On 12/11/25 at 12:55 PM, Administrative Nurse D verified the use of a gown and gloves during care of catheters, and the drainage bag should not have been left lying on the floor. The facility's Indwelling Urinary Catheters policy, dated 05/2025, documented use of standard precautions when handling or manipulating the drainage system. The policy documented to be sure the catheter tubing and drainage bag were kept off the floor.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to resolve recurring issues reported by the Resident Council. Findings included:- A review of the facility's Resident Council Minutes from 12/10/24 to 11/28/25 indicated the council had recurring concerns with call light response times and delivery of care. The Resident Council Minutes for 04/08/25 noted the resident's had concerns with call lights being turned off, staff leaving, and then not returning to complete their requests. In addition, the council requested that staff be quiet during activities like church and movies. The facility's response to the council's concern included that staff were provided with re-education pertaining to answering resident call lights and noted staff would show respect during activities such as church or movies at the nurse's station. The Resident Council Minutes for 05/28/25 again noted the resident call lights were being turned off by staff without completing cares, staff remaining loud during resident activities, and staff being preoccupied/complaining about being short-staffed and complaining about other coworkers. The facility response to the council after reviewing their concerns was to speak to both the day and night shift staff regarding timing of addressing call lights and reminded to ask residents for assistance expectations. The facility's department heads would assist with the council's concerns while in the building, and the facility department heads would reiterate resident concerns at all staff meetings. The Resident Council Minutes for 06/10/25 again noted residents had concerns with call light answer times and noted the staff complaints were ongoing. The facility's response to the resident concerns was to put out education sheets/reviews for staff, but to also discuss the education at an all-staff meeting. The Resident Council Minutes for 07/08/25 again reported the resident's concerns with the timely answer of call lights was not resolved, and staff attitudes were described as snotty. The facility's response to the ongoing concern was to discuss concerns and set out expectations at a mandatory staff meeting. The Resident Council Meeting for 10/16/25 again noted residents had concerns with call lights not being answered promptly. The minutes lacked a response from the facility. The Resident Council Minutes for 11/28/25 noted resident's had concerns, which they reported they felt like a burden to staff with Certified Nurse Aides (CNA) huffing, scoffing, and cussing when the resident's requested care, when answering call lights was delayed too long, and residents were told someone would return shortly to assist them, but no one returned. The facility's response to the residents was they would address their concerns and educate staff of concerns. On 12/11/25 at 08:39 AM, R28 reported the wait for staff to answer call lights was long. R28 reported staff had attitudes toward requests. R28 reported this was an ongoing problem and felt the facility did not have enough staff to care for all the residents. On 12/11/25 at 11:44 AM, Administrative Staff A reported the facility's call light system was being upgraded to track resident use and the length of call light response so the facility could better analyze the root cause of residents' concerns with staff response to call lights. On 12/11/25 at 12:55 PM, Administrative Nurse D reported she had been employed by the facility since 10/2025 and had not had a chance to address the call light concerns. The facility's Resident Council, Family Council policy, dated 08/2025, documented that the community would assign a staff member, who is approved by the council, who is responsible for providing assistance and responding to written requests of the council, and responses are presented at the next meeting or sooner, if indicated. The Quality Assurance Committee within the facility would review the data from the Resident Council as part of their quality review. Issues documented on the council responses forms may be referred to the Quality Assurance Committee.

The facility had a census of 34 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or representative) a fully completed Advanced Beneficiary Notice (ABN) Centers for Medicare and Medicaid Services (CMS) Form 10055 for skilled services for Resident (R) 2, R20, and R28, which included the estimated cost of services.Findings included:- The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that they may not pay for future skilled therapy services and provided a place for a cost estimate of continued services. The form included an option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. The form had a place for the resident to document they understood that if Medicare did not pay, they were responsible for payment but could appeal to Medicare. The form further documented under part (2) the resident could receive therapy listed, but would not bill Medicare, would be responsible for payment for services. Under part (3) the resident could indicate they did not want the listed therapy services.] The Center of Medicare (CMS)-10055 form provided to R2, when the skilled services ended on 07/31/25, lacked the estimated costs of service. The Center of Medicare (CMS)-10055 form provided to R20, when the skilled services ended on 11/30/25, lacked the estimated costs of services. The Center of Medicare (CMS)-10055 form provided to R28, when the skilled services ended on 12/05/25, lacked the estimated costs of services. On 12/11/25 at 11:57 AM, Administrative Staff A reported she had not dealt with beneficiary notices, but the cost should be presented for the possibility of appeal of services. The facility's Beneficiary Notices policy, dated 07/2025, documented that the standard appeals process served a similar function of enabling a beneficiary of possible non-coverage and, if Medicare agrees that coverage is not appropriate, to shift the cost of care from the Skilled Nursing Facility to the beneficiary. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN), CMS-10055, informs the resident of potential non-coverage and documents in the record that the resident understands they are accepting financial liability.

The facility identified a census of 34 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the omission of blood pressure or pulse monitoring for Resident (R) 4 prior to the administration of the antihypertensive (a class of medication used to treat high blood pressure) beta blocker (a medications that reduce the workload of the heart by slowing its rate and relaxing blood vessels) Carvedilol. The facility failed to implement recommendations made by the CP for a dosage amount for R4's Voltaren gel (a topical medication used to relieve arthritis pain). Findings included:- R4's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), aneurysm of the heart (a bulge in the weakened wall of the heart), traumatic brain injury (damage to the brain from an external force, like a blow, jolt, or penetrating object, causing physical, cognitive, emotional, or behavioral changes, ranging from mild to severe), and transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain) R4's admission Minimum Data Set (MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R4 had impairment to one side of his lower extremities. R4 required partial staff assistance to total dependence on staff for his activities of daily living (ADL) care. R4 received an anticonvulsant (medications that control abnormal electrical activity in the brain to prevent or stop seizures). R4's Care Plan revised 08/01/25 revealed the following interventions:Staff were directed to give the resident hypertensive medications as ordered. Staff would monitor for side effects such as orthostatic hypotension (blood pressure dropping with change of position) and increased heart rate. Staff would monitor for and document any edema (swelling) and to notify the physician. Staff would monitor and record medication side effects and report to the resident's physician as necessary. Staff were directed to obtain blood pressure readings weekly, as needed and, as per protocol. Staff were to take blood pressure readings under the same conditions each time. R4's Orders tab documented a physician's order dated 04/22/25 for the beta blocker antihypertensive Carvedilol 6.25 milligrams (mg) tablet twice daily for HTN. This order lacked direction to monitor R4's blood pressure and pulse prior to administration. R4's Orders tab documented a physician's order dated 05/05/25 for Voltaren External Gel 1 % to apply to painful areas topically every six hours as needed for pain. The order was discontinued on 05/09/25. This order lacked a specified dosage amount to apply to the affected area. R4's Orders tab documented a physician's order dated 06/05/25 for Voltaren External Gel 1 % to apply to right knee, left shoulder, and neck topically four times a day for pain or discomfort. This order was discontinued on 06/18/25. This order lacked a specified dosage amount to apply to the affected area(s). R4's Orders tab documented a physician's order dated 06/18/25 for Voltaren External Gel 1 % to apply to bilateral knees topically four times a day for pain or discomfort using the supplied dosing card, apply four grams (gm) (4.5 inches) to affected area four times daily. Do not apply more than 16 gm daily to any one affected joint of the lower extremities. If applied to multiple sites, do not exceed 32 gm per day. This order was discontinued on 07/17/25. R4's Orders tab documented a physician's order dated 07/17/25 for Voltaren External Gel 1% topical to apply to bilateral knees topically four times a day for pain or discomfort using the supplied dosing card, apply four gm (4.5 inches) to the affected area four times daily. Do not apply more than 16 gm daily to any one affected joint of the lower extremities. If applied to multiple sites, do not exceed 32gm per day. And apply to left shoulder topically four times a day for pain. This order lacked a dosage amount for the left shoulder application. Review of the CP Monthly Regimen Review (MRR) from April 2025 to November 2025 revealed the CP did not identify and report that R4's blood pressure and pulse were not monitored/obtained prior to the administration of his Carvedilol. A Consultant Report dated 06/16/25 by the CP documented a recommendation for a dosage amount to apply for the ordered Voltaren gel. The 06/17/25 physician's signed response documented an acceptance for the recommendation as well as a written response to apply to the resident's lower extremity four grams four times a day. The physician did not indicate a dosage amount to be applied to the upper extremity. On 12/10/25 at 07:45 AM, R4 sat in his wheelchair in the dining room awaiting breakfast. On 12/10/25 at 09:08 AM, Certified Medication Aide (CMA) R stated she was not certain of which antihypertensive medication required either a pulse or blood pressure reading. When she obtained the reading, she reported it to the charge nurse if outside of the provided physician's parameters. On 12/11/25 at 12:02 PM, Licensed Nurse (LN) G stated that certain medications for HTN do need a blood pressure or pulse reading prior to being given. LN G stated she did not directly have anything to do with the pharmacy recommendations. LN G stated all medications, including Voltaren require a dosage for administration/application. On 12/11/25 at 12:35 PM, Administrative Nurse D stated that the pharmacist made the recommendations, and she received them and then forwarded them to the physician. Administrative Nurse D stated that R4's Carvedilol was a beta blocker and did require monitoring prior to administration. Administrative Nurse D stated that R4's Voltaren should have a dosage amount to indicate how much to apply to the designated area. A request was made for a policy regarding Pharmacy Review on 12/11/25, but the policy was not received.

The facility identified a census of 34 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that blood pressure or pulse monitoring was obtained for Resident (R) 4 prior to the administration of the antihypertensive (a class of medication used to treat high blood pressure) beta blocker (a medications that reduce the workload of the heart by slowing its rate and relaxing blood vessels) Carvedilol. The facility failed to ensure a physician-ordered dosage amount was indicated for R4's Voltaren gel (a topical medication used to relieve arthritis pain). Finding included:- R4's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), aneurysm of the heart (a bulge in the weakened wall of the heart), traumatic brain injury (damage to the brain from an external force, like a blow, jolt, or penetrating object, causing physical, cognitive, emotional, or behavioral changes, ranging from mild to severe), and transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain). R4's admission Minimum Data Set (MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status (BIMS) score of six, which indicated a severely impaired cognition. R4 had impairment to one side of his lower extremities. R4 required partial staff assistance to total dependence on staff for his activities of daily living (ADL). R4's Care Plan revised 08/01/25 revealed the following:Staff were directed to give the resident his hypertensive medications as ordered.Staff were directed to monitor for side effects such as orthostatic hypotension (blood pressure dropping with change of position) and increased heart rate.Staff would monitor for and document any edema (swelling) and notify the physician if identified.Staff were to monitor and record medication side effects and report to the resident's physician as necessary.Staff were to obtain blood pressure readings weekly, as needed and as per protocol.Staff were to take blood pressure readings under the same conditions each time. R4's Orders tab documented a physician's order dated 04/22/25 for the beta blocker antihypertensive Carvedilol 6.25 milligrams (mg) tablet twice daily for HTN. This order lacked direction to monitor R4's blood pressure and pulse prior to administration. R4's Orders tab documented a physician's order dated 05/05/25 for Voltaren External Gel 1 % to apply to painful areas topically every six hours as needed for pain. The order was discontinued on 05/09/25. This order lacked a specified dosage amount to apply to the affected area. R4's Orders tab documented a physician's order dated 06/05/25 for Voltaren External Gel 1 % to apply to right knee, left shoulder, and neck topically four times a day for pain or discomfort. This order was discontinued on 06/18/25. This order lacked a specified dosage amount to apply to the affected area(s). R4's Orders tab documented a physician's order dated 06/18/25 for Voltaren External Gel 1 % to apply to bilateral knees topically four times a day for pain or discomfort using the supplied dosing card, apply four grams (gm) (4.5 inches) to affected area four times daily. Do not apply more than 16 gm daily to any one affected joint of the lower extremities. If applied to multiple sites, do not exceed 32 gm per day. This order was discontinued on 07/17/25. R4's Orders tab documented a physician's order dated 07/17/25 for Voltaren External Gel 1% topical to apply to bilateral knees topically four times a day for pain or discomfort using the supplied dosing card, apply four gm (4.5 inches) to the affected area four times daily. Do not apply more than 16 gm daily to any one affected joint of the lower extremities. If applied to multiple sites, do not exceed 32 gm per day. And apply to left shoulder topically four times a day for pain. This order lacked a dosage amount for the left shoulder application. On 12/10/25 at 07:45 AM, R4 sat in his wheelchair in the dining room awaiting breakfast. On 12/10/25 at 09:08 AM, Certified Medication Aide (CMA) R stated she was not certain of which antihypertensive medication required either a pulse or blood pressure reading. When she obtained the reading, she reported it to the charge nurse if outside of the provided physician's parameters. On 12/11/25 at 12:02 PM, Licensed Nurse (LN) G stated that certain medications for HTN did need a blood pressure or pulse reading prior to being given, but not all of the physicians ordered them to be monitored. LN G stated all medications including Voltaren required a dosage for administration/application. On 12/11/25 at 12:35 PM, Administrative Nurse D stated that R4's Carvedilol was a beta blocker and did require monitoring of the blood pressure and pulse prior to administration. Administrative Nurse D stated that R4's Voltaren should have a dosage amount to indicate how much to apply to each designated area. The facility's Unnecessary Medications policy dated 04/2025 documented the residents drug regimen would be free from unnecessary drugs (any drug used in excessive dose, including duplicate therapy or for excessive duration, or without adequate monitoring or without adequate indications for its use or in the presences of adverse consequences which indicate the dose should be reduced or discontinued). A physician's order should include diagnoses, the condition or symptoms for what was being ordered; the dose; and the duration.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's injectable medications were not expired. Findings included:- On [DATE] at 08:11 AM, during the medication/treatment cart initial tour, two Lispro injectable pens with an open date of [DATE] were noted for R2. Licensed Nurse (LN) G verified the medication was put into use on [DATE] and expired 30 days after being opened and put into use. On [DATE] 12:55 PM, Administrative Nurse D verified R2's Lispro injectable pens expired 30 days from the open date and stated the pens should be discarded. The facility's Storage of Medication policy, dated 03/2025, documented that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation.

The facility identified a census of 34 residents. The sample included 12 residents, with one resident, Resident (R) 7, reviewed for Hospice care. Based on observation, record review, and interview, the facility failed to ensure the collaboration of care between R7's hospice provider and the facility which included the hospice provider contact information, the services the hospice provider would provide to the resident, the supplies, equipment and medications the hospice provider would provide, as well as how often hospice staff members would visit the facility. Findings included: - R7's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), benign hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart). R7's admission Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R7 required partial to substantial staff assistance with his activities of daily living (ADL). R7 required supplemental oxygen therapy and was on hospice services. R7's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/25/24 documented he required assistance with his activities of daily living (ADL), transfers, toileting, and mobility per wheelchair at times. R7 was incontinent of bowel and bladder. R7 was able to make his needs known and requested assist as needed. R7 admitted to the facility on Hospice Services for end-stage CAD. R7's Care Plan revised 10/02/25 directed staff he was receiving hospice services. The plan of care directed staff to adjust provision of ADLs to compensate for the resident's changing abilities. Staff were to encourage resident participation to the extent the resident wishes to participate. The plan of care directed staff to assess R7's coping strategies and respect resident wishes. The plan of care directed staff to consult with the physician and Social Services to have Hospice care for resident in the facility. The plan of care directed staff to encourage R7 to express feelings, listen with non-judgmental acceptance, compassion. The plan of care directed staff to encourage a support system of family and friends. The plan of care directed staff to observe resident closely for signs of pain, administer pain medications as ordered, and notify the physician immediately if there the plan of care directed staff to refer for Psychiatric consult if indicated. The plan of care directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs was met. The plan of care directed staff to work with nursing staff to provide maximum comfort for the resident. The Plan of Care lacked staff direction regarding the hospice providers contact information. The plan of care lacked staff direction on what hospice staff would visit R7 at the facility or how often. The plan of care lacked staff direction on the supplies and durable medical equipment, and medications provided by the hospice provider. R7's Orders tab documented a physician's order dated 09/12/25 to admit to the facility and hospice services. On 12/10/25 at 09:27 AM, R7 sat in his wheelchair in the hallway awaiting to go outside for his smoke break. On 12/11/25 at 10:35 PM, Certified Nurse Aide (CNA) M stated typically the nurse would let staff know which resident (s) was on hospice. CNA M stated she did not have access to the care plan but did know that hospice did provide supplies like briefs, bed mattresses, and stuff like that. CNA M stated usually the nurse would tell staff when hospice would be visiting. On 12/11/25 at 12:02 PM, Licensed Nurse (LN) G stated R7's care plan did mention he was on hospice but could not say if it had direction as to what supplies hospice provided or when hospice staff would visit. On 12/11/25 at 12:35 PM, Administrative Nurse D stated she expected R7's Care Plan to direct staff on when hospice providers would visit, and what supplies hospice provided and such. Administrative Nurse D stated she would ensureR7's care plan was updated with that information. The facility's Hospice Program policy, dated October 2024, documented the community retained the ultimate responsibility for the care plan. The policy documented to promote continuity of care, collaboration with the hospice, nursing home and resident/representative on a coordinated care plan noted in the medical record. Although, the Hospice provider retained the primary responsibility for the provision of the following hospice care and services, including but not limited to, the community must coordinate the care and ensure the resident received all necessary care and services; providing medical direction and management of the resident; nursing, including assigning a hospice aide as needed support; counseling; social work; providing medical supplies, durable medical equipment; medications necessary for palliation of pain and symptoms associated with terminal illness and related conditions; and all other services that are necessary for the care of the resident's terminal illness and related conditions. The community responsibilities included: 24- hour room and board; meet the resident's personal and nursing needs in coordination with the hospice representative; ensure the level of care provided was based upon their individual needs; administration of prescribed therapies; and report alleged violations involving all types of abuse as defined by state and federal rule by hospice personnel, per the established community policy.

The facility had a census of 34 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to ensure appropriate sanitation of dishware used for preparing, and serving residents' meals, and failed to prepare, store, distribute, and serve food under sanitary conditions for the 34 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness. Findings included: - On 01/30/24 at 08:40 AM, observation revealed Dietary Staff (DS) CC operated the dishwasher and attempted to test the dishwasher rinse for chemical sanitation. The wash and rinse temperatures were 105 degrees Fahrenheit (F). DS CC used sanitizer testing strips which indicated no chemicals. The dishwasher was connected to Betco low-temperature machine sanitizer and used [NAME] All Temperature Rinse Aide and [NAME] All Temperature Dish Machine Detergent. The Dishwasher Temperature Logs, dated January 2024, documented morning, noon, and evening temperatures of 90- and 100 degrees Fahrenheit (F.). The documented chemical sanitation checks recorded 200 parts per million (PPM-the amount of chlorine left over after a process where there is more chlorine than contaminate present.) On 01/30/24 at 8:45 AM, during the initial tour, observation revealed the following: One 4-foot by 3-foot ceiling-mounted heater and air conditioner unit, located at the entrance to the kitchen and blowing air directly across the food preparation area. The air vent grill was covered with a brown grease/sticky substance and a gray fuzzy substance. Continued observation revealed an airflow register/vent located directly above the dishwashing area was covered with a brown grease/sticky substance and a gray fuzzy substance. On 01/30/24 at 10;45 AM, DS CC verified the dishwasher temperature was 105 degrees F. and verified the chemical test strips for bleach sanitization lacked a reading of the chemical sanitization. On 1/31/24 at 12:10 PM, DS BB verified the chemical test strips lacked a reading of the chemical sanitization and verified the January 2024 Dish Machine Temperature/Chemical log recorded temperatures of 90 and 100 degrees and verified the low-temperature dishwasher's lowest reading should be 120 degrees. DS DD verified the facility's chemicals used to wash and rinse the dishes did not provide the appropriate sanitization and stated the hot water booster unit was not turned on and that is why the temperatures were low. DS BB Verified she would be providing education to the dietary staff regarding dish machine temperatures and sanitization. The facility's Dishwashing Machine Use policy, dated 10/2023, stated food service staff are required to operate the dishwashing machine and would be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Dish machines that use hot water to sanitize 165 degrees Fahrenheit (F) for stationary rack, single temperature dish machines. Dish machines that use chemicals to sanitize, must maintain a wash temperature of 120F and have a final rinse of 50 ppm of chlorine. The operator would check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility-approved log. The operator would monitor the gauge frequently during the dish machine cycle. Inadequate temperatures would be reported to the supervisor and corrected immediately. The supervisor would check the calibration of the gauge weekly by running a secondary thermometer through the machine to compare temperatures or using commercial test strips following the manufacturer's instructions. If hot water temperatures or chemical sanitization concentrations do not meet requirements, cease use of the dishwashing machine immediately until temperatures and PPM are adjusted. The facility's Sanitization policy, dated 10/2023, stated the food service area should be maintained in a clean and sanitary manner. All kitchen areas and dining areas should be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The facility failed to ensure appropriate sanitation of dishware used for preparing, and serving residents' meals and failed to prepare, store, distribute, and serve food under sanitary conditions for the 34 residents residing in the facility, who received their meals from the kitchen.

The facility had a census of 34 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 the PBJ report for Quarter 2 indicated the facility had excessively low weekend staff. The PBJ report for Quarter 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on following days: 04/01/23, 04/02/23, 04/08/23, 04/15/23, 04/17/23, 04/19/23, 04/22/23, 04/29/23, 04/30/23, 05/06/23, 05/20/23, 05/27/23, 05/28/23, 06/03/23, 06/10/23, 06/11/23, 06/24/23, and 06/25/23 and had excessive low weekend staff. A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 02/05/24 at 01:15 PM, Administrative Staff A verified the facility failed to send in the correct data to CMS for the PBJ and verified the facility did have licensed nurse coverage The facility's Nursing Services policy, dated 09/2023 recorded the facility would provide adequate staff with the appropriate competencies and skill sets to provide nursing and related services to assure residents' safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility would maintain adequate staffing on each shift to ensure that the resident's needs and services are met and identify any state minimum requirements for staff and compare to current staffing and alter to meet needs. The facility would provide resources to function of staffing to ensure a licensed staff 24 hours a day, 7 days a week. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 34 residents. Based on observation, record review, and interview the facility failed to resolve grievances recorded during resident council meetings. This placed the residents at the facility at risk for unresolved grievances and decreased quality of life. Findings included: - Review of the Resident Council Minutes from February 2023 to January 2024 recorded grievances from the resident council which staff had not addressed the residents' concerns regarding Certified Nurse Aides (CNA) and staff on their personal phones during care (five meetings the concern was expressed), too much noise at nights and TV too loud in the commons area (six meetings the concern was expressed), short staffing (three meetings the concerns were expressed), and various other concerns not addressed. A review of the facility's Grievance/Variance Log from January 2023 to December 2023 recorded grievances that were unresolved or ongoing. On 02/01/24 at 09:30 AM, In an interview with four residents, the residents verbalized they had concerns and grievances with the above-documented concerns. The residents stated they would file a grievance, and discuss concerns over and over each month, however, staff would not inform the residents of the resolution or concern regarding the grievance, or a resolution regarding the expressed grievance. The residents stated there was no system in place, that they knew about, to address grievances and resolutions. On 02/01/24 at 10:30 AM, Administrative Staff A verified the lack of a system in place for the residents to express grievances, or a system to respond to the residents for a resolution or follow through of the grievances. Administrative Staff A stated the facility did not presently have social service staff and said she would be implementing a system and policy for grievances expressed at the resident council meetings. The facility's Resident Council, Family Council policy, dated 10/2023, states the facility supports residents and their desires to be involved and have input in the operations of the facility through the Resident Council and if one exists Family Council. The purpose of the Resident Council is to provide a forum for the residents to have input in the operation of the facility, and discuss concerns. The facility failed to respond to resident council grievances and failed to have a system in place to inform the residents of concerns or grievance resolution from concerns expressed in the resident council meetings, placing the residents in the facility at risk for unresolved issues.

The facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to label insulin (a hormone that lowers the level of glucose in the blood) pens or vials with an opened date or discard date. This placed residents who received the insulins at risk for expired or ineffective insulin. Findings included: - On [DATE] at 08:29 AM, observation revealed the facility's nurses cart held six insulin pens that had not been dated when opened: One Lantus (long-acting insulin) pen open with no date, for Resident (R)16. One Lantus pen and one Humalog (fast-acting insulin) pen, open with no date for R31. One Lispro (rapid-acting insulin) pen, open with no date for R3. One Lantus pen opened, with no date for R9. One Lantus pen opened, with no date, for R30. On [DATE] at 08:29 AM, Licensed Nurse (LN) H verified the lack of dates and stated nurses were to write the date on the insulin pens or vials when they were first opened for use. The facility's Insulin Administration policy, dated ,d+[DATE], stated staff was to record the expiration date on the vial/pen when opening a new vial/pen and follow the manufacturer's recommendations for expiration after opening. The facility failed to label insulin pens or vials with an opened date or discard date, placing residents who received the insulins at risk for expired or ineffective insulin.

The facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for immunizations, Resident (R)3, R4, R10, R16, R19, and R87, to include pneumococcal vaccinations (helps protect against serious illnesses like pneumonia). Based on record review and interviews, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV 20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - Review of R3, R4, R10, R16, R87, and R19's clinical medical records lacked evidence the facility or the resident representative received or signed consent or informed declination for the current pneumococcal vaccine PCV20. On 02/05/24 at 11:30 AM, Administrative Nurse D stated the facility was reviewing resident records to determine if they were eligible for the newest PCV 20 vaccine. She verified no staff had offered the residents the vaccine. The facility's Pneumococcal Vaccine policy dated 09/2023, stated residents would be offered the pneumococcal vaccine to aid in preventing pneumococcal infections. New recommendations were published by the CDC in February 2023. Prior to or upon admission residents would be assessed for eligibility to receive the pneumococcal vaccine and when indicated, will be offered the vaccine unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccination or re-vaccination would be made in accordance with current CDC recommendations. The facility failed to offer the PCV20 pneumococcal vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

The facility had a census of 34 residents. The sample included 12 residents with one reviewed for hospitalization . Based on observation, interview, and record review the facility failed to notify the state's Long Term Care Ombudsman (LTC) Ombudsman (a person who advocates for residents of nursing homes), as required, of Resident (R) 19's discharge from the facility. This placed the resident at risk for impaired rights and/or advocate involvement. Findings included: - R19 's Electronic Medical Record documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polycythemia vera (a chronic blood disorder), malnutrition, cerebral infarction (stroke), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), and viral pneumonia (inflammation of the lungs). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R19 required set-up assistance or supervision for most activities of daily living. R19's Care Plan, dated 01/23/24, stated R19 had altered respiratory status and difficulty breathing related to COPD and directed staff to administer medication and inhalers as ordered and monitor for effectiveness and side effects. The plan directed staff to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. R19's medical record documented she was hospitalized on the following dates: 11/23/23 to 11/27/23 12/08/23 to 12/12/23 12/18/23 to 12/26/23 01/10/24 to 01/16/24 The facility was unable to provide evidence of LTC Ombudsman notification for the above discharge and or transfers. On 01/31/24 at 02:48 PM, observation revealed therapy staff assisted R19 back to her room and into her recliner. On 02/01/24 at 930 AM, Administrative Staff A verified the facility had not notified the LTC Ombudsman of the resident's discharges from the facility in November 2023 and December 2023. The facility's Transfer and or Discharge policy, dated 05/2023, stated the facility would send a notice of the discharge to the State Long Term Care Ombudsman. The facility failed to notify the state LTC Ombudsman, as required, of R19's discharge from the facility. This placed the resident at risk for impaired rights and/or advocate involvement.

The facility had a census of 34 residents. The sample included 12 residents with one reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide Resident (R)19 with a Bed Hold Notice (the right of an individual to resume nursing facility residency after he or she has been away from the facility due to hospitalization or therapeutic leave). This placed the resident at risk of not being allowed to return to the same room upon discharge from the hospital. Findings included: - R19 's Electronic Medical Record documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polycythemia vera (a chronic blood disorder), malnutrition, cerebral infarction (stroke), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), and viral pneumonia (inflammation of the lungs). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R19 required set-up assistance or supervision for most activities of daily living. R19's Care Plan, dated 01/23/24, stated R19 had altered respiratory status, difficulty breathing related to COPD and directed staff to administer medication and inhalers as ordered and monitor for effectiveness and side effects. The plan directed staff to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. R19's medical record documented she was hospitalized on the following dates: 11/23/23 to 11/27/23 12/08/23 to 12/12/23 12/18/23 to 12/26/23 01/10/24 to 01/16/24 The facility was unable to provide evidence that R19 received a Bed Hold Notice prior to her hospitalization s. On 01/31/24 at 02:48 PM, observation revealed therapy staff assisted R19 back to her room and into her recliner. On 02/01/24 at 930 AM, Administrative Staff A verified the facility had not provided the resident or her representative a Bed Hold Notice prior to her discharges from the facility in November 2023 and December 2023. The facility's Bed Hold policy, dated 05/2023, stated the facility would inform the resident or their representative of the bed hold policy upon admission and prior to a transfer for hospitalization and a copy would be filed in the resident's medical record. The facility failed to provide R19 a Bed Hold Notice prior to her four hospitalization s, placing the resident at risk of not being allowed to return to the same room upon discharge from the hospital.

The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported an inappropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of Resident (R)31's antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions). This placed the resident at risk for unnecessary medications and related side effects. Findings included: - R31's Physician Order Sheet (POS), documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbance, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain.) R31's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had short- and long-term memory loss. The MDS recorded the resident was dependent on bed mobility, locomotion on the unit, dressing, and personal hygiene. The MDS documented R13 received an antipsychotic medication during the lookback period. R31's Care Area Assessment, dated 05/14/23 recorded the resident had a stroke, was not able to communicate and had cognitive decline. R31's Care Plan, dated 11/22/23 directed staff to monitor the resident's behaviors and signs and symptoms of depression and talk about feelings and deficits. The Physician Order, dated 10/19/23, directed the staff to administer R31's Zyprexa (antipsychotic medication) 7.5 (mg) milligrams, one time a day, for a diagnosis of vascular dementia with behavioral disturbance. The Pharmacy Consult reviews on 10/31/23, 11/30/23, 12/26/23, and 01/31/24 lacked a recommendation for an appropriate indication for use. R31's clinical record lacked evidence of documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of R31's Zyprexa. On 01/31/24 at 08:00 AM, observation revealed the R31 sat at the dining room table, nicely groomed and dressed, eating breakfast, Certified Medication Aide (CMA) R administered R31's morning medications. On 02/01/24 at 10:00 AM, Administrative Nurse D verified the inappropriate diagnosis of vascular dementia with behavioral disturbances for R31's use of Zyprexa medication. Administrative Nurse D further acknowledged there were no recommendations from the pharmacist for an appropriate indication for the use of Zyprexa. The facility's Medication Regimen Reviews dated 9/2023 documented the consulting pharmacist shall review the medication regimen per state and federal guidelines. The pharmacist would report irregularities to the attending physician, the family medical director, and the director of nursing. Provision of irregularity report on a separate, written report and includes the resident's name, relevant drug, and the irregularity that has been identified. Provide a passage for follow-up on these reports. Provide the Attending Physician with access or a process to document in the resident's medical record that includes the irregularity that has been reviewed, actions if any that have been taken to address it, and rationale for no change based upon the reported irregularity. The facility's Psychotropic Drug Use policy, dated 4/2023, documented a review of the medication regimen to identify the following drug classes, noted to be psychotropic: antipsychotics, anti-depressants, anxiolytics, and hypnotics and review the medication regime for the following types of medications which may include the above, and apply appropriate clinical indications, monitoring, and documentation. CNS (Central Nervous system) systems agent mood stabilizers, anticonvulsants, muscle relaxants, anticholinergic medication, and antihistamines. The physician's order would include diagnosis, condition, or symptom for what is being ordered and dose. During the comprehensive, person-centered care planning process, the resident and/or their representative should be informed of the prescribed treatment. Gradual Dose Reductions will be conducted per CMS guidelines. Through an ongoing assessment process, monitoring should include; medication to medication and medication to food interactions, clinical conditions, properties of the medication boxed warnings, and the resident history of adverse consequences to a similar medication. The facility failed to ensure the Consultant Pharmacist identified and reported the inappropriate indication for R31's use of Zyprexa. This placed the resident at risk for unnecessary use of an antipsychotic medication.

The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R)31. This deficient practice placed the resident at risk for unnecessary psychotropic medication and related complications. Findings included: - R31's Physician Order Sheet (POS), documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbance, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain.) R31's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had short- and long-term memory loss. The MDS recorded the resident was dependent on bed mobility, locomotion on the unit, dressing, and personal hygiene. The MDS documented R13 received an antipsychotic medication during the lookback period. R31's Care Area Assessment, dated 05/14/23 recorded the resident had a stroke, was not able to communicate and had cognitive decline. R31's Care Plan, dated 11/22/23 directed staff to monitor the resident's behaviors and signs and symptoms of depression and talk about feelings and deficits. The Physician Order, dated 10/19/23, directed the staff to administer R31's Zyprexa (antipsychotic medication) 7.5 (mg) milligrams, one time a day, for a diagnosis of vascular dementia with behavioral disturbance. The Pharmacy Consult reviews on 10/31/23, 11/30/23, 12/26/23, and 01/31/24 lacked a recommendation for an appropriate indication for use. R31's clinical record lacked evidence of documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of R31's Zyprexa. On 01/31/24 at 08:00 AM, observation revealed the R31 sat at the dining room table, nicely groomed and dressed, eating breakfast, Certified Medication Aide (CMA) R administered R31's morning medications. On 02/01/24 at 10:00 AM, Administrative Nurse D verified the inappropriate diagnosis of vascular dementia with behavioral disturbance for R31's use of the Zyprexa medications. The facility's Psychotropic Drug Use policy, dated 4/2023, documented a review of the medication regimen to identify the following drug classes, noted to be psychotropic: antipsychotics, anti-depressants, anxiolytics, and hypnotics and review the medication regime for the following types of medications which may include the above, and apply appropriate clinical indications, monitoring, and documentation. The physician's order would include diagnosis, condition, or symptom for what is being ordered and dose. During the comprehensive, person-centered care planning process, the resident and/or their representative should be informed of the prescribed treatment. Gradual Dose Reductions will be conducted per CMS guidelines. Through an ongoing assessment process, monitoring should include; medication to medication and medication to food interactions, clinical conditions, properties of the medication boxed warnings, and the resident history of adverse consequences to a similar medication. The facility failed to ensure an appropriate indication or the required documentation for the use of R31's Zyprexa placing the resident at risk for adverse side effects.

The facility identified a census of 39 residents with three reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure staff immediately reported witnessed abuse. On 10/26/22 between 10:00 PM and 11:00 PM, Certified Nurse Aide (CNA) M, CNA N, and CNA Q repositioned cognitively impaired Resident (R) 1. R1 swatted at CNA M. CNA Q then slapped R1's hand and told him no. CNA M witnessed CNA Q slap R1, but did not report to the charge nurse or facility administrative staff. Later in her shift, CNA M texted the information to CNA P. CNA P identified the incident as reportable and encouraged CNA M to report the incident, however CNA P then delayed reporting the abuse until 02:30 PM on 10/27/22. CNA M and CNA P failed to immediately report the abuse to Administrative Staff A until approximately 16 hours after the event. Due to the failure to report, CNA Q worked the remainder of her shift, until 06:00 AM on 10/27/22, which placed R1, and the 38 other residents CNA Q had access to, in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), psychotic disturbance (major mental disorder characterized by a gross impairment in reality testing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 was rarely/never understood and had severely impaired cognitive functioning. The MDS further documented R1 required extensive assistance of two plus staff for bed mobility, transfer, locomotion on unit, dressing, toileting, personal hygiene, and bathing. R1's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/09/22, documented R1 had cognitive loss related to dementia, had exhibited physical behavioral symptoms directed towards others, and had rejected care. R1's Activity of Daily Living (ADL) CAA, dated 04/09/22, documented R1 had an ADL deficit related to dementia, weakness, and immobility. R1's Behavioral Symptom CAA, dated 04/09/22, documented R1 had exhibited behaviors directed towards others, was resistive to care, had sensory impairments, and a diagnosis of dementia. R1's Care Plan, dated 04/13/22, lacked any interventions related to R1's dementia or behavioral symptoms. The Nurse's Note, dated 10/27/22 at 04:21 PM, documented staff completed a head-to-toe assessment of R1. R1 had a skin tear on his right hand by his thumb; no bruising or redness was noted anywhere else on R1's body. The Facility Investigation, signed on 11/01/22, documented a discussion was held between CNA M and CNA P on 10/27/22 at approximately 05:27 AM that brought up CNA M witnessed CNA Q slap R1 on the hand. CNA P then reported the incident to Administrative Staff A on 10/27/22 at approximately 02:30 PM. The investigation noted that during the course of the investigation CNA N, and CNA Q repositioned cognitively impaired Resident (R) 1. R1 swatted at CNA M. CNA Q then slapped R1's hand and told him no. The Witness Statement, dated 10/27/22, documented by CNA Q stated she went to work on 10/26/22 at 10:00 PM. CNA Q stated in the witness statement there were four CNA's in R1's room checking and changing and repositioning R1. R1 was clinging to the arms of his chair. The CNAs were able to get R1 to release the arms of his chair and reposition R1 in his chair. CNA Q then placed a sheet over R1 and left the room. The Witness Statement, dated 10/27/22, documented by CNA M stated she and two other CNAs were in R1's room to change him for bed when CNA Q walked in to help. After assisting R1 into his chair, R1 slapped CNA M's hand and then CNA Q slapped R1's hand and told him no. On 11/07/22 at 10:00 AM, R1 sat in the living room of the facility in his wheelchair. R1 stared blankly at the television. R1 was unable to respond to any questions or conversation. On 11/07/22 at 11:00 AM, CNA P stated at 05:17 AM on 10/27/22 CNA M texted her regarding CNA Q slapping R1's hand during cares. CNA P stated that she told CNA M she needed to report the incident to Administrative Staff A and CNA M stated she would report it. CNA P stated when she came to work at approximately 02:30 PM she went and talked to Administrative Staff A about the incident and Administrative Staff A was unaware of the incident. CNA P stated she did not report the incident earlier because she thought CNA M was going to report it. On 11/07/22 at 02:28 PM, CNA M stated she provided cares to R1 with the assistance of CNA N and CNA Q. CNA M stated she was on R1's left side and CNA Q was in front of R1. CNA M stated R1 swatted at her hand and then CNA Q slapped R1's hand and told R1 no. CNA M stated she was going to report the incident to the charge nurse immediately, but when she came out of R1's room there were seven call lights going off and so she just went to work. On 11/07/22 at 11:05 AM, Licensed Nurse (LN) H stated she was the charge nurse on 10/26/22 on the 10:00 PM to 06:00 AM shift. LN H stated the incident with R1 was not reported to her the entire shift. LN H stated CNA M should have reported the incident to her so she could have sent CNA Q home to protect R1 and the other residents. On 11/07/22 at 09:30 AM, Administrative Staff A stated that she was unaware of the incident happening to R1 until 10/27/22 at approximately 02:30 PM when CNA P notified her that CNA M texted CNA P about the incident. Administrative Staff A stated that she expected her staff to report the incident immediately to the charge nurse or herself, so CNA Q could have been suspended immediately, a head-to-toe assessment of R1 could have been completed immediately, and the investigation could have been started immediately. Administrative Staff A stated CNA Q was terminated from employment at the facility. The facility's Abuse Prevention Program, policy, dated August 2022, documented residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. The facility administration and employees are committed to protecting residents from abuse by anyone including, but no necessarily limited to: facility staff, other residents, consultants, volunteers, and staff agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Comprehensive policies and procedures have been developed to aid the facility administration in preventing abuse, neglect, or mistreatment. The abuse prevention program provides policies and procedures that govern, as a minimum: protocols for conducting employment background checks, mandated staff training/orientation programs that include abuse prevention, identification, reporting of abuse, and dementia management, policies to prevent and prohibit all types of abuse, identification of occurrences and patterns of potential mistreatment/abuse, protection of residents during abuse investigations, development of investigative protocols governing resident abuse, theft, misappropriation of resident property, resident-to-resident abuse, and resident-to-staff abuse, timely and thorough investigations of all reports and allegations of abuse, reporting and filing of accurate documents relative to the incidents of abuse including the reporting of crimes, ongoing review and analysis of abuse incidents and implementation of changes to prevent future occurrences of abuse. The facility failed to ensure staff immediately reported witnessed staff to resident abuse which allowed CNA Q to work the remainder of her shift, placing R1 and the 38 other residents in the facility in immediate jeopardy. On 10/27/22 the facility completed corrective actions which included staff education on the immediate reporting of abuse, a root cause analysis and review and staff education on the facility's Abuse Prevention Program policy. The deficient practice was cited as past noncompliance. The scope and severity remained at an L.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to monitor laundry temperatures to ensure proper disinfection and cleaning of soiled linens and clothing. This deficient practice placed residents at risk for infection and illness. Findings included: - On 09/21/22 at 12:00 PM, observation in the facility's laundry rooms revealed Housekeeping V checked the temperature logs for the washing machines. Washer 1 (small one used for bleaching) temperature log for August 2022 lacked documentation on 8/1, 8/9, 8/19, 8/20, 8/21, 8/30, and 8/31. Washer 3 (commercial) August 2022 temperature log lacked documentation of temperatures on 8/1, 8/9, 8/11-24, 8/30, and 8/31. The September 2022 temperature logs for Washer 3 lacked documentation from 9/1/22 to 9/9/22. On 09/21/22 at 12:10 PM, Housekeeping V verified the lack of documentation for the washing temperatures. The facility's Soiled Laundry and Bedding policy, dated 11/2017, recommended guidelines for laundry cycles were hot water 160F for 25 minutes. Low temperature washing 71-77 f plus 125 parts per million chlorine bleach rinse. The facility failed to monitor laundry temperatures to ensure proper disinfection and cleaning, placing residents at risk for infection. .

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to provide an environment reasonably free of insects. This deficient practice placed the residents of the facility at risk for irritation and potential insect borne illnesses. Findings included: - 09/20/22 at 11:20 AM, observation in the facility kitchen revealed numerous common flies on surfaces and flying round. The kitchen did not have an outside exit. On 09/20/22 at 11:50 AM the dining room where residents ate their meals also had numerous flies landing on surfaces including their beverages and persons. On 9/20/22 at 12:10 PM, observation in the dining room revealed numerous flies throughout the meal service landed the tip of a resident's sippy cup. Continued observation revealed flies landed on the tables, and on residents' food. Resident (R) 18 had a fly swatter he brought to the dining room from his room and swatted the flies when they landed on his table. R18 got up from the table without his walker to swat the flies. On 09/21/22 at 01:58 PM, observation revealed R186 laid in a recliner in the commons area covered from the top of his head with a green bedspread/blanket. R186 stated the blanket keeps the flies off me. Continued observation revealed seven to twelve flies on the blanket at any given time while the resident was covered. On 09/21/22 at 02:40 PM, Administrative Staff A stated the maintenance staff had contacted the pest control service but she did not know what was done. On 09/22/22 at 08:30 AM, Administrative Staff A stated she had contacted the building supervisor and received a different number to contact the pest control company used by the facility. She reported she called the pest control company and they stated they would send someone to the facility as soon as possible. The facility's invoice from the pest control company, dated 09/02/22, indicated the pest control had serviced the facility by checking exterior bait stations. The facility's Sanitation policy, dated 11/2017, documented all kitchens and dining rooms shall be kept clean and protected from flies and other insects. The facility failed to provide an environment reasonably clear of insects, placing the residents of the facility at risk for irritation and potential insect borne illnesses.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to store hazardous cleaning chemicals in a safe manner. This deficient practice placed the five cognitively impaired, independently mobile residents at risk for injury and/or accidents. Findings included: - On 09/20/22 at 09:05 AM, observation revealed a one-quart spray bottle of CLR mold and mildew stain remover, labeled: keep out of reach of children, avoid contact with eyes or clothing, was found under the sink in an unlocked cabinet in the family/conference room. On 09/20/22 at 09:05 AM, Administrative Staff A verified the chemical should be locked away. On 09/20/22 at 09:10 AM, observation revealed the west soiled utility room unlocked with a quart spray bottle of all-purpose cleaner labeled: flammable, wear rubber gloves, on the counter. The door did not lock even though it had a keypad lock. On 09/20/22 at 09:10 AM, Housekeeping Staff U verified the door should be locked. On 09/20/22 at 09:20 AM, observation revealed the east hall soiled utility room unlocked with a quart spray bottle of all-purpose cleaner labeled: flammable, wear rubber gloves, on the hopper. On 09/21/22 at 04:20 PM, Administrative Staff A stated the soiled utility doors should have been locked or the chemicals secured in a locked area. The facility's Storage Areas, Environmental Services policy, dated 05/2022, documented cleaning supplies should be stored as instructed on the labels of such products. The facility failed to store hazardous cleaning chemicals in a safe manner, placing the five cognitively impaired, independently mobile residents at risk for injury and accidents.

The facility had a census of 31 residents. Based on observation, record review, and interview, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Center for Disease Control and Prevention (CDC) guidance to prevent COVID-19 (a mild to severe respiratory illness) when the facility failed to isolate Resident (R) 1 after she exhibited an elevated temperature, vomiting, congestion, and tested positive for COVID 19, which exposed R1's roommate (R2) to [MEDICAL CONDITION] for three days when she later tested positive for COVID 19. The facility failed to properly educate staff on COVID-19 signs and symptoms, proper donning and doffing of Personal Protective Equipment (PPE), and when to initiate isolation. This failure led to nine residents testing positive for COVID 19 and one death related to [MEDICAL CONDITION]. This failure placed all 31 residents in the facility in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR) revealed R1 and R2 were roommates on [DATE] and continued to live in the same room until [DATE]. The Progress Note, for R1 dated [DATE] at 07:49 PM, documented R1 had [MEDICAL CONDITION] activity, large watery brown emesis (vomit), heart rate of 122 beats per minute (bpm-normal resting 60 bpm), respiratory rate of 22 breaths per minute (normal ,[DATE]), temperature of 100.3 degrees Fahrenheit (F-normal 98.2 F), and congested lung sounds. The Progress Note, for R1 dated [DATE] at 12:09 AM, documented R1's oxygen level at 87% on room air (normal - greater than 90%), oxygen started, temperature of 103.1 F, and congested lung sounds in her upper lobes. The note further documented staff notified the physician who ordered breathing treatments and an antibiotic for five days. The Progress Note, for R1 dated ,[DATE] (3 days after R1's symptoms were noted) at 09:03 AM, documented staff performed a COVDI 19 test on R1 and received a positive result. The Progress Note, for R2 dated [DATE] at 07:41 AM, documented staff performed a COVID 19 test on R2, with negative results. The Progress Note, for R2 dated [DATE] at 08:31 AM (2 days after R1 tested positive), documented staff performed a COVID 19 test on R2, positive results, and R2 relocated to dedicated COVID unit. The Progress Note, for R2 dated [DATE] at 10:31 AM, documented R2 complained of sore throat, weakness and fatigue, crackles heard in both mid to lower lungs, and right lung always had some crackles (high pitched sounds mostly heard in the lower lung bases). The note further documented the resident voiced concern that she would die from the illness. The Practitioner Note, dated [DATE] at 05:17 PM, documented on [DATE] (prior to the resident testing positive) the practitioner reviewed the resident's plan of care with R1's family member, updated him on R1's status, and ordered hospice. The note further documented R1 had two negative COVID 19 tests, however the practitioner recommended to nursing staff and the director of nursing that R1's symptoms were consistent with a COVID 19 infection and recommended full isolation with full PPE precautions to be placed in place. The Progress Note, dated [DATE] at 01:50 AM, documented R1 expired. The Progress Note, for R3 dated [DATE] at ,[DATE] PM, documented the resident tested COVID positive. The Progress Note, for R3 dated [DATE] at 02/:23 PM, documented staff notified the resident's family member, informed of resident's positive COVID test, and resident relocated to the designated unit. The Progress Note, for R4 dated [DATE] at 02:58 PM, documented the facility notified the resident's physician of the resident testing positive for COVID and that she had been moved to the COVID unit. Discussed that the resident was on hospice and the resident's family wished for her to remain on hospice. The Progress Note, for R5 dated [DATE] at 09:48 AM, documented staff called the resident's family and informed of room change due to COVID. The Progress Note, for R8 dated [DATE] at 09:15 AM, documented the resident occasionally had some nasal congestion and cough, resident tested for COVID and tested positive. Staff notified the resident's physician and moved resident to the COVID wing. The Progress Note, for R9 dated [DATE] at 11:30 AM, documented the resident tested positive for COVID and staff relocated him to the COVID unit and isolated. The Progress Note, for R10 dated [DATE] at 12:12 PM, documented the resident tested positive for COVID and staff relocated her to the COVID unit. The Progress Note, for R11 dated [DATE] at 01:01 PM, documented the resident tested positive for COVID and staff relocated her to the COVID unit. On [DATE] at 09:40 AM, observation revealed staff prepared to enter an isolation/presumptive room on 200 Hall. Staff applied an isolation gown and then retrieved a mask and shield form a brown paper sack hanging on the wall with each staff members name on it. The staff member then applied gloves, entered the room, and closed the door. Observation revealed staff exited the room, while standing next to the door, staff removed their gown, rolled it inside itself, and placed it in a trash can next to the door. Staff then removed their gloves and disposed in the trash, applied alcohol gel to their hands, came out of the room, and placed the shield and mask in the brown paper sack. Observation revealed staff again used alcohol gel to hands, returned to another sack that had previous mask and shield in it, donned those items again, used alcohol gel, and continued to their next task. On [DATE] at 03:45 PM, Certified Nurse Aide (CNA) M stated the facility had a binder with updated information related to the COVID 19 virus and staff were to read and check it when they came to work. CNA M stated staff also had computer-based training along with staff in-services, were instructed on putting on gowns, gloves, masks, face shields and goggles, and the removal sequence. CNA M stated staff were always required to wear N95 masks and face shields or goggles due to a resident testing positive. She reported staff asked the residents if they were having any breathing problems, chest tightness or pain, wheezing, or felt warm due to an increase temperature. If anything was different or a resident reported any symptoms, staff were to back out of the room, immediately notify the charge nurse, and set things up to place the resident on isolation until it was determined the resident was not experiencing COVID 19 symptoms and could be tested . On [DATE] at 09:54 AM, Licensed Nurse (LN) G reported nursing staff assessed the residents each shift for signs and symptoms of COVID 19 (shortness of breath, increased temperatures, sore throats, loss of smell and taste, cough, changes in vital signs, and decreased oxygen levels). LN G also stated R1 should have been isolated and tested when the resident had an increased temperature. On [DATE] at 11:00 AM, Administrative Nurse D, stated R1 exhibited signs of COVID 19 on [DATE] with increased temperature, [MEDICAL CONDITION] type activity, emesis, and change in lung status. R1 was not placed in isolation until [DATE] and remained in a semi-private room with a roommate until [DATE]. On [DATE] at 08:02 AM, Administrative Staff A, stated R1 and R2 remained in the same room until R1 tested positive for COVID 19 on [DATE]. Administrative Staff A stated staff suspected aspiration pneumonia as the reason for R1's increased temperature and lower oxygen level, and that was why the facility did not implement precautions. The facility's undated Plan for COVID-19 Outbreak in Facility policy, documented if a resident has any signs or symptoms a rapid [MEDICATION NAME] test will be performed. The facility's Isolation-Initiating Transmission-Based Precautions (Contact, Airborne, Droplet) policy, dated [DATE], documented when Transmission-Based Precautions are implemented, the following is recommended: Protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; Provide a private room as available or appropriate; Cohort residents with same pathogen as able; The resident shares a room with a roommate with limited risk factors (e.g.no indwelling catheters, IV lines, respiratory equipment) Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room; Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room; Place necessary equipment and supplies in the room that will be needed during the period of Transmission-Based Precautions; Be sure that an adequate supply of antiseptic soap and paper towels is maintained in the room during the isolation period; Explain to the resident (or representative) the reason(s) and education for the precautions; Use disposable non-critical equipment, that is cleaned per protocol following the discontinuance of precautions; and Provide for cleaning of surfaces per community protocol. The facility failed to follow CDC and CMS guidelines to prevent COVID-19 when R1 developed signs and symptoms, remained in a shared room, and both residents tested positive. The facility failed to properly educate staff on COVID-19 signs and symptoms, proper use of PPE, and when to initiate isolation. The facility's failure led to nine residents testing positive with one death. This placed all 31 residents in the facility in immediate jeopardy. The facility removed the immediate jeopardy on [DATE] at 11:28 AM, when the facility re-educated staff on signs and symptoms of COVID-19, testing guidelines, when to initiate isolation, proper use of PPE, and appropriate handwashing. The deficient practice remained at a scope and severity of a G.

The facility had a census of 30 residents. The sample included of 13 residents of which 1 was reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide environment free of accident hazards, for 2 of 2 cognitively impaired, independently mobile residents. The facility failed to assess for the use of assistive devices and provide an appropriate intervention for 1 of 1 sampled resident (#16), who became entrapped between a positioning pole and the bed, and the resident had a second incident of entrapment. This deficient practice placed Resident #16 in immediate jeopardy. Findings included: - Resident #16's 14 day (MDS) Minimum Data Set assessment, dated 9/26/16, revealed a (BIMS) Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The assessment revealed the resident required 2 staff assistance for bed mobility, transfers and toileting. The assessment further revealed the resident was occasionally incontinent of urine and received Physical and Occupational therapy services related to [DIAGNOSES REDACTED]. The 9/23/16 (CAA) Care Area Assessment for falls revealed the reason to proceed with the care plan was related to a history of a fall with fracture. The 9/13/16 care plan directed the staff to remind the resident to use the call light, provide assistance for toileting, bed mobility, dressing, and assistive device use of a walker and wheelchair. The 10/8/16 care plan update instructed staff to re-educate the resident frequently on the need to use his/her call light, bed control out of reach, due to the resident will put the bed in an unsafe position, and advise the resident to use call light, if the bed position needs adjustment. The care plan failed to address the resident's use of a transfer pole. Review of the medical record revealed no assessment for the safe use of a transfer device. The 10/8/16 at 4:34 PM, progress notes revealed at 3:30 PM staff found the resident in his/her room on the floor, beside the bed, with his/her left upper arm entrapped between the bed and transfer pole (a device to aide in balance and mobility, attached to the ceiling and floor). The resident was yelling for help, stated he/she had fallen, staff assisted the resident to free his/her arm caught between the bed and the transfer pole, and the resident complained of right hip pain. The note revealed the bed was not in the lowest position, even though staff had placed the bed in the lowest position 15 minutes prior to the fall. The resident stated he/she wanted to see where everybody was as the reason for the fall. The facility sent the resident to the emergency room . The 10/8/2016 at 8:32 PM, progress note indicated the resident returned from the emergency room , with no fractures or injuries, and the resident was alert and confused. The 10/9/2016 at 3:25 PM, progress note revealed at 3:00 PM (23-1/2 hours since the previous fall), staff found the resident, wrapped in blankets, hanging from the side of the bed with his/her torso entrapped between the transfer pole and the bed. The resident's feet were on the mat next to the bed. Staff members assisted the resident onto the mat, then assisted him /her into bed, then to a wheelchair, and out to the lobby area. The medical record progress note revealed the resident transferred out of the facility for mental health services from 10/10/16 and returned to the facility on [DATE]. On 11/9/2016 at 1:10 PM, observation revealed the resident, in his/her room lying in bed. Further observation revealed the bed in low position, with no mat on the floor next to bed. Continued observation revealed a transfer pole, attached vertically, from the floor to the ceiling, with approximately 6-1/2 inches of space between the mattress and the transfer pole. On 11/10/2016 at 1:00 PM, Administrative Nurse I, stated he/she investigated the unwitnessed 10/8/16 incident as a fall and the facility reported this incident to the State Agency. Administrative Nurse I stated he/she was made aware of the occurrence on 10/9/16 when the staff found the of resident wrapped in blankets and torso caught between the bed and transfer the transfer pole. Administrative Staff I, stated he/she did not consider the occurrence as a fall, or entrapment, rather the concern was related to the resident's behavior symptoms and the facility did not assess the resident for the use of the transfer pole. Upon request, the facility did not provide a policy for resident assessment for the safe use of assistive devices. The facility's 2/2014 Accidents and Incidents Policy documented, it is the policy of the facility that accidents/incidents involving resident care will be investigated and documented on the resident incident report, to enable the facility to evaluate care given to the residents, to assist in prevention of incidents, and evaluate interventions implemented in the event of an incident. An accident/incident is any usual event, occurrence, or happening which may or may not result in injury or illness to a resident. The FDA (Food and Drug Administration) Guidance To Reduce Entrapment, dated 3/10/16, stated reassessment for entrapment may be appropriate when accessory assistive devices such as a positioning pole was added or removed. The facility failed to assess the use of assistive devices and provide Resident #16, with appropriate intervention, who fell from his/her bed, became entrapped between the bed and a positioning pole, and less than 24 hours later, and had a second incident of entrapment. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy, on 11/15/16, at 8:17 PM, when it provided an in-service to all staff employed at the facility about side rails assessment and entrapment. This deficient practice remains at the scope and severity of a D. - On 11/07/2016 at 4:41 PM, observation during initial tour revealed the following: A 1/2 full container of Bio Freeze (a topical ointment used for pain relief) stored in an unlocked room used for therapy treatments. The 1/2 gallon, pump dispensing container label stated keep out of reach of children. On 11/07/2016 at 5:00 PM, Administrative Nurse I verified the container of Bio Freeze was to be stored in a locked area. The facility's 05/2012 Storage of Medication policy, stated medication and biologicals are stored safely, securely, and properly, following the manufacturer's instruction or those of the supplier. The medication supply is accessible to only licensed nursing personnel, pharmacy personnel or staff member lawfully authorized to administer medications. Potential harmful substance (such as urine test reagents tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in a locked area separate from medications. The facility failed to ensure medication (topical ointment) was stored safely, securely, properly and only accessible to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer, placing 2 cognitively impaired, independently mobile residents at risk for unsafe use of topical medication. - On 11/8/16 at 3:00 PM, observation revealed a convection oven (a cooking device that heats food by the circulation of hot air) on the counter in the dining room, plugged into an outlet, and accessible to all residents. On 11/8/16 at 4:22 PM, observation revealed a temperature of 247 degrees, inside of the convection oven, after it had been turned on for approximately 5 minutes. On 11/8/16 at 4:30 PM, observation revealed Resident #24, unsupervised, wandering around in the dining room, approximately 2 feet away from the convection oven, for approximately 10 minutes. On 11/15/16 at 4:10 PM, observation revealed the convection oven plugged into the outlet with the on/off switch in the on position and the oven could be turned on with the knobs on the front of the oven. Further observation revealed Administrative Staff B removed the convection oven from the dining room and placed it into the locked kitchen. On 11/8/16 at 3:10 PM, Administrative Staff B verified he/she was not aware the convection oven remained plugged into an electrical outlet at all times and could be turned on by a resident. Administrative Staff B verified the convection oven could be an accident hazard for the 2 cognitively impaired, independently mobile residents who reside in the facility. Administrative Staff B unplugged the convection oven and had an electrician place a switch to turn the power off to the outlet. On 11/8/16 at 4:22 PM, Dietary Staff K verified Resident #24, a cognitively impaired, independently mobile resident, would come into the dining room every day, where the convection oven was located, and wander around, unsupervised. The 7/7/15 Environmental Safety policy stated the each safety committee member would conduct a safety tour at least monthly to maintain a safe environment. The facility failed to provide an environment free of accident hazards as possible and provide adequate supervision, for the 2 cognitively impaired, independently mobile residents, who resided in the facility, placing the residents at risk for burns.

The facility had a census of 39 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to provide the necessary care and services for 3 of 14 residents. Resident #56, who received end of life care, and lacked effective pain management. Resident #22 displayed aggressive behavior when medication was unavailable as ordered by the physician, and Resident #18, who did not recieve treatment for [REDACTED]. Findings included: - Resident #56's medical record revealed the facility admitted the resident into skilled nursing on 7/6/15 and started on comfort care (supportive treatment for [REDACTED]. The (POS) physicians order sheet, dated 7/7/15, revealed the resident had [DIAGNOSES REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 7/13/15, indicated the resident had long and short term memory problems with moderately impaired decision making skills. The assessment revealed the resident required extensive assistance of 2 staff members for dressing, toileting, transfers, bed mobility, and personal hygiene. The assessment further revealed the resident had an infection of the foot, a venous ulcer, no scheduled pain medication, and no as needed pain medication offered. The 7/6/15 initial care plan directed the staff to reposition, and to administer pain medication to the resident. The care plan further directed the staff to evaluate the need for routine scheduled pain medication rather than as needed pain medication and to notify the physician if the pain medication was not effective. The care plan directed the staff to administer pain medication 20 minutes prior to daily wound treatments. The 7/6/15 physician's orders [REDACTED]. Review of the medical record revealed the staff administered, the as needed [MEDICATION NAME] on 7/7, 7/14, 7/15/15 for pain (3 times in 9 days). The medical record revealed no other documentation the staff administered pain medication to the resident. The 7/7/15 physician's orders [REDACTED]. Review of the medical record lacked documentation of an initial pain assessment completed nor pain assessments completed on dayshift on 7/11/15, evening shift 7/9/15, and night shift on 7/8, and 7/12/15. The 7/7/15 physician's orders [REDACTED]. Review of the medical record revealed the resident received Tylenol one time on 7/16/15 at 4:21 PM(13 hours after staff administered the last pain medication). The 7/10/15 physician's orders [REDACTED]. The 7/13/15 at 3:28 PM, nurse's note stated the resident's left lower calf, shin and foot, black and cold and the skin on top of the second toe pulled away with fluid draining from the area. The 7/13/15 at 9:55 PM, nurse's note stated the resident's toes were cleansed with salt water, rebandaged and had a very malodorous (offensive) odor. The 7/14/15 at 1:55 PM, nurse's note stated the physician assessed the resident and contacted the family regarding the gangrene and the changes that would occur with that disease process. The note further stated the family wanted comfort measures only and did not want amputation for the left leg. The 7/15/15 physician's orders [REDACTED]. Review of the medical record revealed the staff administered the [MEDICATION NAME] medication on the following days: 7/17/15- 2 doses 7/18/15- 2 doses 7/19/15- 1 dose 7/20/15- 2 doses 7/21/15- 1 dose. The 7/16/15 at 7:01 PM, nurse's note stated the resident had a lot of pain and the staff were extra gentle with repositioning the resident. The 7/20/15 at 3:07 PM, nurse's note stated the resident would not speak but when asked about pain, he/she moved his/her mouth as if trying to say yes. The note further stated the resident was restless and moaned when moved. The note stated the resident's foot and lower leg, up to his/her knee, was black and the skin peeled off when the staff removed the dressings. The note further stated the leg had a foul odor with serosanguineous (containing or consisting of both blood and serous fluid) drainage. On 7/21/15 at 8:49 AM, observation revealed the resident lying in bed, restless and moving around. On 7/21/15 at 9:56 AM, observation revealed Licensed Nurse B and Nurse Aide C with gown, gloves and masks on, entered the resident's room to change the dressing on his/her left leg. Licensed Nurse B removed the dressings from the resident's left leg and revealed the resident's left leg was black from the knee to the end of the toes. Further observation revealed the resident had 4 x 4 gauze pads on his/her left foot with a brownish colored liquid soaked through one of the pads. When Nurse B removed the gauze pads the skin on the residents left foot also came off with the gauze pads. Nurse Aide C raised the resident's left leg and the resident moaned, then hollered in pain. Licensed Nurse B stated he/she needed to get the resident some pain medication. Licensed Nurse B washed off the resident's left foot with wound cleanser and placed 4 clean 4 x 4 gauze pads on the resident's left foot. Licensed Nurse B rewrapped the left foot up the knee with Kling (non-sterile is an absorbent gauze) dressing and laid his/her leg on the bed causing the resident to holler in pain. Review of the (MAR) Medication Administration Record [REDACTED]. On 7/21/15 at 1:51 PM, Licensed Nurse B stated he/she had administered as needed pain medication to the resident at 10:00 AM, that morning, but had not charted he/she had done so and would chart at the end of the shift. (Although the dressing change was observed at 9:56 AM, and the care plan directed the staff to administer pain medication 20 minutes prior to treatment) On 7/21/15 at 2:50 PM, Licensed Nurse E stated he/she was the only one that ever gave the resident pain medication, usually when the resident moved his right leg around and would get restless. Licensed Nurse E stated he/she had not tried to get the resident scheduled pain medication and would call the physician. On 7/21/15 at 3:15 PM, Nurse Aide F stated the resident became restless, moving his/her right leg around, when he/she was in pain. Nurse Aide F stated the nurses are to give pain medication when the resident was in pain. On 7/21/15 at 4:00 PM, observation revealed the resident lying in bed with the head of the bed elevated approximately 30 degrees, restless, moving his/her right leg around, but not moving his/her left leg. On 7/22/15 at 9:22 AM, Administrative Nurse A stated staff should administer pain medication more often because the resident frequently displayed nonverbal, signs of pain and was frequently restless. Administrative Nurse A verified the nurses should document at the time they administered the pain medication and not at the end of the shift. On 7/22/15 at 10:00 AM, Nurse Aide C stated the nurse usually gave the resident pain medication prior to the dressing change on the resident. Nurse Aide C verified the nurse had stated he/she needed to give the resident pain medication during the dressing change the previous day, when the resident verbalized signs of pain. The 2014 facility Pain Assessment and Management Policy stated the staff will assess the resident's pain upon admission, quarterly, and as needed based on their exhibiting symptoms of pain or upon report of new onset of pain. The policy further stated documentation relative to pain management may be reflected in the electronic MAR, the care plan, the MDS, and the progress notes. The facility failed to provide effective pain management and administer pain medication, in a timely manner, to Resident #56, who was on end of life care and exhibited pain. - Resident #22's (POS) physician's orders [REDACTED]. The admission (MDS) Minimum Data Set Assessment, dated 6/11/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition. The assessment revealed the resident required extensive assistance of 2 staff members for toileting, bed mobility, transfers, locomotion on the unit, and 1 staff member assistance for personal hygiene, dressing, and locomotion off the unit. The assessment further revealed the resident had verbal and physical behaviors towards others, interferes with cares, puts others at risk for injury, and the resident had a change in behaviors. The 6/11/15 (CAA) Care Area Assessment for behavior stated the resident had behaviors of grabbing staff and not letting go, throwing food trays, tearing up items, and uncooperative with cares. The 6/12/15 care plan directed the staff to provide medications, as ordered by the physician, and evaluate for effectiveness. The care plan directed the staff to observe for changes in level of conscienceless, restlessness, confusion, and anxiety. The care plan stated the resident had a poor response to others, and the environment, and directed the staff to help the resident to stay focused and to involve the resident in memory magic activities to promote recall and discussion. The care plan directed the staff to help the resident participate in his/her favorite activities. The 6/1/15 physician's orders [REDACTED]. Review of the June 2015 (MAR) Medication Administration Record [REDACTED]. The 6/9/15 at 11:22 AM, nurse's note stated the resident spilled his/her water on the bed and shoved his/her breakfast plate to the floor. The 6/9/15 at 6:02 PM, nurse's note stated the physician ordered the staff to administer [MEDICATION NAME], 1(mg) milligram/0.5 (ml) milliliter, (IM) intramuscularly, 1 time dose because the resident was physically abusive to staff and had attempted to be abusive to residents. The 6/10/15 at 9:32 AM, nurse's note stated the resident took his/her bedside table into the hall and slammed it into the wall and into the copy/fax machine. The note further stated the staff tried to redirect the resident and he/she became physically and verbally abusive towards the staff. The note stated (EMS) Emergancy Medical Service transported the resident to the local hospital emergency room with the additional assistance of 2 police officers. The note stated the staff notified resident's DPOA of the resident's transfer. The 6/10/15 at 8:15 PM, nurse's note stated the resident returned from the local hospital, requiring 3 attendants to assist the staff with the resident. The note stated 1 attendant tried to hold the resident's legs and the other attendant tried to hold his/her arms to transfer the resident into bed. The 6/11/15 at 12:00 AM, physician's orders [REDACTED]. (an increase in dose) The 6/11/15 at 12:35 AM, nurse's note stated the resident was yelling loudly and ripped his/her bed apart, and threw his/her pillow to the floor. The note stated the resident started pulling the mattress apart from the liner. The resident took his/her mattress off of the bed frame, grabbed the bed frame and tried to throw it. The note stated the resident tried to grab the staff by the legs when they walked by. The note further stated the resident grabbed a drawer from his/her chest of drawers and threw it onto the floor. The staff attempted to redirect the resident without success. The 6/11/15 at 1:40 PM, physician's orders [REDACTED]. The [MEDICATION NAME] was given on 6/11, 6/12, and 6/13/15 and discontinued on 6/13/15. On 6/11/15 at 8:45 pm, nurse's note stated the resident's [MEDICATION NAME] 2 mg was unavailable from the dispensary at this time. The 6/12/15 at 3:59 PM, nurse's note stated the resident only received 1mg of [MEDICATION NAME] due to the order was not updated with the pharmacy. (Review of the medical record revealed the resident was to receive [MEDICATION NAME] 2mg) The 6/13/15 at 4:00 AM, nurse's note stated the resident's [MEDICATION NAME], 2mg, was not available. The 6/13/15 at 9:05 AM, directed the staff to administer [MEDICATION NAME], 2mg, 2 tablets, by mouth, every 6 hours. (an increase in dose) The 6/13/14 untimed, physician's orders [REDACTED]. The 6/14/15 at 3:08 PM, a late entry nurse's note stated the resident had been aggressive with staff, grabbing a staff member's wrist causing it to turn blue. The note further stated the resident would raise his/her recliner in the stand-up position and attempted to transfer out of the chair independently. The note further stated the resident continued to do this throughout the shift and attempted to kick at the nurse. The note stated staff offered toileting and transfer into his/her wheelchair, the resident refused at first and then changed his/her mind. The note further stated the nurse assisted the resident to stand and as they crossed the room, the resident attempted to grab a bundle of papers out of the nurse's hand. The note stated, the nurse was trying to assist the resident to sit in the wheelchair, the resident stepped behind the wheelchair and tried to ram the nurse with the chair. The staff contacted the (EMS) emergency medical service to transfer the resident to the hospital due to aggressive behavior and a risk to him/herself and others. The nurse administered [MEDICATION NAME], 0.5ml, intramuscularly, before the resident left the facility and transferred to an out of town hospital. On 7/22/15 at 9:22 AM, Administrative Nurse A stated the resident was very intelligent but could be manipulative to staff. Administrative Staff A stated the resident would be pleasant and cooperative, and then his/her mood would change, and he/she became a danger to residents and staff. On 7/22/15 at 10:01 AM, Nurse Aide P stated the resident had grabbed his/her wrist and he/she had to get assistance from the activity director to get the resident to let go. Nurse Aide P further stated the resident had tried to run into him/her with his/her wheelchair causing Nurse Aide P to fall into the wall. On 7/22/15 at 2:15 PM, Social Service Staff J stated the resident started having behaviors right after he/she was admitted and he/she attempted to discuss the behaviors with the resident's DPOAs a couple times. The resident was only at the facility for a short time before he/she was discharged . On 7/23/15 at 9:25 AM, Licensed Nurse N stated the resident was pleasant when he/she was first admitted but he/she started throwing plates, his/her bed side table, ripping up the mattress, and the resident became a danger to staff and residents. Licensed Nurse N stated he/she was the nurse for the resident when he/she was discharged to the hospital on [DATE], and stated the physician had given the facility orders to discharge the resident if he/she became violent. The 2/12/15 Facility's Behavior Management Guideline was developed to optimize the functional abilities of residents while monitoring for adverse side effects and improved behaviors. The guidelines stated a monitoring system is established for targeted behaviors, interventions, and medication effectiveness and side effects. The guidelines stated a care plan is developed for residents exhibiting negative behaviors. The facility failed to provide the appropriate [MEDICATION NAME] dosage to Resident #22 after a physician order [REDACTED]. - Resident #18's annual (MDS) Minimum Data Set assessment, dated 4/27/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 8. (moderately impaired cognition). The assessment revealed the resident required extensive assistance of 2 staff members for bed mobility, dressing, toileting, and assistance of 1 staff member for locomotion on and off the unit. The assessment further revealed the resident used a wheelchair for mobility. The 4/27/15 (CAA) Care Area Assessment for falls stated the resident was able to propel him/herself in the wheelchair. The 4/27/15 care plan stated the resident had decreased safety awareness and directed the staff to keep the environment free of clutter, and to complete skin assessments per facility policy. The 7/16/15 updated care plan directed the staff to assist the resident closer to the middle of the hall when he/she was close to the wall, handrails or doorways. The 7/15/15 at 1:20 PM, nurse's note stated the resident's right finger was red, swollen, and looked like it may have been caught in something. The note further stated the staff placed the resident in his/her recliner with an ice pack wrapped in a towel and placed on the resident's hand. Review of the medical record revealed an undated fax sent to the physician stating the resident's hand got caught in a door and smashed his/her right ring finger which resulted in swelling and bruising of the finger. The 7/17/15 physician's orders [REDACTED]. (The medical record lacked documentation of monitoring or providing an ice pack to the resident after 7/15/15.) On 7/16/15 at 7:43 AM, observation revealed the resident seated in the dining room, eating breakfast, telling Nurse Aide L his/her finger hurts real bad and Nurse Aide L stated, that looks like it really hurts. Further observation revealed the resident telling Nurse Aide L not to touch his/her finger. Review of the medical record revealed the resident had not received any pain medication for his/her sore finger. On 7/20/15 at 3:15 AM, observation revealed the resident's right ring finger, swollen and light purple and the resident stated,Don't squeeze my hand, it hurts. On 7/21/15 at 9:08 AM, Nurse Aide C stated he/she was unsure what happened to the resident's finger and had reported this to the nurse when he/she first saw it was red. On 7/21/15 at 9:21 AM, Licensed Nurse I stated the resident's first three fingers on his/her right hand were red and staff placed an ice pack on his/her hand. Licensed Nurse I stated, he/she had not initiated an investigation because he/she was unsure of how to start the process and the staff that had been on duty had left for the day. Licensed Nurse I further stated the resident's ring finger was now swollen and purple but he/she had not had a chance to do anything about it. On 7/22/15 at 9:22 AM, Administrative Nurse A stated the nurse on the shift should have given the resident pain medication when the resident complained of pain. The 2014 facility Pain Assessment and Management Policy stated the staff will assess the resident's pain upon admission, quarterly, and as needed based on their exhibiting symptoms of pain or upon report of new onset of pain. The policy further stated documentation relative to pain management may be reflected in the electronic MAR, the care plan, the MDS, and the progress notes. The facility failed to provide effective pain management and administer pain medication, for cognitively impaired Resident #18's,who complained of pain associated with a swollen and bruised finger.

The facility had a census of 32 residents. The sample included 5 residents with 4 reviewed for hydration. Based on observation, record review and interview, the facility failed to provide adequate fluids and monitor hydration status for 1 of 4 sampled residents, who was cognitively impaired, dependent on staff, a history of dehydration, who had elevated sodium level and a [DIAGNOSES REDACTED]. (#1) Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 2/17/15, indicated the resident had long term and short term memory problems with severely impaired decision making skills. The assessment revealed the resident required extensive assistance of 2 staff members for transfers, dressing, toileting, personal hygiene and extensive assistance of 1 staff member for bed mobility and eating. The assessment further revealed the resident received a mechanically altered diet and was not dehydrated. The 5 day Medicare (MDS) Minimum Data Set assessment, dated 2/10/15, indicated the resident had long term and short term memory problem with severely impaired decision making skills. The assessment revealed the resident required extensive assistance of 2 staff members for bed mobility, transfers, dressing, toileting, personal hygiene and extensive assistance of 1 staff member for eating. The assessment further revealed the resident received a mechanically altered diet and was not dehydrated. The 3/19/15 care plan stated the resident had a potential for inadequate oral food/beverage intake due to less required, swallowing problems, difficulty with self-feeding, and weight loss. The care plan directed the staff to assess and report signs and symptoms of dehydration, provide Ensure (a supplement) with protein powder twice a day, nectar thickened liquids, additional fluids at medication pass or other times such as between meals. The care plan stated the resident's ability to feed his/herself varied, and to provide assistance when needed. The 5/2/14 physician's orders [REDACTED]. Review of the April 2015 (MAR) Medication Administration Record [REDACTED]. The 2/6/15 and 4/16/15 (RD) Registered Dietician's nutritional assessment, indicated the resident's estimated daily fluid needs of 1322-1543 (cc) cubic centimeters. The assessment further indicated interventions for the staff to assist in the resident receiving the daily fluid needs. The facility's intake and output charting in the Kiosk (computer documentation) revealed the nurse aides document the fluid intake by mouth, not including supplements, in cc's every shift. Review of the facility's intake and output report for April 1-20 revealed the following total daily fluid intake: 4/1/15- 900 cc 4/2/15- 300 cc 4/3/15- 840 cc 4/4/15- 440 cc 4/5/15- 870 cc 4/6/15-780 cc 4/7/15- 520 cc 4/8/15- 660 cc 4/9/15- 1100 cc 4/10/15- 920 cc 4/11/15- 1160 cc 4/12/15- 460 cc 4/13/15- 840 cc 4/14/15- 750 cc 4/15/15- 230 cc 4/16/15- 720 cc 4/17/15- 1020 cc 4/18/15- 360 cc 4/19/15- 240 cc 4/20/15- 50 cc The April 2015 (MAR) Medication Administration Record [REDACTED]. Further review of the medical record indicated for the months of February and March 2015, the resident's lowest daily fluid intake was 240 cc and the highest daily intake was 1100 cc. which is less than the 1322-2543 cc per day of fluid to meet his/her needs. The 4/20/15 at 12:10 PM, physician's orders [REDACTED]. The 4/20/15 laboratory report revealed the resident had a sodium level of 175 which was a critical level, normal sodium level was 135-145. The 4/20/15 untimed, physician's orders [REDACTED]. The 4/18/15 at 10:35 AM, nurse's note stated the resident let fluids run out of his/her mouth and did not want to swallow his/her drink. The 4/19/15 at 9:19 PM, nurse's note stated the resident had not eaten or drank well since last Tuesday. The note further stated the resident drank 100 cc of his/her supplement and approximately 60 cc of his her thickened water. The 4/21/15 at 3:06 AM, nurse's note stated, on 4/20/15 at 6:45 PM, staff started the IV in the resident's left forearm and elevated on a pillow. The note further stated the IV infiltrated (an accumulation of fluids in the tissue surrounding the IV site) and the resident's arm was swollen. The note stated staff attempted to restart the IV in two other areas and was unsuccessful. The 4/21/15 at 9:31 AM, nurse's note stated the physician suggested a PICC line (a form of intravenous access that can be used for a prolonged period of time) but the family declined and wanted the IV restarted by the facility. The 4/21/15 at 12:33 PM, nurse's noted stated staff restarted the IV. On 4/15/15 at 9:36 AM, observation revealed the resident sat in a wheelchair in his/her room, with his/her head down and eyes closed. Further observation revealed no fluids were available in his/her room. Continued observation revealed Nurse Aide G came into the resident's room and proceeded to propel him/her down the hall into the commons area. Nurse Aide G and Nurse Aide H assisted the resident into a recliner, covered the resident with a blanket, and did not offer fluids to the resident. On 4/15/15 at 12:30 PM, observation revealed the resident, sat in the dining room, and staff assisted him/her with the noon meal. Further observation revealed the resident did not have any liquids in front of him/her at the table. Continued observation revealed, at 12:45 PM, Nurse Aide B went to the kitchen door and asked the dietary staff for a drink for the resident and stated the resident was almost finished with his/her meal. The dietary staff brought a 240 cc glass of thickened juice to the table and the staff did not offer a drink to the resident for 10 minutes. Nurse Aide B took the glass and placed it to the resident's lips and the liquid fell out of the resident's mouth onto the clothing protector. Nurse Aide B asked another nurse aide what he/she should do. Nurse Aide C told Nurse Aide B to give the juice to him/her with a spoon. Nurse Aide B gave the resident a spoonful of thickened juice that the resident did not swallow, as it all dribbled out of his/her mouth. On 4/20/15 at 12:05 PM, observation revealed the resident lying on the bed. Further observation revealed on the resident's bedside table, an eaten food tray with 2 - 240 cc glasses full of juice, and 1 - 240 cc glass full of milk. Continued observation revealed after approximately 30 minutes, the resident unable to independently drink the fluids, staff took the meal tray out of the resident ' s room. On 4/20/15 at 5:01 PM, observation revealed the resident lying in his /her bed and a 240 cc glass of thickened liquid with saran wrap over the top of it. Further observation revealed the resident had not drank any of the fluid prior to this surveyor leaving the facility for the evening at 6:00 PM. On 4/21/15 at 8:25 AM, observation revealed the resident lying in his/her bed, and an uneaten room tray, ½ glass of thickened water with a toothette in it, a glass full of thickened juice, and an small opened uneaten Jell-O cup. On 4/21/15 at 11:00 AM, observation revealed the resident lying in his/her bed, and a full glass of thickened juice on the bedside table. Further observation revealed the same glass of thickened juice on the bed side table with a toothette (oral swabs used to clean and refresh the mouth and oral cavity) in the juice at 12:30 PM. On 4/21/15 at 1:40 PM, observation revealed the resident laying in his/her bed, and a toothette in a 240 cc glass of thickened juice. Further observation revealed at 3:00 PM, the resident had not consumed any of the thickened juice. On 4/15/15 at 1:00 PM, Nurse Aide B stated the resident received fluids in his/her room twice a day but do not document how much he/she drank, only the fluids at meals are documented in a computer program. Nurse Aide B further stated the resident usually drank well but was not him/herself today. On 4/20/15 at 5:02 PM, Licensed Nurse D stated the resident did not want to drink any fluids and provided fluids by swabbing his/her mouth with a toothette often. Licensed Nurse D stated the lab called and stated the resident had a sodium level of 175 which indicated dehydration and stated " that's what happens when you don't drink much for 2 days ". Nurse C further stated he/she was waiting for any orders from the physician. On 4/21/15 at 9:00 AM, Physician E stated the resident was dehydrated, and not responding well to the IV fluids. Physician E further stated he/she was unsure why the resident was dehydrated as the resident was not vomiting or having any diarrhea. On 4/21/15 at 4:15 PM, Administrative Nurse A stated the staff should be given fluids at meals, and offered a drink during cares. Administrative Nurse A further stated the staff should document the fluid intake in the kiosks at the end of their shift and refusal of the fluids can also be documented in the kiosk. On 4/23/15 at 11:50 AM, Registered Dietician L stated the resident's daily fluid needs are 1322-1543 cc per day and interventions for the staff to assist with the resident receiving the recommended daily fluid needs are to offer him/her 480 cc at meals, and 120 cc three times a day of fluid. Registered Dietician L further stated the staff can offer the resident the fluids and the resident can refuse them. Registered Dietician L stated he/she did not look at the Intake and Output documentation of the resident and was unaware of the amount of daily fluid the resident consumed. The 2/3/15 facility policy for hydration stated the dietician calculates daily fluid requirements for all patients annually or with changes in condition. The policy further stated the risk factors for dehydration were functional impairments making it difficult to drink, reach for fluids or communicates fluid needs; thickened liquids, dementia residents, and refusal of fluids. The facility failed to provide adequate fluids and monitoring for this cognitively impaired dependent resident who became dehydrated.