Every finding on record at Wind River Rehabilitation and Wellness

Based on medical record review and staff interview, the facility failed to ensure catheter care was provided according to physician orders for 1 of 3 sample residents (#3) reviewed. The findings were:1. Review of the 2/4/26 quarterly MDS assessment showed resident #3 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment, and had diagnoses which included bladder obstruction, renal insufficiency, heart failure, diabetes mellitus, non- Alzheimer's dementia and history of a cerebrovascular accident. Review of the physician's orders showed the resident had an order dated 10/20/25 to change the foley catheter every 28 days. The following concerns were identified:a. Review of a nursing note attached to the foley catheter orders dated 2/14/26 and timed 4:10 PM showed .Unable to get to before resident was up and.will not allow staff to lay [him/her] back down. Will attempt in AM. Review of a progress note dated 2/15/26 and timed 12:30 PM showed the note was created on 5/21/26 at 12:33 PM. Further review showed .Reattempt to change foley this AM was unsuccessful. There was no evidence the staff had reattempted to change the urinary catheter or evidence the foley catheter was changed in the month of February.b. Review of a nursing note dated 3/14/26 and timed 3:26 PM showed the note was created on 5/21/26 at 12:28 PM. Further review showed .Resident refused foley change this shift despite multiple attempts and education. There was no evidence the staff had reattempted to change the urinary catheter or evidence the catheter was changed in the month of March. c. Review of medical record showed no evidence the urinary catheter had been changed in April prior to the resident's discharge from the facility on 4/11/26. 2. Interview with the MDS coordinator on 5/21/26 at 1:03 PM confirmed the urinary catheter had not been changed between February and April. 3. Interview with the DON on 5/21/26 at 1:20 PM revealed staff were expected to follow physician orders and change urinary catheters monthly. 4. Interview with the DON on 5/21/26 at 1:28 PM revealed the facility had no policy regarding the frequency of urinary catheter changes.

Based on medical record review and staff interview, the facility failed to ensure laboratory reports were in the residents medical record for 1 of 3 sample residents (#3) reviewed. The census was 56. The findings were:1. Review of the 2/4/26 quarterly MDS assessment showed resident #3 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment and had diagnoses which included bladder obstruction, renal insufficiency, heart failure, diabetes mellitus, non- Alzheimer's dementia and history of a cerebrovascular accident. Further review of the resident's medical record showed the presence of an indwelling urinary catheter (foley) and chronic urinary tract infections (UTI). Review of the physician's orders showed the resident had an order dated 3/17/26 to obtain a urinalysis following behavioral and cognitive changes as well as a history of chronic UTI's. The following concerns were identified: a. Review of the medical record showed a urinalysis was collected on 3/19/26; however, there was no evidence of the facility received or followed up on the results of the urinalysis. b. Interview with the DON on 5/21/26 at 11:30 AM confirmed there was no evidence of the urinalysis result in the resident's chart. The DON revealed there was no indication the urinalysis had been tested at the laboratory. Further interview revealed the facility had not attempted to obtain the results or follow-up on the results of the urinalysis.

Based on medical record review, staff interview, facility medication error report review, and in-service education review, the facility failed to ensure medications were available for 1 of 4 sample residents reviewed for medication administration. Corrective measures were implemented prior to the survey and compliance was determined to be met on 1/21/26. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a brief interview for mental status score of 13 out 15, which indicated the resident was cognitively intact, and had diagnoses which included paraplegia, cervicalgia, spina bifida, and morbid obesity. Further review showed the resident received insulin injections on 1 day during the 7-day look-back period. Review of the physician orders showed the resident was ordered alendronate sodium (bisphophonate) 70 milligrams (MG) per 75 milliliters (ML) by mouth one time per day every seven days for osteoporosis and Zepbound (tirzeptide) 5 MG per 0.5 ML inject 7.5 ML subcutaneously on time per day every Monday related to morbid obesity. The following concerns were identified:a. Review of the resident's medication administration record (MAR) for August 2025 showed the alendronate sodium was not administered on 2 out 3 opportunities for administration and was marked on order from pharmacy on 8/15/25 and 8/22/25.b. Review of the resident's MAR for September 2025 showed the alendronate sodium was not administered on 2 of 4 opportunities for administration and was marked on order from pharmacy on 9/5/25 and 9/26/25. c. Review of the resident's MAR for October 2025 showed the alendronate sodium was not administered on 4 of 5 opportunities for administration and was marked on order from pharmacy on 10/3/25, 10/10/25, 10/17/25, and 10/24/25.d. Review of the resident's MAR for November 2025 showed alendronate sodium was not administered on 4 of 4 opportunities for administration and was marked on order from pharmacy on 11/7/25, 11/14/25, 11/21/25, and 11/28/25. e. Review of the resident's MAR for December 2025 showed alendronate sodium was not administered on 3 of 4 opportunities for administration and was marked on order from pharmacy on 12/5/25, 12/12/25, and 12/19/25. Further review showed the Zepbound was to be administered at a dose of 2.5 mg until 12/1/25, with a start date of 11/9/25. An order for Zepbound 5 mg was ordered from 12/22/25 to the discontinue date of 1/5/26. There was no evidence of an order for Zepbound or administration from 12/1/25 through 12/22/25.f. Review of the resident's MAR for January 2026 showed alendronate sodium was not administered on 4 of 5 opportunities for administration and was marked on order from pharmacy on 1/9/26, 1/16/26, and 1/30/26 and was marked other/see progress notes on 1/23/26. g. Review of a physician's consult dated 12/13/25 showed . Apparently [resident #4] ran out of tirzeptide and one called for a refill, will refill today, reviewed w/ [with] nursing and DON that they need to call our clinics for refills . tolerated the 2.5 mg dose of tirzeptide. SNF [skilled nursing facility] hasn't picked up the alendronate yet, need to do this, reviewed w/ [with] nursing and DON . reviewed with SNF staff need to pick up the alendronate and tirzeptide from [address], do not let [him/her] run out as lapses in tirzeptide can lead to worse side effects .h. Interview with the resident's physician on 2/4/26 at 10:30 AM revealed he had issues with medications not being available and the facility did not notify him, or the facility did not pick up the medications from the pharmacy. The physician revealed he has communicated with the facility and let them know when medications were ordered, they would be available for pick-up between 24 and 48 hours after they were ordered. Further interview revealed if the medications were not available, he was told the facility could get them from a local pharmacy.i. Interview with the administrator on 2/5/26 at 2:01 PM revealed the facility had identified the alendronate and tirzeptide medication errors on 1/20/26 and performed an audit back 30 days. Further interview revealed a performance improvement plan was implemented.j. Review of an Inservice Education Summary dated 1/21/26 showed the training content was If medication is not received from pharmacy, floor nurse is to contact pharmacy and inquire information regarding medication not being delivered and then notify MD regarding missed dosage of medication. Then document notification in PCC [point click care]. 2. Review of the facility's plan of correction dated 1/21/26 showed the following interventions were implemented as a result of the incident:a. A Medication Error/Adverse Drug Reaction Report was completed on 1/21/26 for resident #4's missed Zepbound and Alendronate doses.b. Education was provided to all nurses related to Medication not Received from Pharmacy on 1/21/26.c. Audits were implemented on 1/21/26. 3. The implementation of the plan of correction was verified during the survey.

Based on observation, staff interview, record review and policy and procedure review, the facility failed to ensure enhanced barrier precautions were implemented for 1 of 3 sample residents (#4) during wound care. The findings were:1. Review of a telephone order dated 1/11/26 showed resident #4 had an open wound to his/her sacrum. Review of a progress note dated 1/18/26 and timed 11 PM showed the resident had an open wound to his/her right lower extremity. Review of the hospital Discharge summary dated [DATE] showed the resident was discharged from hospital on 1/23/26 where s/he was treated for a right lower extremity wound and cellulitis, had an open sacral wound, and a new foley catheter placement. The following concerns were identified:a. Observation of wound care for the resident on 2/5/26 at 9:22 AM showed the DON and LPN #1 entered the resident's room, performed hand hygiene, and donned gloves. At that time, the DON performed perineal care and foley catheter care due to the resident being incontinent of loose stools. The DON doffed her gloves, performed hand hygiene with soap and water, donned clean gloves, removed a dressing to the resident's sacral wound, and cleaned the wound. The DON doffed her gloves and donned clean gloves, applied a clean dressing, doffed her gloves, performed hand-hygiene, and exited the room. No additional personal protective equipment was used during the wound care.b. Interview with the DON on 2/5/26 at 2:06 PM revealed enhanced barrier precautions should be used for all residents with wounds, catheters, and dialysis or other types of ports. Further interview revealed gloves and gowns should be worn for enhanced barrier precautions during wound care and she confirmed resident #4 should have been on enhanced barrier precautions. 2. Review of the policy titled Transmission-Based Precautions (Isolation) last updated March 2025 showed .Enhanced Barrier Precautions (EBP) are designed to reduce transmission of multidrug-resistant organisms (MDROs). EBP involve the use of gowns and gloves by care providers, during high-contact resident care activities. EBP are used when caring for residents with colonization or infection with a targeted and epidemiologically important MDRO, chronic wounds, or indwelling medical device/s .

Based on observation and staff interview, the facility failed to ensure a clean environment free of odors in 1 of 4 resident care units. The census was 55. The findings were: 1. Observation on 6/23/25 at 3:06 PM revealed a strong urine odor was present on the hallway near the assisted dining room. 2. Observation on 6/24/25 at 8:37 AM revealed a strong urine odor was present near rooms [ROOM NUMBERS]. 3. Observation on 6/25/25 at 10:26 AM revealed resident #13's room smelled strongly of urine. Staff provided assistance to the resident and the resident left the room; however, the odor remained present in resident's room. 4. Observation on 6/26/25 at 8:10 AM revealed a strong urine odor was present in the assisted dining area. 5. Interview with the facility administrator on 6/26/25 at 9:36 AM revealed the facility was aware of the strong urine odors and revealed the odor had gotten better; however, it still needed improvement. Further interview revealed the facility had been discussing an alternate soiled linen storage on the hall.

Based on observation, staff interview, policy and procedure review, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The census was 55. The findings were: 1. Observation on 6/25/25 beginning at 9:43 AM showed cook #1 prepared a pan of vegetables, doffed her gloves, and placed the pan in the oven. At 9:54 AM she sanitized her hands with Purell gel hand sanitizer, donned gloves and prepared a salad. At 10:09 AM she removed raw meat that was wrapped in plastic from the refrigerator, donned gloves, removed and threw away the meat wrapping, doffed gloves, sanitized hands with gel sanitizer, and seasoned the meat. At 10:19 AM she washed her hands with soap and water. 2. Interview with cook #1 on 6/25/25 at 12:27 PM confirmed she used hand sanitizer if she did not wash her hands in between tasks. 3. Interview with the dietary manager on 6/25/25 at 12:28 PM revealed it was his first time to hear they should not use hand sanitizer in the kitchen. Further interview revealed staff usually used hand sanitizer between gloves after they already washed their hands. 4. Review of the facility policy titled Handwashing and last updated March 2016 showed .Antimicrobial gels cannot be used in place of proper handwashing techniques in a foodservice setting . 5. According to the 2022 FDA Food Code showed 2-301.16 Hand Antiseptics (A) A hand antiseptic used as a topical application, a hand antiseptic solution used as a hand dip, or a hand antiseptic soap shall: (1) Comply with one of the following: (a) Be an APPROVED drug that is listed in the FDA publication Approved Drug Products with Therapeutic Equivalence Evaluations as an APPROVED drug based on safety and effectiveness; or (b) Have active antimicrobial ingredients that are listed in the FDA monograph for OTC Health-Care Antiseptic Drug Products as an antiseptic handwash, and (2) Consist only of components which the intended use of each complies with one of the following: (a) A threshold of regulation exemption under 21 CFR 170.39 -Threshold of regulation for substances used in FOOD-contact articles; Pf or (b) 21 CFR 178 - Indirect FOOD Additives: Adjuvants, Production Aids, and Sanitizers as regulated for use as a FOOD ADDITIVE with conditions of safe use, or, (c) A determination of generally recognized as safe (GRAS). Partial listings of substances with FOOD uses that are GRAS may be found in 21 CFR 182 - Substances Generally Recognized as Safe, 21 CFR 184 - Direct FOOD Substances Affirmed as Generally Recognized as Safe, or 21 CFR 186 - Indirect FOOD Substances Affirmed as Generally Recognized as Safe for use in contact with FOOD, and in FDA's Inventory of GRAS Notices, or(d) A prior sanction listed under 21 CFR 181 - Prior Sanctioned FOOD Ingredients, or (e) a FOOD Contact Notification that is effective, and (3) Be applied only to hands that are cleaned as specified under § 2-301.12. (B) If a hand antiseptic or a hand antiseptic solution used as a hand dip does not meet the criteria specified under Subparagraph (A)(2) of this section, use shall be: (1)Followed by thorough hand rinsing in clean water before hand contact with FOOD or using gloves; or (2) Limited to situations that involve no direct contact with FOOD by the bare hands .

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 1 of 2 sample residents (#25) reviewed for foley catheters, for 1 of 1 sample resident (#51) with a UTI, for 2 of 2 sample residents (#27, #29) reviewed for respiratory health, for 1 of 4 sample residents (#3) reviewed for medication administration, and during 1 random observation of linen transportation. The findings were: Related to foley catheters: 1. Observation on 6/26/25 at 10:34 AM showed resident #25 was in bed, and his/her catheter bag was on the floor and uncovered. 2. Interview with the DON on 6/26/25 at 12:08 PM confirmed when residents were in bed, the catheter bag should be stored below the residents waist on the bed and with a catheter cover bag. 3. Review of the facility policy titled Catheter and Perineal Care dated 2022 showed .ensure that the catheter bag is secured to a non-movable part of a bed or chair, the tubing is not dragging on the floor, and the bag is below the level of the bladder . Related to UTI: 1. Review of resident #51's medical record showed s/he was diagnosed with pneumonia on 3/21/25 and received Azithromycin 12.5ml (milliliters) by mouth one time a day 3/24/25 through 3/27/25. Further review showed s/he was diagnosed with a UTI on 4/7/25 and received Doxycycline Hyclate 100 mg (milligrams) by mouth 2 times a day for 7 days, 4/7/25 through 4/13/25. 2. Interview on 6/26/25 at 9:08 AM with the resident's representative revealed the resident's tablemate had been ill, and the staff had gone back and forth between the resident and his/her tablemate. Further interview revealed the resident became ill with pneumonia, which caused diarrhea and stomach upset, and then the resident became ill with a UTI. 3. Interview on 6/26/25 at 12:08 PM with the DON revealed there were residents in the facility that had URI or pneumonia in mid March. Related to respiratory health: 1. Observation on 6/23/25 at 3:11 PM showed resident #27's oxygen tubing was balled up on tank, with the nasal cannula resting on the concentrator and the concentrator was on, but not in use. Observation on 6/25/25 at 5:52 PM showed the resident's oxygen tubing was balled up on top of the concentrator. 2. Observation on 6/24/25 at 10:19 AM showed resident #29's oxygen tubing was hanging on his/her concentrator and the nasal cannula was touching the concentrator. Further observation showed the concentrator was against the wall next the resident's bathroom door. Observation on 6/25/25 at 5:50 PM showed resident's oxygen tubing was hanging on his/her concentrator and the nasal cannula was touching the concentrator. Further observation showed the concentrator was against the wall next the resident's bathroom door. 3. Interview with the DON 6/26/25 at 8:19 AM revealed oxygen tubing should be stored in bags when not in use. 4. Review of the facility policy titled Respiratory Care: Equipment Care and Handling last updated November 2018 showed equipment .Storage & waste .Nasal Cannula or Face Mask .Store in mesh bag, paper sack, or in compartment/container between use. Discard in regular waste . Related to medication administration: 1. Observation on 6/25/25 at 9:34 AM showed LPN #1 applied gloves, opened the medication cart, and began removing medications for resident #3. The LPN removed 4 acidophilus capsules, a duloxetine capsule, and 3 phenytoin capsules by placing them on a wash cloth placed on top of the medication cart. Without removing his gloves, the LPN picked up each capsule and broke them open into a medication cup. The LPN then mixed the broken capsules, crushed medications, and applesauce and then administered the medications to the resident. 2. Interview with the DON on 6/26/25 at 11:56 AM revealed nurses should wash their hands when they are going to be handling medications and she would expect gloves to be changed before touching the medications if other items were touched with the gloves. Related to linen transport: 1. Observation on 6/24/25 at 2:44 PM showed an unidentified staff member exited room [ROOM NUMBER] with unbagged soiled linen in her hand. The staff member walked across the hall to the housekeeping closet, was unable to open door, walked toward the end of the hall, and returned to room [ROOM NUMBER]. The linen remained in her ungloved hand during transport. 2. Interview with the DON on 6/26/25 at 11:56 AM revealed soiled linen should be bagged when removed from a resident room. 3. Review of the policy titled Soiled Laundry and Bedding dated May 2015 showed .2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. 3. Anyone who handles soiled laundry wears protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely) .

Based on observation, medical record review, policy and procedure review, and manufacturer recommendation review, the facility failed to ensure medication error rates were not greater than 5% during medication administration for 1 of 4 sample residents (#3) observed during medication administration. The medication error rate was 7.69%, 2 out 26 observations. The findings were: 1. Observation on 6/25/25 at 9:34 AM showed LPN #1 prepared 7 medications for resident #3 which included potassium chloride (mineral supplement) 20 meq (milliequivalents) tablet and duloxetine hydrochloride (antidepressant) 40 mg (milligrams) capsule. Further observation showed the LPN broke open the duloxetine capsule and placed it in a medication cup, then crushed the potassium chloride tablet with other medications before adding it to the medication cup. The LPN added applesauce and administered the medications to resident #3. Review of the physician orders for the resident showed an order May crush meds unless contraindicated dated 11/6/2014, duloxetine hydrochloride delayed release particles 40 mg give 1 capsule by mouth one time a day dated 2/1/25, and potassium chloride extended release 20 meq give 10 meq by mouth one time a day dated 4/2/25. The following concerns were identified: a. Review of the medication label for Cymbalta (duloxetine hydrochloride) delayed release last revised on 10/2010 showed .Cymbalta should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents be sprinkled on food or mixed with liquids . b. Review of the medication label for potassium chloride extended release dated 2013 showed .tablets are to be swallowed whole without crushing, chewing or sucking the tablets . 2. Review of the facility policy provided by the DON and titled Medication Administration General Guidelines dated 01/21 showed .5. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber .b. Long-acting, extended release or enteric coated dosage forms should generally not be crushed; an alternative should be sought .

Based on observation, resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure individual activities of preference were provided to 2 of 3 sample residents (#1, #43) reviewed for activities. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included paraplegia, spina bifida, and morbid obesity. Further review showed the resident indicated it was very important to have books, newspapers, and magazines to read, music to listen to, and to go outside to get fresh air when the weather was good and s/he was dependent on staff to roll left and right. All other mobility items were coded as not applicable. The following concerns were identified: a. Interview with the resident on 6/24/25 at 2:07 PM revealed the resident was bed ridden and wanted to get up to do things; however, s/he did not have a wheelchair at the facility. S/he revealed s/he was told the facility was going to get him/her a wheelchair; however, they had not gotten one. S/he revealed the facility staff told him/her there was not enough people available to get up. S/he revealed she was unable to go to activities and s/he felt the facility needed more people to go to resident rooms and talk to residents. Observation at that time showed no evidence of a wheelchair in the resident's room or in the hall near the resident's room. b. Review of the resident's activity participation record from 4/12/25 through 6/25/25 showed the resident did not participate in any of the 73 documented group activities and received 1 to 1 activities on 5 days out of 73 days, on 4/16, 4/23, 6/11, 6/18, and 6/20. All other documented activities were indicated as independent. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #43 had a BIMS score of 14 out 15, which indicated the resident was cognitively intact, and had diagnoses which included anxiety disorder and depression. Review of the admission assessment dated [DATE] showed the resident felt it was very important to listen to music, have books, newspapers, and magazines to read, be around pets, and keep up with the news. The following concerns were identified: a. Interview with the resident on 6/24/25 at 8:41 AM revealed there were no activities at the facility that s/he enjoyed participating in. b. Review of the activity participation record from 3/22/25 through 6/25/25 showed the resident participated in 1 out of 92 documented group activities, on 3/24/25, and received a 1 to 1 activity on 2 days out of 94 days, on 4/1/25 and 5/25/25. All other documented activities were indicated as independent. 3. Interview with the activities director on 6/26/25 at 8:26 AM confirmed resident #1 was bed bound and revealed she went to see the resident twice per week. She confirmed the documented activity participation for resident #1 and resident #43 did not reflect 1 to 1 activities being performed twice per week. She revealed when resident #1 admitted to the facility, s/he had a lot of family visits and the resident was picked back up for 1 to 1 activities when family stopped coming as frequently. The activity director revealed resident #43 was a night person and she revealed there were no activities for residents at night. She revealed the activities the facility does for younger residents included karaoke, happy hour, and scary movie nights. Further interview revealed resident #43 has participated in scary movie nights; however, neither resident #1 or resident #43 participated in karaoke or happy hour. 4. Review of the facility policy titled Activity Program last revised July 2015 showed .5. Activities include individual, small and large group, one-on-one, and independent activities to meet resident's needs, abilities, and interests. For residents confined to, or who choose to, remain in their room, the Activity Department provides and assists with in-room activities/projects/leisure pursuits in keeping with needs, abilities, and interests .

Based on observation, record review, staff interview, resident interview, representative interview, and policy review the facility failed to ensure residents were safe for 1 of 2 residents (#7) reviewed for elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on 6/6/25. The findings were: 1. Review of the medical record for resident #7 showed the 4/11/25 admission MDS assessment had a BIMS score of 2 out of 15 which indicated the resident had severe cognitive impairment, as well as verbal behaviors towards others. S/he had a diagnosis of dementia, moderate, with other behavioral disturbance, as well as alcohol abuse, tobacco use, and nicotine dependence, cigarettes. a. The Elopement risk evaluation performed on 4/7/25 showed the resident was not an elopement risk. On 5/22/25 the resident was an elopement risk, and had left the facility without staff knowing. b. The care plan initiated on 4/14/25, showed the resident was an elopement risk/wanderer related to history of attempts to leave the facility unattended, impaired safety awareness, and verbalized wanting to go home. c. Review of a progress notes showed 5/22/25 17:14 [5:14 PM] Resident was noticed missing at 330pm. Resident has been going outside and sitting in the front most of the day because the weather has been pleasant. Resident did not have any voiced wants to leave during that time. Staff noticed that resident was not outside, nor in [his/her] room. Called overhead, but unable to find resident. Staff went out to search for resident in private vehicles, on foot, and searched the building and all rooms. Local law enforcement was called and a report was filed. Approximately 15 minutes later, resident was found walking back towards the facility . When asked the resident where [s/he] went, [s/he] stated [s/he] walked up to the store to pick up some [NAME], which resident did have in [his/her] possession. This writer reminded resident that [s/he] forgot to let us know that [s/he] was leaving and [s/he] replied, oh yeah, I forgot. d. Review of a progress note dated 5/30/25 at 11:45 AM showed It was found that [resident name] was not in [his/her] room around 1015AM. An elopement alert was announced, and all staff searched the whole building for [resident name]. Other staff was assigned to start looking outside of the building. While searching [residents name] room, staff found the wanderguard on the floor. [Name of city] Police were notified around 1020am after initial search was completed. Staff found resident walking up the main street around 1035am, unharmed. Staff brought [resident name] back to the facility, but [s/he] refused a full body skin assessment. [Resident's name] was offered a meal and was placed on 1:1 r/t [related to] [him/her] taking [his/her] wanderguard off. Review of a progress note dated 6/11/25 at 1:41 PM showed, This writer spoke with daughter and [ex-spouse] regarding resident's current status. Resident remains on 1 on 1 while awake. Resident is offered to go outside the front and in the courtyard multiple times per day with staff. Resident is offered activities, but usually refuses, except [s/he] likes to watch TV in the TV room. Multiple staff members engage resident in conversations as a distraction when resident talks about going home, which resident does more and more often each day. Resident will become verbally aggressive towards staff when [s/he] feels like [s/he] is being watched, so 1 on 1 will give resident [his/her] space and privacy but knows resident's location at all times. Resident continues to be a high elopement risk, but is not suitable for the secure unit because of the space being small and [s/he] feels enclosed even with the secured courtyard. Will continue to monitor. 2. Observation 6/23/25 at 4:32 PM showed the resident out front of the building, sitting on a bench. S/he was upset that they made him/her come back in. Other observations during the survey showed 1 on 1 staff were within range of the resident during the day. The resident was observed sitting on the bench in front of the building multiple times throughout the survey. Interview with the resident on 6/24/25 at 10:28 AM revealed s/he likes to be outside no matter the weather. S/he used to be a carpenter and likes to be outdoors. 3. Interview with the resident representative on 6/24/25 at 3:06 PM revealed the resident liked to spend time outdoors. She stated the facility was working with her for a more appropriate placement in another facility for the resident. 4. Review of the Performance Improvement Plan (PIP) showed the following: 1. Identified Area for Assessed Improvement: Actual Elopements, High Risk Elopements and Elopement Monitoring. 2. Plan, what is being done: Elopement Risk Audit, Wanderguard System, Unit Placement as needed, and Education. 3. Action Steps to Implement Plan was Audit of High-Risk Elopement, Audit Wanderguards, Update Care Plans, Audit Elopement Evaluations, and Audit/Update Elopement Books. 4. Objective Measures to Evaluate Effectiveness: Initial Risk Assessment upon Admission, Daily Wanderguard Checks for function and placement in TARS, and Weekly Audits of Residents who are High-Risk. The plan was completed on 6/6/25. The staff Inservice Education showed it was completed on 5/27/25 at 2:30 PM. 5. Interview with the DON on 6/26/25 at 12:04 PM revealed the resident had eloped, and a PIP and staff education had been completed. 6. Review of policy Elopement/Wandering undated February 2025 showed .4. Based on the results of the Elopement/Exit-Seeking Evaluation, care plan interventions to manage wandering and/or exit seeking behaviors are initiated/implemented. The care plan addresses the resident's wandering behavior, potential to exit Center, and/or actual episodes of elopement and the measures taken to manage those behaviors.

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure accommodation of resident needs for 1 of 14 sample residents (#1) reviewed. The census was 55. The findings were: 1. Review of the admission MDS dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included paraplegia, spina bifida, and morbid obesity. Further review showed the resident was dependent on staff to roll left and right. All other mobility items were coded as not applicable. The following concerns were identified: a. Interview with the resident on 6/24/25 at 2:07 PM revealed the resident was bed ridden and required a wheelchair to get around. The resident revealed s/he was told the facility would get him/her in a wheelchair and assist the resident to bath in the whirlpool; however, s/he had not been out of bed since admitting to the facility. The resident revealed s/he would like to get out of bed and sit in the chair. Observation at that time showed there was no wheelchair in the room or in the hall near the resident's room. b. Interview with the social services director on 6/26/25 at 9:15 AM revealed he had not received any information about the resident's desire to get up or his/her bathing preferences. c. Interview with the facility administrator and DON on 6/26/25 at 9:30 AM revealed the administrator had talked to therapy and thought therapy was trying to get in touch with the resident's family to obtain his/her wheelchair. They confirmed bathing was part of the reason they were attempting to get the wheelchair. They revealed they have a shower chair; however, the resident does not have good trunk control and his/her personal wheelchair was designed for him/her. They confirmed the resident had not been out of bed since admitting to the facility. d. Interview with the regional clinical director on 6/26/25 at 12:10 PM revealed she talked to the therapy department to see if the resident was safe to sit in a wheelchair the facility had available. Further interview revealed therapy spoke with the resident and s/he was going to talk to his/her family about his/her personal chair.

Based on medical record review, staff and physician interview, and review of policies, the facility failed to provide care in accordance with physician's orders and professional standards of practice for 2 of 2 sample residents (#7, #8) with pressure ulcers. The findings were: 1. Review of the 10/7/24 annual MDS assessment showed resident #8 had one stage 3 and two stage 4 pressure ulcers. The 11/4/24 discharge MDS assessment showed the resident had 3 stage 4 pressure ulcers. Review of the 10/9/24 physician progress note showed the resident was bedbound due to myelopathy of the lower extremities and .recurring sacral pressure sores. despite best efforts to heal [his/her] wounds and work with pressure relief, the pressure sores keep recurring. Review of a progress note by the wound care nurse on 10/29/24 showed .Resident stage 3 on sacrum has developed into stage 4 pressure injury with coccyx palpable and visible. Large amount of drainage observed with slight odor; measuring 12x12x0.8 cm [centimeters] with undermining from 12 to 2 measuring 2.5cm Call made to MD making him aware of current situation. MD also made aware of refusals to be rotated or turned off buttocks; made request for [infectious disease] referral and MD agreed stating that was what family wanted at well. No new dressing order at this time. Staff continue to try to encourage resident to be repositioned throughout day and night. Resident frequently refuses. Review of the 10/29/24 weekly skin assessment for the sacrum wound showed the pressure sore measured 12 x 12 x 0.8 cm with undermining and was a stage 4. Review of the 10/31/24 weekly skin assessment for the right buttock wounds showed two stage 4 wounds, one measured 0.4 x 0.4 x 1.5 cm and the other measured 1.5 x 1.5 x 0.5 cm. Review of a 11/4/24 progress note by the wound care nurse showed [infectious disease] still had not received the referral, and so she encouraged the resident and spouse to allow the resident to go the emergency room to be fully evaluated, including a wound culture swab. The resident was transferred to the ER. During an interview on 11/14/24 at 2:17 PM physician #2 stated the resident has had chronic recurring pressure ulcers and 4 years ago was on comfort care due to wounds. He stated the resident was on an air mattress, had good nutrition and had diabetes control. However, he stated the resident would refuse to allow staff to rotate (reposition) [him/her]. He stated multiple staff told him the resident would refuse repositioning. The following concerns were identified: a. Review of physician orders showed from 10/4/24 to 10/21/24 the sacrum wound dressing was ordered to be changed every shift (twice per day). Review of the October 2024 medication administration record (MAR) showed wound care documentation was lacking on 10/10 day shift, 10/15 day shift, 10/16 day shift, and 10/20 night shift. b. Review of physician orders showed starting 10/22/24 the sacrum wound dressing was ordered to be changed once per day. Review of the October 2024 MAR showed no documentation on 10/25 or 10/30. c. Review of physician orders showed the dressings on the two wounds on the right buttock were ordered to be changed every shift (twice per day) from 10/4 to 10/23. Review of the October 2024 MAR showed no documentation for 10/5 day, 10/10 day, 10/15 day, 10/16 day, 10/20 night, and 10/21 day. d. Review of progress notes for the days of missing documentation showed no evidence the wound care was done. e. During an interview on 11/14/24 at 3:08 PM the administrator stated the facility did not have a wound care policy, but stated it was standard of practice that nurses follow physician orders. f. On 11/14/24 at 4:08 PM the administrator stated nursing staff should document when dressings are changed. She further stated they looked at the wound care documentation for resident #8 and found 22 out of 174 times where the documentation was missing. 2. Review of the 10/28/24 admission MDS assessment showed resident #7 with diagnosis of cellulitis of groin, multi-drug resistant organism (MDRO) and encounter for surgical aftercare following surgery on the skin. The following concerns were identified: a. Interview with the wound care nurse on 11/14/24 at 8:50 AM revealed the resident was supposed to have a wound vac placed upon admission to the facility (10/28/24), but the wound vac did not arrive until 10/29/24. The wound care nurse stated she did a dressing change on 10/28/24 with verbal orders from the provider, but did not enter them into the computer. b. Record review revealed only admit orders for the wound vac to be changed Monday, Wednesday and Friday. There lacked orders for wound care until the wound vac was received. c. Review of a progress note dated 10/28/24 at 9:30 AM confirmed the wound was cleansed with wound cleanser, packed with calcium alginate and covered with Optilock and ABD dressing. No other dressing changes were documented in the treatment administration record or progress notes until the wound vac was applied on 10/29/24. d. Review of the facility policy titled, Physician Order Recaps updated April 2024, confirmed that the licensed nursing staff was responsible for inputting admission, telephone and verbal physician's orders into the electronic health record immediately upon receipt from the provider. e. Interview with physician #1 on 11/14/24 at 4 PM revealed he gave the nurse an order for wound care prior to the wound vac arrival and placement as the wound was very wet with a lot of drainage.

Based on medical record review, staff interview, and review of facility investigation and education documentation, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 4 residents (#10) reviewed for allegations of abuse. The findings were: 1. Review of the 11/4/24 quarterly MDS assessment showed resident #11 (perpetrator) had a BIMS score of 6, indicating severe cognitive impairment. The resident exhibited physical behavioral symptoms 1-3 days during the assessment period. Review of a progress note dated 10/28/24 showed the resident was ambulating to his/her room and encountered another resident. Resident #11 reached over and pinched the other resident in the arm. Review of the care plan showed on 10/28/24 the care plan was updated to reflect the resident to resident altercation. The resident was placed on a 1:1 for supervision following the incident. 2. Review of the 9/6/24 quarterly MDS assessment showed resident #10 (victim) had a BIMS score of 3, indicating severe cognitive impairment. A progress note dated 10/28/24 showed the resident was pinched in the arm by another resident. The resident's arm had bruising and a slight scrape. A 10/28/24 note by the social services director showed the resident had scratch marks with dried blood on his/her arm. Review of an interdisciplinary team (IDT) note dated 10/28/24 showed .Resident has small scrape to right lower extremity as result of altercation, area is being monitored. Social services notes dated 10/28/24, 10/29/24 and 10/30/24 showed the resident was at baseline and no psychological harm was noted. 3. Review of the facility's investigation documentation showed on 10/28/24 resident #11 was witnessed by staff pinching the arm of resident #10. Resident #11 was placed on a 1:1. Resident #10 had a small bruise to the arm. Right after the incident, resident #11 told the CNA that resident #10 was in [his/her] way, but later did not recall the incident. 4. Documentation to show steps taken after the incident was requested, including education to staff, any audits/monitoring, and quality assurance. On 11/14/24 at 1:19 PM the administrator stated the last education on abuse to staff was 8/5/24 (prior to the incident). Review of the provided abuse education confirmed it was 8/5/24. No other documentation was provided.

Based on medical record review and staff interview, the facility failed to provide medications to meet the needs of the resident for 1 of 11 sample residents (#13). The findings were: 1. Review of the 9/3/24 admission MDS assessment showed resident #13 had diagnoses including abscess liver, CAD [coronary artery disease], hypertension, and diabetes mellitus. Review of a progress note by physician #1 dated 9/26/24 showed the physician documented the following medication changes: a. Start aspirin 81 milligrams (mg) every day for CAD. b. Start Ursodiol 300 mg, three times per day, for pericholecystic abscess. c. For primary hypertension, will stop Furosemide while we monitor volume status. d. For diabetes mellitus, will stop Glipizide and start Empagliflozin 25 mg once per day. The following concerns were identified: a. Review of the medication administration record (MAR) from 9/26/24 until discharge on [DATE] showed the medication changes from the 9/26/24 progress note were never implemented. b. On 11/14/24 at 10:23 AM the DON stated the nurses reviewed physician progress notes, and then she did too. She stated the 9/26/24 progress note was during the transition (she was new to the DON role). c. During an interview on 11/14/24 at 4:10 PM physician #1 confirmed the facility did not implement the medication changes from his 9/26/24 progress note. d. On 11/14/24 at 6 PM the administrator stated the facility received the medications (new medications from the 9/26/24 progress note) from the pharmacy, but they did not get put into the system and the resident did not receive the medications. She stated she spoke to the nurse who signed for the medications and was told the nurse thought they were refills. She did not realize they were new medications.

Based on medical record review and staff and physician interview, the facility failed to ensure monitoring in accordance with physician's orders for 2 of 2 sample residents (#14, #16) with edema. The findings were: 1. Review of the 10/31/24 admission MDS assessment showed resident #16 had diagnoses including heart failure, renal insufficiency, pulmonary hypertension and localized edema. Review of a 10/29/24 progress note by physician #1 showed the resident had 2+ lower extremity edema up to the thighs. Review of physician orders showed on 10/29/24 daily weights were ordered. The following concerns were identified: a. Review of the medical record showed daily weights were not documented on 10/29, 10/30, 11/4, 11/7, 11/8 and 11/10 (the resident was discharged on [DATE]). b. On 11/14/24 at 1:19 PM the administrator stated she was unable to locate any additional weights and confirmed the weights were not done per physician orders. During another interview on 11/14/24 at 3:08 PM the administrator stated the facility did not have a policy, but stated it was standard of practice for nurses to follow physician orders. c. During an interview on 11/14/24 at 4:08 PM physician #1 stated he ordered daily weights to monitor for edema. He stated the daily weights were not done in accordance with orders. 2. Review of the 11/4/24 timed at 11:26 PM progress note revealed resident #14 was crying and stating s/he was worried about his/her swollen legs. Documentation quoted the resident as saying Oh my gosh, I am so worried. My legs are so swollen that I cannot bend them. Documentation by RN #1 indicated trace edema to bilateral lower legs. Review of the 11/4/24 physician progress note revealed documentation of lower leg swelling and weight gain. The note further indicated that the resident gained weight, from his/her admission weight of 254.8 pounds to a weight of 261.8 pounds on 11/4/24. The note further indicated the need to start diuresis and daily weights. Review of the medical record confirmed an order dated 11/4/24 for daily weights for 5 days and to notify the physician if 3 pound gain in 24 hours. The following concerns were identified: a. Review of the treatment administration record for November revealed one weight documented on 11/5/24. b. Review of the vital signs log revealed an admission weight and one weight on 11/5/24. c. Interview with the administrator on 11/14/24 at 1:20 PM confirmed there was an order for daily weights for five days, and stated they were either not done or not documented, I don't know. d. Interview with physician #1 on 11/14/24 at 4 PM confirmed daily weights were not done.

Based on observation, medical record review, and staff and resident interview, the facility failed to promptly identify and intervene for an acute change in condition for 2 of 4 sample residents (#29, #31) who experienced a change in condition. This failure resulted in actual harm to residents #29 and #31 who experienced changes in condition including limited movement and pain following a fall and did not receive a thorough assessment in a timely manner to assess for injuries based on their signs and symptoms. The findings were: 1. Review of the 2/13/24 significant change MDS assessment showed resident #29 had diagnoses including polyosteoarthritis, non-Alzheimer's dementia, and other chronic pain. The resident received scheduled pain medication and had no pain in the last 5 days. Review of a progress note dated 3/10/24 showed the resident was found on the floor beside the bed. A new 2 cm curved lacerated noted on left forearm. Denies hitting head, admits to shoulder pain. Range of motion limited and at baseline. Chronic shoulder deformity related to previous surgery noted and at baseline. No swelling or discoloration noted .Shoulder pain treated with PRN ordered pain medications .on call provider notified. New orders received to schedule resident appointment with primary clinic for further evaluation related to recent frequent falls and further evaluation to rule out additional injuries. A progress note dated 3/11/24 and timed 5:28 AM showed .Will remind day shift nurse that [his/her] MD is requesting to see [him/her] at the clinic. The following concerns were identified: a. Observation on 3/11/24 at 3:43 PM showed RN #2 asked the resident about pain and the resident said his/her pain was an 8. b. Observation on 3/11/24 at 5:08 PM showed the resident complained of shoulder pain to CNA #1. The resident was cradling his/her left arm with the other arm and stated s/he couldn't raise their arm up. When the CNA asked the resident how s/he would rate the pain, the resident replied 10. The resident stated the nurse put some cream on his/her shoulder earlier, but it didn't help. When the surveyor asked what happened, the resident replied s/he fell the day before and had not seen a doctor. c. Observation on 3/11/24 at 5:33 PM showed the resident wasn't eating much of his/her dinner and kept looking at his/her left arm and telling the surveyor s/he couldn't raise their arm. d. On 3/11/24 at 5:40 PM RN #2 came to the SCU and CNA #1 told her the resident was complaining of pain at a 10 and couldn't raise his/her arm. The nurse evaluated the resident's arm and the resident winced when the nurse moved his/her left arm. There was bruising visible to the resident's outer bicep area. At 5:46 PM the RN cleaned a bleeding scab on the resident's arm and told the resident she would call the doctor to see if he wanted treatment for the scab. e. On 3/11/24 at 5:48 PM RN #2 took the resident to his/her room. The resident told her the pain level was a 9. The resident told the nurse s/he fell the day before. At 5:54 PM the RN applied a cream to the resident's left shoulder and arm. She stated she applied cream to the resident earlier. She also told the resident s/he last had Tylenol at noon and she would check on any other orders. The RN told the surveyor she was not notified in report that the resident fell the day before. f. On 3/11/24 at 6:03 PM the RN clarified to the surveyor that the report sheet did say the resident fell the day before, but it stated there were no injuries. g. Review of the nursing note dated 3/11/24 and timed 7:52 PM showed .Resident has been complaining of left shoulder to the hand pain. [S/he] has been favoring left extremity throughout the day. Topical Diclofenac Sodium Gel was applied to the shoulder and po Tylenol was given. A noted abrasion to left forearm was cleaned and left open to air. PCP appt needs to be made for resident . h. Review of progress notes from 3/11/24 and the morning of 3/12/24 showed no evidence nursing had made an appointment for the resident with his/her doctor, despite the nursing notes dated 3/10/24 and 3/11/24 which indicated an appointment was supposed to be made. i. Review of the MAR for 3/11/24 showed the resident was administered the routine medications of Diclofenac Sodium gel 1%, apply 2 grams to upper extremities, at 7 AM, 3 PM and 11 PM and Tylenol ES 500 mg, give 2 tablets, at 8 AM, noon and 4 PM. Further review of the MAR showed the resident was ordered Oxycodone HCL 5 mg every 8 hours as needed for severe pain. However, the resident was not administered any Oxycodone on 3/11/24. j. On 3/12/24 at 11:23 AM physician #1 entered the SCU and the surveyor asked if he was there to see resident #29. He stated no, he was not the resident's physician, but asked what was going on. The surveyor told the physician about the resident's complaints of shoulder pain following a fall and the physician stated he would examine the resident. The physician went in the resident's room and exited a few moments later and told the surveyor they would be getting xrays for the resident. k. During an interview on 3/12/24 at 4:34 PM the DON stated physician #1 told them to get in touch with the resident's physician, so she stated she called the resident's physician at 12:30 PM. She stated the physician had not gotten back to her yet. She stated the resident was complaining of pain, which was normal, but was worse since the fall. l. Observation on 3/12/24 at 4:56 PM showed the staff development coordinator (SDC) took the resident to his/her room to assess the resident. When the surveyor asked the resident if s/he still had pain in that arm the resident indicated yes, and stated the upper and lower arm hurt. When the SDC was asked if the resident normally complained of pain, she stated not usually in the upper extremities. m. Review of a nursing note dated 3/12/24 and timed 5:46 PM showed .Resident had complaint of increased pain to left shoulder .Resident was unable to lift up left arm at this time. Faded bruise to left upper inner arm observed .bruise appears old .Due to increased pain and decreased function of arm, resident is being sent to receive imaging per MD order. n. Review of a progress noted dated 3/12/24 and timed 5:46 PM showed Received order from MD to send resident out to ER for X-ray to left shoulder. o. Review of a nursing note dated 3/12/24 and timed 9:30 PM showed .Resident recently returned to the facility from [hospital] ER tonight. Resident received x-rays to r/o [rule out] injury of left upper extremity r/t [related to] recent fall per complaints of pain. Per verbal report, resident has old, resolved injuries to left upper extremity that have been aggravated by recent fall. No acute injury. Resident was sent home with sling in place to left upper extremity. Rest of left upper extremity and follow up with Orthopedics if condition does not improve. Resident was medicated for pain at [hospital] ER before returning to the facility . p. A progress note dated 3/13/24 read IDT aware of resident's c/o left shoulder/arm pain. MD was contacted. Resident sent to ER for X-Ray to left shoulder. Resident returned from ER with diagnoses for contusion of left shoulder and post-traumatic osteoarthritis of left shoulder .Resident sent back to facility with sling in place. Therapy referral initiated. q. On 3/13/24 at 4:25 PM RN #2 stated on 3/11/24 the resident was exhibiting signs of pain and holding his/her arm. She stated she did not give the resident the ordered PRN Oxycodone because she was told to only give it to him/her at night because the resident got up and walked by himself/herself. She stated she was told that day the resident needed to see his/her PCP (primary care physician), but she was told to pass it along to the regular nurse since she was just filling in. She stated she told the night nurse, who was supposed to pass it along to the regular day nurse who would be working the following day and would know how to contact the physician. r. During an interview on 3/14/24 at 8:45 AM the resident stated his/her pain was a 9, but stated the sling on his/her arm made his/her arm more comfortable. s. Review of a nursing note dated 3/13/24 at 9:59 PM showed .Sling to left upper extremity remains in place .Slight swelling noted to left hand . 2. Review of the 1/22/24 quarterly MDS assessment showed resident #31 had a BIMS score of 0, indicating severe cognitive impairment, had a diagnosis of non-Alzheimer's dementia, had no indicators of pain, and had one fall with no injury since the previous assessment. Observation on 3/11/24 at 4:51 PM and on 3/12/24 at 9:16 AM revealed the resident was in bed. Review of an IDT note dated 3/4/24 showed on 3/3/24 the resident fell while standing in front of the recliners. The note showed the resident was exhibiting increased back pain. The following concerns were identified: a. Review of a nursing note dated 3/5/24 and timed 2:15 PM showed .Recent fall approximately 2 days ago. Declined offers to have breakfast this AM and remained in bed until lunch .Guarding of lower back also noted with repositioning .Resident agreed to get up for lunch. Resident noted to be leaning back while sitting in chair, grimacing and lower back guarding noted when resident leans forward . b. Review of a nursing note dated 3/9/24 and timed 1:37 PM showed .Resident remained in bed today .Guarding of lower back noted when resident is repositioned, otherwise no indications of pain while at rest c. Review of a nursing note dated 3/10/24 and timed 6:58 PM showed Remained in bed for shift. Facial grimacing and guarding of lower back noted with repositioning, however no other indications of pain noted while at rest. d. Review of the MAR for March 2024 showed the resident received PRN Tylenol 650 mg on 3/3 for back pain at a 6; on 3/6 for pain at a 4; on 3/7 for pain at a 4; on 3/10 for back pain at a 2; and on 3/12 for pain at a 3. e. Review of a progress note dated 3/12/24 and timed 8:21 AM showed Resident sent out for X-Rays to [his/her] lower back following [his/her] fall the other day. Since the fall, resident has been displaying non-verbal indicators of pain. X-ray was done. Age-indeterminate compression fractures found at L2 and L3 with degenerative arthroplasty to L5-S1 .Resident has been remaining in bed for the majority of [his/her] days . f. During an interview on 3/14/24 at 10:55 AM the DON was asked why the resident was not sent for x-rays sooner. The DON stated that she was not notified by nursing what was going on with the resident. She stated once she found out, she sent the resident for x-rays.

Based on observation, medical record review, staff and resident interview, and review of policies and procedures, the facility failed to adequately treat pain for 1 of 6 sample residents (#29) reviewed for pain management. This failure resulted in actual harm to resident #2 who experienced a change in condition including limited movement and pain following a fall and was not treated for severe pain. The findings were: 1. Review of the 2/13/24 significant change MDS assessment showed resident #29 had diagnoses including polyosteoarthritis, non-Alzheimer's dementia, and other chronic pain. The resident received scheduled pain medication and had no pain in the last 5 days. Review of a provider progress note dated 2/7/24 showed the resident had chronic pain of the right knee and lift hip. Review of the care plan for pain initiated 4/13/24 showed Administer analgesia as per orders . and Evaluate the effectiveness of pain interventions Q shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of physician orders and the MAR for March 2024 showed the resident was ordered the following routine medications for pain: Diclofenac Sodium 1% gel to the upper and lower extremities (4 grams to lower extremities, 2 grams to upper extremities) every 8 hours for pain (at 7 AM, 3 PM and 11 PM) and Tylenol ES 500 mg, give two tablets, three times per day (6 AM, noon, 4 PM). In addition, the resident was ordered Oxycodone HCL 5 mg every 8 hours PRN (as needed) for severe pain. Further review of physician orders and the MAR showed staff were instructed to monitor pain every shift and indicate pain level and location if applicable. The following concerns were identified: a. Review of a progress note dated 3/10/24 showed the resident was found on the floor beside the bed. A new 2 cm curved lacerated noted on left forearm. Denies hitting head, admits to shoulder pain. Range of motion limited and at baseline. Chronic shoulder deformity related to previous surgery noted and at baseline. No swelling or discoloration noted .Shoulder pain treated with PRN ordered pain medications .on call provider notified. New orders received to schedule resident appointment with primary clinic for further evaluation related to recent frequent falls and further evaluation to rule out additional injuries. b. Observation on 3/11/24 at 3:43 PM showed RN #2 asked the resident about pain and the resident said his/her pain was an 8. c. Observation on 3/11/24 at 5:08 PM showed the resident complained of shoulder pain to CNA #1. The resident was cradling his/her left arm with the other arm and stated s/he couldn't raise their arm up. When the CNA asked the resident how s/he would rate the pain, the resident replied 10. The resident stated the nurse put some cream on his/her shoulder earlier, but it didn't help. When the surveyor asked what happened, the resident replied s/he fell the day before and had not seen a doctor. d. Observation on 3/11/24 at 5:33 PM showed the resident wasn't eating much of his/her dinner and kept looking at his/her left arm and telling the surveyor s/he couldn't raise their arm. e. On 3/11/24 at 5:40 PM RN #2 came to the SCU and CNA #1 told her the resident was complaining of pain at a 10 and couldn't raise his/her arm. The nurse evaluated the resident's arm and the resident winced when the nurse moved his/her left arm. f. On 3/11/24 at 5:48 PM RN #2 took the resident to his/her room. The resident told her the pain level was a 9. The resident told the nurse s/he fell the day before. At 5:54 PM the RN applied a cream to the resident's left shoulder and arm. She stated she applied cream to the resident earlier. She also told the resident s/he last had Tylenol at noon and she would check on any other orders. g. Review of the nursing note dated 3/11/24 and timed 7:52 PM showed .Resident has been complaining of left shoulder to the hand pain. [S/he] has been favoring left extremity throughout the day. Topical Diclofenac Sodium Gel was applied to the shoulder and po Tylenol was given. A noted abrasion to left forearm was cleaned and left open to air. PCP appt needs to be made for resident . h. Review of the MAR for 3/11/24 showed the resident was administered the routine medications of Diclofenac Sodium gel 1%, apply 2 grams to upper extremities, at 9:30 AM, 3:40 PM and 11 PM and Tylenol ES 500 mg, give 2 tablets, at 8 AM, noon and 4 PM. However, the resident was not administered any PRN Oxycodone on 3/11/24, despite the resident indicating s/he had severe pain. i. Review of the MAR for March 2024 showed the day shift nurse did not document the resident's pain (pain level and location) on 3/11/24. Review of the vital signs in the electronic medical record showed pain level was not documented on 3/11/24. j. Observation on 3/12/24 at 4:56 PM showed the SDC took the resident to his/her room to assess the resident. When the surveyor asked the resident if s/he still had pain in that arm the resident indicated yes, and stated the upper and lower arm hurt. When the SDC was asked if the resident normally complained of pain, she stated not usually in the upper extremities. k. Review of a nursing note dated 3/12/24 and timed 5:46 PM showed .Resident had complaint of increased pain to left shoulder .Resident was unable to lift up left arm at this time. Faded bruise to left upper inner arm observed .bruise appears old .Due to increased pain and decreased function of arm, resident is being sent to receive imaging per MD order. l. Review of a nursing note dated 3/12/24 and timed 9:30 PM showed .Resident recently returned to the facility from [hospital] ER tonight. Resident received x-rays to r/o [rule out] injury of left upper extremity r/t [related to] recent fall per complaints of pain. Per verbal report, resident has old, resolved injuries to left upper extremity that have been aggravated by recent fall. No acute injury. Resident was sent home with sling in place to left upper extremity. Rest of left upper extremity and follow up with Orthopedics if condition does not improve. Resident was medicated for pain at [hospital] ER before returning to the facility . m. On 3/13/24 at 4:25 PM RN #2 stated on 3/11/24 the resident was exhibiting signs of pain and holding his/her arm. She stated she did not give the resident the ordered PRN Oxycodone because she was told to only give it to him/her at night because the resident got up and walked by himself/herself. n. Review of a progress note dated 3/13/24 showed .Resident was very agitated and restless at the beginning of this shift. Resident replied yes when asked if [s/he] wanted a pain pill. Resident was medicated for pain and agitation has improved. o. Review of the MAR for 3/12/24 and 3/13/24 showed the resident did receive PRN Oxycodone on those days. p. During an interview on 3/14/24 at 8:45 AM the resident stated his/her pain was a 9, but stated the sling on his/her arm made his/her arm more comfortable. 2. Review of the facility's policy Pain Management, updated August 2023, showed .2. Resident's pain level is evaluated every shift by the LN [licensed nurse]. Noted pain is evaulated and treated accordingly by the LN .a. Pain level is monitored and documented on the MAR using the Wong-Baker Pain Scale .3. When pain is not adequately controlled by current regimen, or if there is newly identified pain, the LN contacts the physician for consideration of new or modified treatment orders.

Based on observation, staff interview, and review of the 2022 Food Code, the facility failed to store and prepare food in accordance with professional standards related to expired food, hair restraints, and hand hygiene/gloving during 3 of 3 observations in the kitchen and 1 of 1 observation of tray line service. The findings were: 1. The following concerns were identified related to hair restraints: a. Observation on [DATE] at 3:15 PM in the kitchen revealed the certified dietary manager (CDM) was wearing a hair restraint, but was not wearing a beard restraint to cover his beard. b. Observation on [DATE] at 12:21 PM revealed the CDM was assisting staff with tray line service (putting sour cream on the trays in the carts) and was not wearing a beard restraint to cover his beard. c. During an interview on [DATE] at 4:32 PM the CDM stated he had heard about beard restraints but had never worn one. Review of the 2022 Food Code, US Food and Drug Administration, showed XXX,d+[DATE] Hair Restraints ,d+[DATE].11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES. 2. The following concerns were identified related to hand hygiene/gloving: a. Observation during tray line service on [DATE] from 12 PM to 12:59 PM showed cook #1 washed her hands and put on gloves at the beginning of the service. During the service, the cook was observed to touch the microwave buttons and handle with her gloved hands, and then touched the bread of grilled cheese sandwiches, tortillas, and cooked baked potatoes with the same gloved hands. This happened on at least five occasions. b. During an interview on [DATE] at 4:32 PM the CDM stated staff had been educated on hand hygiene and glove use. He stated staff should perform hand hygiene and change gloves between tasks and confirmed the cook should have performed hand hygiene after touching the microwave surface and before handling food. Review of the 2022 Food Code, US Food and Drug Administration, showed XXX,d+[DATE].14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ,d+[DATE].11(B); P (D) Except as specified in ,d+[DATE].11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 3. The following concerns were identified regarding expired food: a. Observation of the dry storage room on [DATE] at 3:15 PM showed 2 packages of flour tortillas that expired [DATE]. b. Observation on [DATE] at 10:52 AM of the dry storage showed one of the two packages of expired flour tortillas remained on the shelf. c. On [DATE] at 10:55 AM the CDM stated everything in dry storage was useable, and stated he did not know the tortillas were expired. d. On [DATE] at 11:20 AM in the kitchen the CDM showed the surveyor a box which contained flour tortillas. He stated that was the box the flour tortillas from the dry storage came from and they received the box on [DATE]. He showed the surveyor that all of the tortillas in the box expired in [DATE].

Based on observation and staff interview, the facility failed to ensure a safe environment for residents, staff, and public. The census was 56. The findings were: 1. Observation on 3/12/24 at 4:40 PM showed broken floor tiles outside the soiled utility room near room [ROOM NUMBER]. The area had built-up dirt and debris in the tile cracks which appeared black in color. In addition, the hand rails in the area were discolored and the sealant had been worn away, which created a porous surface, and the rails could not be effectively sanitized. 2. Observation on 3/12/24 at 4:43 PM showed an EZ Way sit to stand mechanical lift positioned in the hallway, outside room [ROOM NUMBER]. The lift had dirt and debris built-up on the standing platform which appeared black in color. 3. Observation on 3/12/24 at 4:46 PM showed a heater vent cover in room [ROOM NUMBER] which had visible rust and damaged brackets sticking out. The damaged brackets had sharp edges visibly noticeable. 4. Observation on 3/12/24 at 4:48 PM showed the carpet in the owl creek common area was worn down and appeared shiny from wear. The area was black in color. Further observation showed the tan and black couch had visible discoloration on the seating area and tears in the cushions. 5. Observation on 3/12/24 at 4:50 PM showed the hand rails in the main dining room were discolored and the sealant had been worn away, which created a porous surface, and the rails could not be effectively sanitized. 6. Observation on 3/12/24 at 4:53 PM showed a urine smell was present in the hallway near room [ROOM NUMBER]. There were no residents present in the area. In addition, the hand rails in the area were discolored and the sealant had been worn away, which created a porous surface, and the rails could not be effectively sanitized. 7. Observation on 3/12/24 at 4:53 PM showed the transition between the secure unit and the hall way had built-up dirt and debris which was black in color. 9. Observation on 3/12/24 at 4:55 PM showed a urine smell was present in the hallway near room [ROOM NUMBER]. There were no residents present in the area. In addition, the hand rails in the area were discolored and the sealant had been worn away, which created a porous surface, and the rails could not be effectively sanitized. 10. Observation on 3/12/24 at 4:55 PM showed built-up dirt and debris in the transition between the hallway and room [ROOM NUMBER] which appeared black in color. 12. Observation on 3/12/24 at 4:56 PM showed broken tiles with built-up dirt and debris in the transition between the hallway and room [ROOM NUMBER] which appeared black in color. 13. Observation on 3/12/24 at 4:56 PM showed built-up dirt and debris in the transition between the hallway and room [ROOM NUMBER] which appeared black in color. 14. Observation on 3/12/24 at 4:57 PM showed built-up dirt and debris in the transition between the hallway and room [ROOM NUMBER] which appeared black in color. 15. Observation on 3/12/24 at 4:57 PM showed built-up dirt and debris in the transition between the hallway and room [ROOM NUMBER] which appeared black in color. 16. Interview with the administrator on 3/14/24 at 11:05 AM revealed she was aware of some cleanliness concerns and the facility was in the process of ending the contract with the current housekeeping agency. In addition, the facility had plans for some upgrades which included the carpet in the television area. She revealed the facility was aware of the condition of the handrails revealed she planned to request for new handrails because attempts to sand and stain took a long time. 17. Observations with maintenance director and housekeeping manager on 3/14/24 beginning at 11:15 AM showed a heater vent cover in the secure unit which was pulled away from the wall, which created a gap large enough for residents to place their hands, and was damaged in a way the vent cover had sharp edges. A second heater vent cover, near the emergency exit, was dented on one side which created a protruding metal angle sticking out and was sharp. In addition, there was a chipped area in the wood hand rail near room [ROOM NUMBER] and a chipped area in the wood hand rail near the purple sage dining room, which created sharp edges. Interview with the maintenance director and housekeeping supervisor, during the observations, confirmed the hand rails could not be effectively sanitized. It was confirmed the identified transitions were not cleaned appropriately. The housekeeping supervisor revealed they could not clean the transition into the secure unit due to the doors sounding an alarm if they are open for too long. They revealed there was a plumbing leak on owl creek and the discoloration outside the soiled utility room was due to the leak. Further interview confirmed the maintenance had attempted to sand and seal hand rail; however, the process was very time consuming to complete. Further interview revealed the damaged heater vent cover and hand rails created a safety risk to residents.

Based on observation, review of the menu, and staff interview, the facility failed to ensure the menu was followed for 1 of 1 meals observed for meal preparation and tray line service. The findings were: 1. Review of the menu for the 3/13/24 lunch meal showed it included cranberry glazed pork loin, baked potato, beets, and a roll for the regular diet. However, the CCHO (consistent carbohydrate diet for diabetes) menu consisted of a baked pork loin, 1/2 baked potato, beets, and no roll. The following concerns were identified during tray line service on 3/13/24 from 12:03 PM through 12:59 PM: a. Resident #40 had a CCHO diet and was served cranberry sauce over the pork, a whole potato, beets, and a roll. b. Resident #39 had a CCHO diet and was served cranberry sauce over the pork, half a potato, beets, and a roll. c. Resident #28 had a CCHO diet and puree texture and was served pureed pork with the cranberry sauce, pureed beets, mashed potatoes, and pureed bread. d. Resident #34 had a CCHO diet and soft and bite sized texture and was served ground pork with cranberry sauce, mashed potatoes, ground beets, and a roll. e. Resident #1 had a CCHO diet and was served pork with cranberry sauce, half a potato, beets, and a roll. f. Resident #24 had a CCHO diet and was served pork with cranberry sauce, half a potato, beets and a roll. g. Resident #13 had a CCHO diet and was served pork with cranberry sauce, half a potato, beets and a roll. 2. During an interview on 3/13/24 at 4:32 PM the certified dietary manager (CDM) confirmed residents with a CCHO diet order should not have received the cranberry sauce over the pork, should have received half a potato, and should not have received a roll.

Based on observation, staff interview, medical record review, and policy review, the facility failed to protect the residents' right to be free from physical abuse by staff and by a resident for 2 of 6 sample residents (#4, #8). This failure resulted in harm to resident #4 and to resident #8, who showed evidence of psychosocial harm such as crying and shaking. The findings were: 1. Review of the admission record showed resident #4 was initially admitted to the facility on [DATE]. The resident had a brief interview for mental status (BIMS) score of 0 out of 15, indicating the resident was severely cognitively impaired. Review of the resident's 7/20/23 diagnosis report showed the resident's diagnoses included chronic dementia with other behavioral disturbance, other specified depressive episodes, unsteady on feet, abnormalities of gait and mobility, lack of coordination, and abnormal posture. The following concerns were identified: a. Review of the nurse progress note dated 7/2/23 at 7:30 PM showed Resident was slapped on the face today. Resident tearful after although is doing better and does not remember incident. b. Interview on 7/20/23 at 1:00 PM with hospitality aide (HA) #1 revealed she witnessed the 7/2/23 incident. The HA stated [CNA #1] slapped [the resident] on the left side of [his/her] face while changing/toileting [him/her]. After [CNA #1] hit the resident [the resident] cried for about 15 minutes. The HA also stated that after the incident, the nurse was called, and the administrator, the police and family were notified. c. Telephone interview with CNA #1 on 7/20/23 at 5:50 PM revealed the incident occurred early in in the morning on 7/2/23, before the medication pass. The CNA described how the resident was refusing to help with cares, was grabbing onto the bathroom bar by the toilet, spitting, swinging his/her arms, pulling on his/her clothes, and refusing to sit on toilet. The CNA #1 stated that while providing care to the resident, she controlled the resident's arms and movements while trying to toilet him/her and change the resident's undergarments and clothes. The resident hit her multiple times and the CNA #1 slapped the resident's face. The CNA further stated, .I know it was wrong of me but I reported it right away, I knew I was in trouble. They got rid of me. 2. Review of the admission record showed resident #8 was initially admitted to the facility on [DATE]. The resident had a BIMS score of 3 out of 15, indicating the resident was severely cognitively impaired. The resident had diagnoses listed which included fracture of other parts of pelvis, hypoxemia, mild cognitive impairment, need for assistance with personal care, dementia with other behavioral disturbance, abnormalities of gait and mobility. Review of the resident's care plan updated 6/9/23 showed the resident needed extensive assistance with activities of daily living. The following concerns were identified: a. Review of the progress note for resident #3 dated 7/1/23 at 3:22 PM showed I was called to the Unit and saw [resident #8] on the floor crying. The CNA then reported that [resident #3] just threw a cup of fluids then [s/he] got out of [his/her] recliner went over to [resident #8], whom was approx. 10 feet away on the other side of a table, and grabbed [resident #8] by [his/her] hair pulling [his/her] head back and forth several times then pulled [resident #8] out of [his/her] chair onto the floor. This resident then went directly to [his/her] room and shut the door. The administrator was notified she attempted to notify the MD and families, messages left. 1 on 1 was started. c. Review of the facility incident report form dated 7/1/23 at 11:50 AM showed after the altercation resident #8 was visibly shaking, crying, and difficult to console. The resident stated Why would a [man/woman] hurt a [man/woman] like that. Further review showed the resident was escorted to his/her room and assessed for injury. No injury was noted at that time. d. Interview with the facility administrator 7/20/23 at 11:05 AM confirmed an assessment was completed following the incident, no injuries were identified, and the physician and resident daughter were notified. e. Interview with CNA #1 on 8/1/2023 at 1:42 PM confirmed she witnessed the incident and confirmed the events as described in the 7/1/23 at 3:22 PM progress note. The CNA stated resident #8 was pulled from the wheelchair onto the floor and was screaming and crying as a result of the incident. The CNA stated the altercation happened in less than 2 minutes and there was no time to anticipate or react to prevent it. 3. Review of the facility's policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated October 2022, showed: Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse .In some abuse or neglect situations, it may be difficult to determine the psychosocial outcome to the resident. In these situations, it is appropriate to consider how a reasonable person in the resident's position would be impacted by the incident.

Based on medical record review, staff interview, and hospital record review, the facility failed to ensure pain associated with a change in condition was treated effectively for 1 of 5 sample residents (#2) with a change in condition. This failure resulted in harm to resident #2, whose pain was not assessed or treated for [REDACTED]. The resident was transferred out to the hospital and found to have hip and clavicle fractures. The findings were: Review of the 12/5/18 quarterly MDS assessment showed resident #2 required supervision for bed mobility, transfer, and locomotion on and off the unit. The resident required limited assistance for walking in room and extensive assistance with dressing and toileting. According to this MDS assessment the resident's brief interview for mental status (BIMS) score was not completed; however, on the 9/18/18 annual MDS assessment the resident was cognitively intact with a BIMS score of 15/15. Review of the interdisciplinary team (IDT) note dated 12/17/18 at 8:43 AM showed the resident had an unwitnessed fall in his/her bathroom on 12/16/18 at 6:07 PM. The resident reported falling onto his/her right side while attempting to close the door. The 12/16/18 timed at 7:07 PM nursing note showed the resident was alert and able to make needs known, and was moving all extremities. The resident was assisted to bed with assist of 2, stance was weak and had unsteady balance. There was no mention of pain in the note, there were injuries which included a skin tear to the right elbow, and abrasion to the right ear, and a bump to the right upper side of the head. The physician and family were notified and neurological (neuro) checks were initiated. Review of a 12/16/18 pain evaluation timed at 6:29 PM showed the resident was interviewable and denied any pain or discomfort. Review of the neuro checks showed they were within normal limits. The following concerns were identified: a. Review of the 12/17/18 timed at 6:53 AM nursing notes showed, .Complained of pain on right leg. Administered pain medication with expected outcomes. Neuro checks continued and is WNL (within normal limits). Resident didn't sleep well last noc (night). Will continue to monitor for changes. b. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. This pain medication was administered on 12/17/18 at 5:30 AM. There was no documentation to show the pain level or the effectiveness of the medication was assessed. The MAR indicated [REDACTED]. c. Review of the resident's functional performance record for (MONTH) (YEAR) showed the resident declined in bed mobility, transfers, ambulation, and locomotion after the fall on 12/16/18. The resident had been supervision or limited assistance in these areas and declined to extensive assistance beginning on 12/17/18. d. Interview with CNA #1 on 12/21/18 at 9:53 AM verified he worked with the resident on 12/17/18 during the day shift (6 AM to 6 PM) and the resident was up and was able to transfer to the toilet, and had gotten up for the noon meal. The CNA stated the resident required more help than usual, and had no complaints of pain. e. Interview with CNA #2 on 12/21/18 at 10:05 AM revealed she had worked with the resident on 12/18/18 during the day shift (6 AM to 2 PM). She recalled the resident required extensive assistance and was sore from falling but she did not remember specific complaints of pain. f. Interview with LPN #1 on 12/20/18 at 6:27 PM revealed she had cared for the resident the night shift (6 PM to 6:30 AM) on 12/17/18 to 12/18/18. She recalled helping the aides provide care to the resident in bed at approximately 5:30 AM on 12/18/18, and the resident stated s/he hurt really bad, a 10 out of 10 the nurse stated when she raised the resident's right foot slightly off the bed s/he screamed out in pain. The nurse also revealed she saw noticeable bruising to the right leg and shoulder area. The nurse stated she had not documented this; however, she passed it onto the oncoming day shift nurse. She further stated the resident was treated for [REDACTED]. g. Interview with LPN #2 on 12/21/18 at 9:35 AM revealed she was made aware on the morning of 12/18/18 the resident had a bad night. She stated after breakfast around 9 AM the resident was complaining of pain saying his/her leg hurt. She also stated she saw the bruising at that time. However, the LPN confirmed she had not documented a pain assessment or administered any pain medication. Review of the 12/18/18 timed at 12:08 PM nurses note showed LPN #2 documented resident c/o (complaint of) right leg and knee pain purplish discoloration on back of leg .requested an order for [REDACTED].#2 documented the resident was up for lunch and was having difficulty eating. The note showed the resident voiced moving the arm in upright position hurt, and there were multi purple discoloration around the shoulder area. h. Interview with the DON on 12/21/18 at 8:36 AM verified the resident was experiencing pain on the morning of 12/18/18. The DON stated she was made aware the resident was having a change in condition and LPN #2 was requesting to have the resident sent out for x-rays. The DON completed the change in condition assessment. She confirmed there was no evidence in the medical record to show an assessment of the resident's pain level, or any pain treatment was provided after 12/17/18 at 5:30 AM. i. Review of the DON's note dated 12/18/18 timed at 1:04 PM showed she was informed of the x-ray results which showed abnormality in Right Hip. Orders were received to transfer the resident to the hospital of the family's choice in a nearby town for further evaluation. j. Review of the hospital record physician note dated 12/18/18 at 3:40 PM showed the resident had complaints of pain in the right hip and was not able to ambulate or bear weight. k. Review of the hospital radiology report dated 12/18/18 showed 2 views of the right shoulder revealed a clavicle fracture with minimal displacement. l. Review of the hospital nurse's notes dated 12/18/18 at 6:55 PM showed the resident was transferred to another hospital for orthopedic services. m. Review of the receiving hospital's physician notes/assessment on 12/18/18 at 10:49 PM showed the resident was admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED].

Based on observation, resident, family, and staff interview, and medical record review, the facility failed to ensure interventions for pain were effective for 3 of 6 sample residents (#5, #11, #124) reviewed for pain. This failure resulted in actual harm for resident #11 who had identified pain that was not addressed effectively. The findings were: 1. Review of the 8/15/18 care plan showed resident #11 required assistance with all activities of daily living and had severe cognitive impairment, impaired thought processes, communication problems, and potential for chronic pain related to [MEDICAL CONDITION]. Interview on 11/5/18 at 4:31 PM with a family member revealed the resident complained about pain in his/her left arm that worsened when moved or repositioned. The family member stated an x-ray of the resident's arm showed no fractures, but the resident continued to complain of the pain. The family member also stated the resident had experienced pain due to arthritis in the past and it would be good if there was some way to prevent the pain when staff used the mechanical lift for transfers. During the interview, the resident was observed sitting in the wheelchair using his/her right arm to hold the left arm close to his/her stomach and performed continuous massaging motions on the left arm. The following concerns were identified: a. Interview on 11/5/18 at 4:05 PM with LPN #1 revealed staff were aware of the resident's complaints about the pain in his/her left arm; but the x-rays showed the resident did not have a fracture. She further stated the resident's family mentioned something about arthritis, however she was not aware of any follow up care that had been implemented to address it. b. Observation on 11/7/18 at 11:45 AM showed CNA #2 and CNA #1 used a mechanical sit-to-stand lift to transfer the resident from the recliner chair to the bathroom. During the observation, the resident held his/her left arm with the right arm; and cried out in pain when the CNAs gently moved the resident's left arm to the support bar on the lift. Continued observation showed throughout the interaction the resident used his/her right arm to support and protect the left arm and repeatedly stated my arm hurts. c. On 11/7/18 at 4:38 PM interview with CNA #1 revealed direct care staff were aware of the resident's complaints about the pain in his/her left arm; but they had not received any instructions about support/positioning techniques, pain medication prior to transfers, or specific interventions to address the pain. d. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. This review showed no additional pharmacological, and no non-pharmacological interventions for arm pain. e. On 11/8/18 at 11:10 AM interview with the resident care manager revealed she knew the x-ray was negative and family reported the resident had arthritis. She stated the care plan interventions addressed pain, but did not include measures to alleviate the pain in the resident's arm because staff had not developed pharmacological or non-pharmacological interventions that specifically addressed arm pain. 2. Review of the 10/31/18 admission MDS assessment showed resident #124 was admitted to the facility on [DATE], had a BIMS score of 15/15 (cognitively intact), and had a [DIAGNOSES REDACTED]. Interview with the resident on 11/6/18 at 11:42 AM revealed s/he had pain which radiated through his/her eye and sometimes down his/her nose. Observation at that time showed the resident was rubbing his/her head and grimacing. Review of the current physician's orders [REDACTED]. [MEDICATION NAME] (medication for nerve pain) 100 mg 2 capsules 3 times a day was also prescribed. Review of the admission pain evaluation dated 10/24/18 showed the resident had mild to moderate pain which was made worse by lack of pain medications. The following concerns were identified: a. Review of the physician's orders [REDACTED]. b. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the pain management flowsheet showed no documentation the medication had been administered or the effectiveness determined. c. Review of the (MONTH) (YEAR) pain management flowsheet showed the resident had a pain level of 7 on 10/29/18 at 8:50 AM and again on 10/30/18 at 6:42 AM. The resident was given 650 mg of Tylenol. The Follow-up evaluation of intervention and/or discomfort showed the pain level remained at a 7. The non-medication intervention was noted as decrease environmental stimulation. d. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the pain management flowsheet showed no documentation the medication had been administered or the effectiveness determined. e. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the pain management flowsheet showed no documentation the medication had been administered or the effectiveness determined. 3. Review of the 11/1/18 quarterly MDS assessment showed resident #5 had a BIMS score of 12/15 (moderate cognitive impairment) and was coded as having frequent, mild pain. Review of a physician order [REDACTED]. The following concerns were identified: a. Review of the (MONTH) (YEAR) Pain Management Flowsheet showed no documentation the medication had been evaluated for effectiveness 4 of the 12 times the [MEDICATION NAME] was administered. b. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the pain management flowsheet showed no documentation the medication had been administered or effectiveness determined for 8 of the 12 times the medication was administered. 4. Interview with the DON on 11/7/18 at 2:25 PM revealed the nurses should have been more mindful of the time and administered the [MEDICATION NAME] instead of the Tylenol to resident #124. In an additional interview on 11/8/18 at 12:33 PM the DON confirmed the pain management flowsheets were not complete.

Based on observation, medical record review, fall investigation report review and staff interview, the facility failed to ensure interventions were implemented/developed to prevent and minimize falls for 1 of 6 sample resident (#35) who had falls. This failure to develop and/or implement fall interventions resulted in repeated falls causing head and facial injuries that required medical intervention. The findings were: 1. Review of the actual falls care plan, revised on 8/28/15, showed resident #35 was at high risk for falls related to diabetic neuropathy, poor balance, and poor safety awareness. Review of the 11/3/15 fall evaluation showed the resident was at high risk for falls and an intervention review was required. The following concerns were identified: a. Review of the 7/26/15 post-fall investigation showed the resident had fallen out of his/her wheelchair at 7 AM that day. Review of the 7/26/15 progress note, timed 8:50 AM showed the resident had been observed reaching for something on the floor while seated in the wheelchair. The resident fell forward out of the wheelchair onto the floor, causing a laceration above the resident's right eyebrow. The resident was transported to the emergency room for evaluation. b. Review of the 8/20/15 post-fall investigation showed the resident was found on the floor on 8/19/15 at 10:20 AM. The resident was nonverbal, unresponsive, with fixed pupils after being assisted off the floor. The resident was sent to the emergency room for evaluation. Review of the 8/19/15, timed 11:41 PM, progress note showed the resident returned from the emergency room with a [DIAGNOSES REDACTED]. c. Review of the 8/22/15 post-fall investigation showed the resident was witnessed to fall from the wheelchair to the floor on 8/21/15 at 1:35 PM, resulting in a wound to the head. The resident was transported to the emergency room for further evaluation. d. Review of the resident's care plan for falls showed it was last revised on 8/25/15, and was reviewed on 10/22/15. Interventions revised or added to the care plan on 8/25/15 included the following: (resident name) is encouraged/reminded to use (his/her) call light for assistance with all transfers including from (his/her) bed to (his/her) wheelchair and Review of care plan for appropriate and timely interventions. There were no interventions that addressed the resident's tendency to fall forward out of the wheelchair, resulting in head and facial injuries. e. Review of the 9/2/15, timed 11:27 AM, progress note showed .OT (occupational therapy) has made changes to residents WC (wheelchair), PT (physical therapy) is evaluating. No change of care at this time. f. Review of the 9/3/15, timed 9:57 AM, progress note showed the resident was found on the floor in the television room. The resident had been seated in the wheelchair prior. The resident was bleeding from the head and nose. g. Observation of the resident on 11/3/15 at 10:40 AM showed the resident was leaning forward in the wheelchair, holding his/her right arm, and complaining of pain. Review of the 11/3/15 fall scene investigation report showed the resident slow rolled out of the wheelchair and landed on the floor that same day at 1:40 PM. Review of the 11/3/15, timed 1:40 PM, progress note showed the resident had been seated in the wheelchair when another resident moved the wheelchair forward. The movement caused the resident to roll out of the wheelchair and land on the floor. The resident was bleeding above the right eye and was sent to the emergency room for evaluation. Review of the 11/3/15, timed 5:20 PM, progress note showed the resident returned from the emergency room with sutures holding laceration intact. h. Interview with the DON on 11/18/15 at 1:45 PM revealed the the facility failed to identify interventions to prevent falls from the wheelchair and confirmed there were no interventions added to the care plan to prevent future falls from the wheelchair.

Based on medical record review, observation and staff interview, the facility failed to ensure assessments and interventions were timely and consistent to prevent worsening of pressure ulcers for 2 of 3 sample residents (#7, #15) identified as having pressure ulcers. The lack of timely assessments and intervention resulted in harm for resident #15. The findings were: 1. Review of the medical record for resident #15 showed s/he had [DIAGNOSES REDACTED]. Observation on 9/9/14 at 10:45 AM showed the resident had an open wound on his/her coccyx. Further, the resident used a wheelchair with a padded seat for locomotion and wore an incontinence pad. The following concerns were identified: a. Review of the 6/17/14 quarterly MDS assessment showed the resident was not at risk for developing a pressure ulcer and did not have a pressure ulcer. The assessment showed the resident did not walk and used a wheelchair for mobility. Review of the nurse's note dated 6/20/14, 3 days following the completed MDS assessment, showed the resident complained of a "sore on my rectum." The nurse examined the area and noted: "a very angry red area on tail bone approximately 3 cm x 3 cm with a 1.5 cm open area." The wound was cleaned and barrier cream applied. There was no documentation to show the physician was notified. b. The nursing note dated 6/23/14 showed there were 2 open areas located above the coccyx area that each measured 2 cm by 0.75 cm. A [MEDICATION NAME] dressing was placed over the wound. There was no indication the physician was notified. c. Review of the nurse's note dated 6/29/14 showed the wound measured 4 cm by 2 cm with a depth of 1 cm, indicating it was a Stage III pressure ulcer. The note further showed the physician would be notified (9 days after the initial observation of the wound). d. A physician order [REDACTED]. e. Review of the physician office visit note dated 7/3/14 showed the resident had a sacral decubitus ulcer. He described the wound as follows: "This is big and looks infected. It was deep. (His/her) chances of good wound healing are poor given (his/her) known vascular disease, and diabetes, obesity, urinary incontinence, mobility problems." Review of the policy and procedure for prevention and treatment of [REDACTED]." Further, the policy showed the staff was to communicate with the physician and document the communication. At the time of the exit on 9/11/14 at 12:20 PM the corporate nurse indicated there was no further evidence the physician had been notified of the initial development of the pressure ulcer before 6/30/14 when the wound was noted to be a Stage III ulcer. As of 9/25/14 the facility failed to provide any additional information to the state survey agency to demonstrate the pressure ulcer was unavoidable. 2. Review of the medical record for resident #7 showed s/he had [DIAGNOSES REDACTED]. Review of the weekly pressure ulcer report dated 5/28/14 showed the resident developed a new Stage II pressure ulcer that measured 2.6 cm by 1 cm. Further, the documentation failed to show the physician was notified of the new pressure ulcer. Additional measurements and staging was completed on 6/4/14, 6/11/14 and then not until 7/1/14 (20 days later). At that time, the documentation showed the ulcer measured 2.5 cm by 1 cm and remained a stage II pressure ulcer. Further review showed no additional documentation had been completed for the pressure ulcer to show wound progress or regression. Review of the care plan related to pressure ulcers showed interventions included a weekly pressure ulcer condition report. The size and staging of the wound were to be included. Interview with the DON and corporate nurse on 9/11/14 at 10:30 AM revealed the pressure ulcer needed to be monitored weekly.