Every finding on record at Avir at Abilene

Based on interview and record review, the facility must not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 of 2 (NCNA A) non-certified nurse aides reviewed.The facility failed to ensure full-time NCNA A was certified within four months of her hire date of 12/16/25.This failure placed residents at risk of receiving inappropriate care from an individual whose skill level was not known. Findings included:Record review of NCNA A's employee filed indicated she was hired on 12/16/25 as a full-time nurse aide. NCNA A's training document revealed orientation and annual training completed on 11/1/1/25, and EMR/NAR completed on 11/7/2025. There was no evidence of a competency evaluation, NATCEP registration, or completion of nurse aid training.Record review of Nurse staffing schedule from June 01, 2026-August 11, 2026, reflected NCNA A worked as the only nurse aide on the hall with one nurse:-Hall 100 from 6 am-6pm on June 1, 2026;-Hall 100 from 6 am-6 pm on June 2, 2026;-Hall 100 from 6 am-6 pm on June 5, 2026;-Hall 100 from 6 am-6 pm on June 6, 2026;-Hall 100 from 6 am-6 pm on June 7, 2026;-Hall 100 from 6 am-6 pm on June 10, 2026;-Hall 100 from 6 am-6 pm on June 11, 2026;-Hall 100 from 6 am-6 pm on June 15, 2026;-Hall 100 from 6 am-6 pm on June 16, 2026;-Hall 100 from 6 am-6 pm on June 19, 2026;-Hall 100 from 6 am-6 pm on June 20, 2026;-Hall 100 from 6 am-6 pm on June 21, 2026;-Hall 100 from 6 am-6 pm on June 24, 2026;-Hall 100 from 6 am-6 pm on June 25, 2026;-Hall 100 from 6 am-6 pm on June 29, 2026;-Hall 100 from 6 am-6 pm on June 30, 2026;-Hall 100 from 6 am-6 pm on July 3, 2026;-Hall 100 from 6 am-6 pm on July 4, 2026;-Hall 100 from 6 am-6 pm on July 5, 2026;-Hall 100 from 6 am-6 pm on July 8, 2026;-Hall 100 from 6 am-6 pm on July 9, 2026;-Hall 100 from 6 am-6 pm on July13, 2026;-Hall 100 from 6 am-6 pm on July 14, 2026;-Hall 100 from 6 am-6 pm on July 17, 2026;-Hall 100 from 6 am-6 pm on July 18, 2026;-Hall 100 from 6 am-6 pm on July 19, 2026;-Hall 100 from 6 am-6 pm on July 22, 2026;-Hall 100 from 6 am-6 pm on July 23, 2026;-Hall 100 from 6 am-6 pm on July 27, 2026;-Hall 100 from 6 am-6 pm on July 28, 2026;-Hall 100 from 6 am-6 pm on July 31, 2026;-Hall 100 from 6 am-6 pm on August 1, 2026;-Hall 100 from 6 am-6 pm on August 2, 2026;-Hall 100 from 6 am-6 pm on August 5, 2026;-Hall 100 from 6 am-6 pm on August 6, 2026;-Hall 100 from 6 am-6 pm on August 10, 2026 andHall 100 from 6 am-6 pm on August 11, 2026.Record review of the facility resident matrix dated 8/12/26 revealed there were 25 residents who resided on Hall 100.During an interview on 8/14/26 at 05:30 a.m., CNA B stated the NCNA would have been checked off on skills by the DON. CNA B stated the skills check-off would include feeding a resident, transferring a resident and providing a shower to the residents. CNA B stated an NCNA would have to work with a CNA. CNA c stated the nurses oversee the NCNA.During an interview on 8/14/26 at 6:50 a.m., the DON stated NCNA A had completed CNA classes at a sister facility and was regenerated to take the test. The DON stated she was not aware NCNA A had not tested. The DON stated she failed to follow up with NCNA A to see if she had tested her certification. The DON stated she was not aware that an NCNA A could not work past 4 months of hire without the certification. The DON stated her expectations were new NCNA's would be certified within 4 months of date of hire. The DON stated she did not feel this failure had caused any harm to the residents. The DON stated the facility did not have a policy for an NCNA position. The DON stated NCNA A had provided her with an authorization to test. The DON stated she did not have a copy of the receipt for NCNA A authorization to test. NCNA was removed from the schedule.During an interview on 8/14/26 at 08:15 a.m., the ADMN stated his expectations were if an NCNA did not pass the certification test after 4 months of being hired they should have been taken off the schedule. The ADMN stated there was no harm to the residents due to this failure. The ADMN stated this failure occurred due to oversight. The ADM stated the DON was responsible for ensuring the CNAs were certified after 4 months of hire date.Attempted interview with NCNA A via telephone on 8/14/26 at 08:45 am., NCNA A did not answer or return this surveyors telephone call.

Based on observation, interview, and record review the facility failed to ensure that the residents were able to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 of 6 residents (Resident #1, Resident #3, Resident #4) reviewed for physical environment. The facility failed to ensure the volume on the call light system monitor at the nurse's station was not turned down, resulting in nursing staff not being able to hear if a resident activated their call light. This failure could place the residents at risk of inadequate care and services.Findings included: In an observation on 7/19/2026 at 11:35 A.M., upon entry into the facility, there were no call light sounds or lights noted.In an observation on 7/19/2026 at 12:29 P.M., there were no call light sounds or lights noted.Record review of Resident #4's face sheet reviewed on 7/19/2026, reflected a [AGE] year-old female, with an admission date of 6/24/2026. Resident #4 had diagnoses of polyneuropathy (neurological condition where multiple peripheral nerves throughout the body are damaged simultaneously), muscle spasm (sudden, involuntary muscle contraction), Parkinsonism (an umbrella tern that can be triggered by other neurological disorders and characterized by four primary motor symptoms: resting tremors, slowness of body, rigid muscles, and postural instability), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Urinary Tract Infection (bacterial infection in the urinary tract).In an interview on 7/19/2026 at 1:00 P.M. with Resident #4, she stated it would take staff 2-3 hours before they answer her call light. Resident #4 stated staff come in and turn off the light and then leave without helping her. She stated she waits about 5 minutes and turns it back on again. Resident #4 stated she had brought it to staff's attention and it was still happening. Resident #4 stated she had redness in the crease of her right leg where the brief rubbed and from moisture due to long wait times. She stated staff do apply cream to help when she was changed.Record review of a Grievance form dated 6/26/2026 from Resident #4 reflected on the evening of 6/24/2026 Resident #4 was left in a wet diaper and poop until the next morning. The form further reflected staff were educated on resident's needs.Record review of Skin Observation Task reviewed on 7/20/2026 for Resident #4 reflected red area on 7/8/26 at 1:44 P.M., 7/9/2026 at 12:24 A.M.; 7/10/2026 at 12:50 A.M.; 7/18/2026 at 1:27 P.M.; 7/19/2026 at 12:10 P.M.; and 7/20/2026 at 12:42 A.M.In an observation on 7/19/2026 at 1:35 P.M., there were no call light sounds or lights noted.Record review of Resident #3's face sheet reviewed on 7/19/2026 reflected an [AGE] year-old female, with an admission date of 4/1/2023. Resident #3 had diagnoses which included: Stress incontinence (involuntary leakage of urine caused by physical pressure on the bladder), occlusion and stenosis of unspecified carotid artery (narrowing or blockage of either the main arteries that supply blood to the brain), rheumatoid arthritis (autoimmune disease where immune system mistakenly attacks the lining of your joints), Chronic kidney disease (kidneys damaged and lose ability to filter blood properly), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Need for assistance with personal care (daily activities such as bathing, dressing & mobility), History of Urinary Tract Infection (bacterial infection in the urinary tract), Persistent asthma (inflamed airways), Lack of coordination and muscle weakness.In an interview on 7/19/2026 at 1:40 P.M. with Resident #3, she revealed she utilized her call light, but it could take over an hour at times so she would yell at staff as they walked by to get them to come and take care of her.In an observation on 7/19/2026 at 2:23 P.M., there were no call light sounds or lights noted.Record review of Resident #1's Face Sheet reviewed on 7/19/2026 reflected an [AGE] year-old female, with an admission date of 3/9/2026. Resident #1 had diagnoses which included: Chronic Kidney Disease Stage 1 through Stage 4 (severe kidney damage and lose the ability to filter blood properly), Malignant Neoplasm of female breast (breast cancer), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Dehydration (loses more fluid than it takes in disrupting fluid/,mineral balance), Limitation of Activities due to disability (participation restrictions in normal activities such as seeing, hearing, walking, or problem solving), Muscles wasting and atrophy (shrinking of muscle tissue resulting in weakness and loss of mass).In an interview on 7/19/2026 at 2:54 P.M. with Resident #1, she stated she waited an hour for staff to respond to her call light button being activated. Resident #1 stated that one unknown night she had activated her call light and a nurse came in after awhile and stated there was an emergency and Resident #1 was not changed until the following morning. Resident #1 stated she had a wound on her rectum, but that staff were treating it, and it was slowly getting better. Resident #1 stated she had come to the facility with the wound.In an observation on 7/19/2026 at 3:15 P.M., there were no call light sounds or lights noted.In an interview on 7/19/2026 at 3:55 P.M. with ADON C, she furrowed her brow when asked if the call light system worked and stated she is pretty sure the call lights work and walked away.In an interview on 7/19/2026 at 4:00 P.M. with CNA E, he revealed he had been told by a resident that they had not been checked on all night but he could not recall the resident's name and he reported it to ADM A. CNA E stated he had been told by some residents that they wait 2-3 hours for call lights to be answered but he could not recall their names. He stated he also had a resident tell him one time that she could not sleep at night for fear of not being checked on and now that he was on shift she could sleep because she knew he would care for her. CNA E stated he could not recall her name either. CNA E stated there was a call light monitor at the nurse's station and regular call lights have no audible sound while bathroom lights do. CNA E could not provide any information on any negative resident impact from call light times reported.In an observation on 7/19/2026 at 4:48 P.M., a call light sound was heard in the hallway and stopped at 4:52 P.M.In an interview on 7/20/2026 at 10:12 A.M. with ADON C, she revealed she checked the call light monitor at the nurse's station yesterday (7/19/26) after she was asked if the call light system worked and she realized she had not heard any call light sounds either. ADON C stated she found the volume was turned down on the monitor at the nurse's station. ADON C stated that was why there were no call lights sounding but she turned it back up and informed ADM A. ADON C stated she would have to educate staff to ensure the volume is not turned down and monitor daily to see who and why it got turned down.Record review of Resident Rights policy dated 2001 reflected Employees will treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 6 residents (Resident #1, Resident #2, Resident #4, Resident #6) reviewed for care plans.The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, Resident #4, Resident #6 described the resident's goals for admission and desired outcomes. The facility failed to ensure the comprehensive care plan for Resident #1, Resident #2, Resident #4, Resident #6 described the resident's preference and potential for future discharge. The facility failed to ensure the comprehensive care plan Resident #1, Resident #2, Resident #4, Resident #6 documented a desire to return to the community was assessed. This failure could place the residents at risk of not receiving adequate care.Findings included: Record review of Resident #1's Face Sheet reviewed on 7/19/2026 reflected an [AGE] year-old female, with an admission date of 3/9/2026. Resident #1 had diagnoses which included: Chronic Kidney Disease Stage 1 through Stage 4 (severe kidney damage and lose the ability to filter blood properly), Malignant Neoplasm of female breast (breast cancer), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Dehydration (loses more fluid than it takes in disrupting fluid/,mineral balance), Limitation of Activities due to disability (participation restrictions in normal activities such as seeing, hearing, walking, or problem solving), Muscles wasting and atrophy (shrinking of muscle tissue resulting in weakness and loss of mass). Record review of Resident #1's MDS dated [DATE] reflected there was no active discharge planning occurring for Resident #1 to return to the community but possible discharge date 3 or fewer months away. Record review of Resident #1's undated Care Plan reviewed on 7/19/2026 reflected no assessment for a residents return to the community, desired outcomes, preference and potential for future discharge was located. Record review of Resident #2's face sheet reviewed on 7/19/2026 reflected an [AGE] year-old male, with an admission date of 3/10/2026. Resident #2 had diagnoses which included: atrial fibrillation (chaotic, rapid quivering in the heart's upper chambers causing irregular and often fast heartbeat), syncope and collapse (fainting and falling to the ground), muscle wasting and atrophy (shrinking of muscle tissue resulting in weakness and loss of mass), Need for assistance with personal care (daily activities such as bathing, dressing & mobility). Record review of Resident #2's MDS dated [DATE] reflected there was no active discharge planning occurring for Resident #2 to return to the community and not to be asked on future assessments. The MDS further reflected this to be documented in the resident's clinical record. Record review of Resident #2's undated Care Plan reviewed on 7/19/2026 reflected no assessment for a residents return to the community, desired outcome, preference and potential for future discharge was documented. Record review of resident #4's face sheet reviewed on 7/19/2026, reflected a [AGE] year-old female, with an admission date of 6/24/2026. Resident #4 had diagnoses of polyneuropathy (neurological condition where multiple peripheral nerves throughout the body are damaged simultaneously), muscle spasm (sudden, involuntary muscle contraction), Parkinsonism (an umbrella tern that can be triggered by other neurological disorders and characterized by four primary motor symptoms: resting tremors, slowness of body, rigid muscles, and postural instability), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Urinary Tract Infection (bacterial infection in the urinary tract). In an interview on 7/20/2026 at 1:45 P.M. with Resident #4, she revealed she was at the facility to complete therapy so she could get better and go home with her family. Record review of Resident #4's undated Care Plan reviewed on 7/19/2026 reflected no assessment for a residents return to the community, desired outcome, preference and potential for future discharge was documented. Record review of Resident of Resident #6's face sheet reviewed on 7/20/2026 reflected a [AGE] year-old-female with the admission date of 7/1/2026. Resident #6 had diagnoses that included: Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Chronic respiratory failure with hypoxia (long-term inability of the lungs to adequately oxygenate the blood), Stimulant abuse (continued use of stimulants, such as cocaine, amphetamine, methamphetamine, ecstasy, and prescription drugs such as Adderall and Ritalin, despite harm to the person using them). In an interview on 7/20/2026 at 10:02 A.M. with Resident #6, she revealed she was at the facility short-term and planned to go home. Record review of Resident #6's undated Care Plan reviewed on 7/20/2026 reflected no assessment for a residents return to the community, desired outcome, preference and potential for future discharge was documented. In an interview on 7/20/2026 at 11:54 A.M. with MDS G, she stated she was responsible for completing the MDS assessment and completing some of the care plans. MDS G stated DON B also completed some care plans. MDS G stated discharge information should be in the care plans. She stated a negative impact of it not being included could be the facility might not follow through with discharge planning but that had not happened. MDS G stated Resident #1, Resident #2, and Resident #4 had no active discharge plan. MDS G stated Resident #4 would like to eventually go home after therapy and Resident #2 went back and forth with his desire to go home or stay in the facility. In an interview on 7/20/2026 at 12:13 P.M. with DON B, she revealed she did not realize discharge information was to be documented in the care plan. DON B stated she felt it made sense to include discharge information in the care plan because it would be part of the comprehensive plan for the resident's goals and outcomes. DON B did not answer when asked how this might affect the residents. Record review of Care Plans, Comprehensive Person-Centered policy dated 2001 reflected, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the residents stated goals upon admission and desired outcomes.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 1 facility reviewed for physical environment. The facility failed to provide a sanitary and comfortable environment with clean floors for residents, staff, and the public. This failure could create a potential risk for residents' safety and comfortability.Findings included:In an observation on 7/19/2026 at 11:40 A.M., the floors on hall 200, 300, around the nurse's station and the entrance of the dining room had black marks, dirty with pieces of dirt and pieces of glue, and small pieces of white paper on them. Hall 300 smelled of body odor and had discolored sticky floors. Two barrels were sitting in hall 300 outside the soiled linen closet. In hall 300, there was a bed and a Hoyer lift on the left side of the hallway towards the rear of the hallway. In the middle of hall 300, there was a Sit-to-stand, wheelchair, and an empty bedside commode on the left side of the hallway. In hall 300, there was a linen cart, loveseat, and a chair that sat on right side of hallway. Styrofoam cups were setting on the top of the chair in plastic wrap. A coffee cup filled with wet napkins inside and overflowing the coffee cup sat on the arm of the loveseat. An empty pill cup sat on arm of loveseat with two sugar packets on the cushion of the loveseat. [NAME] liquid was observed on the floor next to the loveseat.In an observation on 7/19/2026 at 12:08 P.M., the paper towel holder on hall 400 women's bathroom across from the activity room was full of paper towels but did not dispense the towels.Record review of Resident #4's face sheet reviewed on 7/19/2026, reflected a [AGE] year-old female, with an admission date of 6/24/2026. Resident #4 had diagnoses of polyneuropathy (neurological condition where multiple peripheral nerves throughout the body are damaged simultaneously), muscle spasm (sudden, involuntary muscle contraction), Parkinsonism (an umbrella term that can be triggered by other neurological disorders and characterized by four primary motor symptoms: resting tremors, slowness of body, rigid muscles, and postural instability), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Urinary Tract Infection (bacterial infection in the urinary tract).In an observation on 7/19/2026 at 1:00 P.M. in Resident #4's room, the floor was sticky making suction noises when walking. Unknown spills appeared in 3 areas but tracked as the floor was sticky from the bathroom door to the middle of the room. One spill appeared by the bathroom door, one by the roommate's bed and one by Resident #4's bed. Three wipes were on the floor next to the spill near Resident #4's bed and wipes appeared discolored.In an interview on 7/19/2026 at 1:00 P.M. with Resident #4, she stated the facility could do better with the cleanliness of her room. She stated housekeeping was to come daily but she had not seen them since Thursday (7/16/26). Resident #4 stated she was not happy with her floors and the smell on the hall (hall 300). She stated she had family come and they smelled the hall and it was embarrassing.In an observation on 7/19/2026 at 1:35 P.M., there were multiple dark brown pieces of glue and dirt on the floor in the dining room near the dining room entrance that appeared to have been swept from the dining room floor by housekeeping staff. Two housekeeping staff stood near a housekeeping cart next to the pile of brown pieces.In an interview on 7/19/2026 at 1:35 P.M. with HSK F, she stated it was her and her coworker's responsibility to clean the floors. HSK F stated housekeeping staff clean every room every day. HSK F did not answer when asked how residents were impacted from the floors in the current condition, but she thought it was from the wheelchairs.Record review of Resident #3's face sheet reviewed on 7/19/2026 reflected an [AGE] year-old female, with an admission date of 4/1/2023. Resident #3 had diagnoses which included: Stress incontinence (involuntary leakage of urine caused by physical pressure on the bladder), occlusion and stenosis of unspecified carotid artery (narrowing or blockage of either the main arteries that supply blood to the brain), rheumatoid arthritis (autoimmune disease where immune system mistakenly attacks the lining of your joints), Chronic kidney disease (kidneys damaged and lose ability to filter blood properly), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Need for assistance with personal care (daily activities such as bathing, dressing & mobility), History of Urinary Tract Infection (bacterial infection in the urinary tract), Persistent asthma (inflamed airways), Lack of coordination and muscle weakness.In an interview on 7/19/2026 at 1:40 P.M. with Resident #3, she stated she was concerned with the condition of the floors and had voiced them to ADM A. Resident #3 stated there was stuff tracked all over the hallways and she believed it was from the wheelchairs. She stated that the floor cleaner had left too much water in spots and it ruined parts of the floor and the glue was tracked.In an interview on 7/19/2026 at 4:00 P.M. with CNA E, he stated his best guess on why the floors were dirty was because housekeeping staff had changed recently. CNA E stated the facility had a resident pass away that morning and that is why the bed and possibly the other items were moved out of the room to get things ready for the next resident. He further stated that may be the smell that was in the hallway. CNA E did not respond to the impact of dirty floors or on residents.In an interview on 7/19/2026 at 4:56 P.M. with LVN H, she stated the floors were filthy and staff have brought it up to administration. LVN H stated housekeeping was to clean rooms daily, but she had not had any complaints from residents.In an interview on 7/20/2026 at 10:12 A.M. with ADON C, she stated housekeeping was responsible for keeping the floor clean. She stated the floor technician quit a few weeks ago. ADON C stated housekeeping was to clean each room daily, but the facility had more traffic on the weekends from family members. ADON C did not answer when asked about the effects on the residents. In an interview on 7/20/2026 at 12:13 P.M. with DON B, she stated housekeeping was responsible and they got a new supervisor and the floor technician quit and another staff in laundry quit. DON B stated she felt the cleaning was getting better. DON B did not answer when asked about the smell, bedside commode, and bed in hallway 300. DON B stated the coffee cup, and spill was probably from a resident sitting down drinking coffee at that location. DON B did not answer about the effects on the residents or whether she had received complaints.In an observation on 7/20/2026 at 1:50 P.M., dark brown pieces of dirt and glue with one white piece of trash were on the floor in the common lobby area.In an interview on 7/20/2026 at 2:20 P.M. with ADM A. he stated he got a new supervisor in housekeeping and there had been quite a bit of turnover but felt it was getting better. ADM A stated he did not feel the previous supervisor held staff to the current standard that the new supervisor was and that was why staff turnover occurred. ADM A stated the facility had a floor machine and it broke and he wanted it replaced and corporate was getting it fixed but had not yet as of today. However, regional maintenance came today, and ADM A told him the facility had received complaints about the floors. The housekeeping staff had to scrape the floors and then sweep it (debris) up from the wheelchairs. ADM A did not answer when asked about the impact of residents.Record review of the Homelike environment policy dated 2021 reflected, Residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect A personalized home like setting. These characteristics include: a. Clean, sanitary and orderly environment.3. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect depersonalized institutional setting. These characteristics include.b. Institutional odors.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 2 (Resident #3, Resident #4) of 6 residents reviewed for quality of care. The facility failed to follow standard practices of care in keeping the intake and filter clean on the oxygen concentrator for Resident #3 and Resident #4. The facility failed to keep the intake clean in the oxygen concentrators for Resident #3 and Resident #4. This failure could place the residents at potential risk of inadequate respiratory care.Findings included: Record review of Resident #3's face sheet reviewed on 7/19/2026 reflected an [AGE] year-old female, with an admission date of 4/1/2023. Resident #3 had diagnoses which included: Stress incontinence (involuntary leakage of urine caused by physical pressure on the bladder), occlusion and stenosis of unspecified carotid artery (narrowing or blockage of either the main arteries that supply blood to the brain), rheumatoid arthritis (autoimmune disease where immune system mistakenly attacks the lining of your joints), Chronic kidney disease (kidneys damaged and lose ability to filter blood properly), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Need for assistance with personal care (daily activities such as bathing, dressing & mobility), History of Urinary Tract Infection (bacterial infection in the urinary tract), Persistent asthma (inflamed airways), Lack of coordination and muscle weakness.Record review of Resident #3's physician order dated 1/12/2026 reflected to check oxygen concentrator filter for placement and clean filter every week and PRN.In an interview on 7/19/2026 at 1:40 P.M. with Resident #3, she pointed to her oxygen concentrator and stated staff change her water and tubing and date it every Sunday, but when she told a nurse the day prior there should be a filter, the unknown nurse stated it did not have a filter. Resident #3 stated she had not had any issue with the concentrator or her breathing and it seemed to do the job.In an observation on 7/19/2026 at 1:40 P.M., Resident #3 opened the back of the oxygen concentrator that her nasal cannula was attached to and revealed the intake and filter of the oxygen concentrator. The intake was covered in dust, and the filter had a cover over it and appeared white in color. Resident #4 removed the nasal cannula and stated, that can't be good. Resident #4 informed ADM A and he took the concentrator out of the room. DON B brought the concentrator back into the room with no more dust on the intake and changed and dated the tubing and water bottle and turned the concentrator back on for use.Record review of resident #4's face sheet reviewed on 7/19/2026, reflected a [AGE] year-old female, with an admission date of 6/24/2026. Resident #4 had diagnoses of polyneuropathy (neurological condition where multiple peripheral nerves throughout the body are damaged simultaneously), muscle spasm (sudden, involuntary muscle contraction), Parkinsonism (an umbrella tern that can be triggered by other neurological disorders and characterized by four primary motor symptoms: resting tremors, slowness of body, rigid muscles, and postural instability), Chronic Obstructive Pulmonary Disease (progressive incurable group of lung disease causing breathing difficulties), Urinary Tract Infection (bacterial infection in the urinary tract).Record review of Resident #4's physician order dated 7/19/2026 reflected to check oxygen concentrator filter for placement and clean filter every week and PRN.In an interview on 7/19/2026 at 7:15 P.M. with Resident #4, she stated staff come and check on her oxygen concentrator weekly and she is not sure what they do because she is unable to look behind her. Resident #4 stated she did not have any issue with her oxygen and she wore it nightly.In an observation on 7/19/2026 at 7:18 P.M., LVN D opened the oxygen concentrator for Resident #4. The intake appeared covered in dust and the filter was covered by a plastic covering and appeared white.In an interview on 7/19/2026 at 7:18 P.M. with LVN D, she stated she was responsible for the oxygen concentrators and usually she changed tubing and water and dated it and put the tubing in a bag that was attached to the concentrator. LVN D stated she usually changed the filter and was to do it every Sunday. LVN D stated, after she opened the concentrator and looked at the intake and filter, it did not look like it had been cleaned weekly and should not look like that. LVN D stated the intake was supposed to be clean. LVN D stated she was cleaning it right now and this concentrator came from the closet recently because Resident #4 had not been in the facility for very long. LVN D did not respond to the negative resident impacts from the dust on the intake.In an interview on 7/20/2026 at 10:12 A.M. with ADON C, she stated the filter or intake covered in dust could impact the resident's air intake or the air they got could not be as clean as it should be. ADON C stated the residents might not be getting the concentration of oxygen set or get bacteria. ADON C stated it had not caused any harm, and it had been added to the list of weekly checks.In an interview on 7/20/2026 at 12:13 P.M. with DON B, she revealed she was not aware of who was responsible for cleaning the oxygen concentrator intake. She stated nurses change tubing and felt it was not nursing's responsibility to change the filter when a screwdriver was involved. DON B stated it had been added to the task list but there had been no issue from the concentrators. DON B did not answer when asked what resident impact could occur.In an interview on 7/20/2026 at 2:20 P.M. with ADM A, he stated the concentrators were added to the rounds weekly by administration staff but did not answer when asked about how the dust on the oxygen concentrator could impact the residents.Record review of Oxygen Administration policy dated 2010 reflected The purpose of this procedure is to provide safe guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.Record review of Physician Orders policy dated 2001 reflected, the purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:The low-temperature dishwasher failed to reach the required hot water minimum temperature of 120 degrees in the kitchen.This failure placed the residents at risk for foodborne illness from dishes not being sterilized properly. The findings included:In an observation of the initial tour of the kitchen on 04/07/2026 at 9:25 a.m., the low-temperature dishwasher was being utilized by [NAME] A. The hot water temperature was observed at 100 degrees on the bottom thermometer attached to the dishwasher. The top thermometer was observed at 90 degrees. In an interview with [NAME] A, she said the hot water temperature only gets to 100 degrees since they put in the new hot water heater. There are 2 thermometers on the machine, and she looks at the bottom one when recording the temperature for the day. A record review of the facility dishwasher testing log on 04/08/2026, revealed the following temperatures for:April 2026 for morning, noon and night:1st - 100 degrees, 90 degrees, 100 degrees2nd -100 degrees, 90 degrees, 100 degrees3rd - 100 degrees, 100 degrees, 110 degrees4th - 90 degrees, 100 degrees, 100 degrees5th - 100 degrees, 90 degrees, 95 degrees6th - 110 degrees, 100 degrees, 110 degrees7th - 90 degrees, 98 degrees, 90 degrees8th - 98 degrees, 98 degrees, 98 degrees.In an interview with the Dietary Manager on 04/07/2026 at 2:55 p.m., she said the hot water temperature had been below 120 degrees since they got the new hot water heater. She said that she had not told anyone about it. She said a potential negative outcome would be food borne illnesses. She said she had not received any reports of food borne issues. In an interview with the Maintenance Director on 04/08/2026 at 10:30 a.m., he said no one had said anything to him about the hot water temperature of the dishwashing machine not being hot enough. He said they recently got a new hot water heater, and the temperature had been set to 130 degrees. In an interview and record review of the infection control log with the DON - Infection Control Specialist on 04/09/26 at 9:43 a.m., she said there had not been any outbreaks of food borne illnesses in the facility. Review of the infection control log revealed no foodborne illnesses. In an interview and observation on 04/09/26 at 9:46 am, [NAME] A said the water was a lot hotter than it was. An observation of the temperature of the dish machine was 140 degrees when it was tested at that time. In an interview with the Administrator on 04/09/26 at 9:55 a.m., he said the dishwashing machine was now testing at 140 degrees.Record review of the facility policy Sanitization, dated as revised November 2022, revealed the following [in part]: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation:5b. Low-Temperature Dishwasher (Chemical Sanitization):(1) Wash temperature (120 degrees).

Based on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 5 residents (Resident #1, Resident #58 and Resident # 97) reviewed for comprehensive care plans.he facility failed to ensure the comprehensive care plan addressed:- Resident #1's wound on the right side of his neck. -Resident #58's plan for discharge. -Resident #97's care and maintenance of his double lumen PICC line (a line used to administer medications through a vein). These deficient practices could result in residents not receiving needed care to maintain optimum health and placing them at risk for infection and/or deterioration in their condition. Findings include:Resident #1 Record review of Resident #1's electronic face sheet dated 04.08.2026 revealed an [AGE] year-old male admitted on 05.19.2025 with diagnoses that include other fracture of upper and lower end of right fibula (bone in lower leg), shortness of breath, morbid obesity, and hypertension (high blood pressure). Review of Resident #1's quarterly MDS dated 01.28.2026 revealed Section C Cognitive Patterns BIMS score of 15 (cognitively intact). Record review of Resident #1's Care plan dated 01.28.2026 revealed no evidence of wound care for Resident #1's wound to the right side of his neck. Review of Resident #1's physician orders dated 04.08.2026 revealed: wound care treatment to right side of the neck: clean with normal saline/wound cleanser, pat dry with gauze, apply xeroform gauze, self-adhesive dressing. Every day shift for cyst to right side of neck. Lidocaine external gel 4%: apply to right neck topically every day shift for daily dressing changes. During an observation on 04.07.2026 at 10:00 a.m., Resident #1 was lying in bed with his eyes closed. Resident #1 had a dressing to the right side of neck dated 04.07.2026. Resident #58 Review of Resident #58's electronic face sheet dated 04.08.2026 revealed an [AGE] year-old female admitted on 03.10.2026 with diagnoses of Type 2 diabetes mellitus (chronic metabolic condition leading to high blood sugars), bipolar disorder (mental health condition), hypertension (high blood pressure), and chronic pain. Review of Resident #58's admission MDS dated 03.13.2026 revealed Section C-Cognitive Patterns BIMS score of 12 (cognitively intact), Section Q indicated Participation in assessment and goal setting-resident's overall goal remain in the facility. Record review of Resident #58's care plan dated 03.24.2026 revealed no evidence of a discharge plan. Review of Resident #58's physician orders dated 04.01.2026 revealed a regular diet, mechanical soft texture, regular consistency, quetiapine, trazadone, duloxetine, antiplatelet monitoring, Code status: Full Code. Resident #97 Review of Resident #97's electronic face dated 04.01.2026 sheet revealed a [AGE] year-old male admitted 03.17.2026 with diagnosis included Infection and inflammatory reaction due to unspecified internal joint prosthesis, Anxiety, Atrial Fibrillation (heart disease), Dementia (decline in memory). Review of Resident #97's admission MDS dated 03.17.2026 revealed Section C Cognitive status BIMS score of 3 (severely impaired), Section N Medications-antibiotic-yes. Section O Special treatments, procedures and programs- IV medications-yes, IV access-yes. Review of Resident #97's care plan dated 03.17.2026 revealed no evidence of goals or interventions for the use and maintenance of Resident #97's PICC line and no evidence of goals or interventions for PICC dressing change. Review of Resident #97's physician orders dated 04.01.2026 included: EBP (enhanced [NAME] precautions) Tyzavan (antibiotic) intravenous solution 200 mL intravenously every 18 hours for MRSA (methicillin-resistant staphylococcus aureus-bacteria) until 04.08.2026. There were no physician orders for maintenance of PICC line or dressing changes for PICC line. During an observation on 04.07.2026 at 10:30 a.m., Resident #97 was lying in bed with IV antibiotic infusing via gravity to double lumen PICC line located in right upper arm. The dressing was clean, dry, and intact and the skin surrounding the dressing was intact and no redness. During an interview with LVN A on 04.09.2026 at 11:19 a.m., she stated she had provided IV medications for Resident #97,she stated he had a double lumen PICC to RUA. She was unable to locate a physician order for PICC line flushes or dressing changes. She stated there should be an order, she said it was not on the TAR for PICC dressing changes or on the MAR for flushes of PICC line it could get missed. She stated not flushing the PICC line after each IV ABX dose could cause the PICC line to become blocked or not patent. She stated this could delay treatment for the resident. During an interview on 04.09.2026 at 11:25 a.m., RN B stated she changed the PICC line dressing for Resident #97 every 7 days. She stated she documented this in the progress notes. She stated there should be an order for PICC line dressing changes and for PICC line flushes for maintenance. She stated not having these orders could result in the task not being done. She stated PICC line dressing changes are done to prevent infection at insertion site of PICC and that flushes helped maintain the patency of the PICC line. She stated the resident came from another facility with the PICC line in place. She stated not maintaining patency of PICC line could delay treatment for the resident. There was no documentation in nurses progress notes for this dressing change. During an interview on 04.09.2026 at 12:25 p.m., the DON stated there should be physician orders for a PICC line for general maintenance. She stated there should be a physician order for saline flushes and dressing changes for the PICC line. She stated the negative outcome could be the PICC line not being patent, the dressing becoming soiled or loose and cause the resident to get a secondary infection. She stated wound care, wounds, discharge plans, and PICC lines should be care planned. She stated she was responsible for monitoring physician orders for accuracy. She stated she did not know how this failure occurred. She stated by it not being care planned the care for the PICC line could be missed. She stated LVN C was responsible for the care plans and that she (DON) was responsible for monitoring accuracy of the care plans. She stated the care plan addressed the PICC line being used for antibiotic therapy and felt that was sufficient. She stated she did not know that wound care for resident had not been care planned or the discharge plans for a resident. During a telephone interview on 04.09.2026 at 12:37 p.m., LVN C stated she had care planned the use of the PICC line. She stated she did not know that wound care for resident had not been care planned or the discharge plans for a resident. Review of facility's policy titled Care Plans Revision date March 2022 revealed: Policy statement A care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy interpretation and implementation The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan is developed withing seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident and hazards as was possible and each resident receive adequate supervision and assistance devices to prevent accidents for 1 of 14 resident rooms reviewed for accident and hazards. The facility failed to ensure:The cover of an air conditioning unit was off on the ground in a 1 of 1 resident's room exposing the insides to the machine. The findings included:Observation of resident room [ROOM NUMBER] on 04/07/26 at 10:18 a.m., revealed in the secured unit, the cover of the air conditioning unit was off the unit and sitting on the floor. The insides to the air conditioner unit were exposed to the resident that occupied the room. In an observation and interview with LVN B on 04/09/2026 at 9:30 a.m., she said they had spring cleaning a few weeks ago and must not have been put back on correctly. A potential negative outcome for a resident is they could get shocked if they stuck their hand in the unit. LVN B put the cover back on the air conditioning unit. In an interview with the Maintenance Director on 04/09/2026 at 9:36 a.m., he said they had a spring cleaning on 3/18/26 facility wide, including washing the air conditioning units. It must not have been put back on correctly. In an interview with the DON on 04/09/2026 at 9:43 a.m., she said the facility had a spring cleaning a few weeks ago and cleaned all of the air conditioners. She said she was not aware of any covers being off the air conditioners. She said a potential negative outcome would be that a resident could stick their hand in it. In an interview with the Administrator on 04/09/2026 at 9:55 a.m., he said he was not aware of any covers being off the air conditioners. He said a potential negative outcome would be rodents would be able to get in the facility and a resident could stick their hand in it. A policy was requested but not provided by time of exit.

Based on interviews, observations, and record review the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #97) reviewed forIV therapy. The facility failed to obtain physician orders for the use and maintenance of Resident #97's PICC line. This deficient practice could result in residents not receiving needed care to maintain optimum health and placing them at risk for infection and/or deterioration in their condition. Findings include: Review of Resident #97's electronic face sheet dated 04.08.26 revealed [AGE] year-old male admitted 03.17.2026 with diagnoses including Infection and inflammatory reaction due to unspecified internal joint prosthesis, Anxiety, Atrial Fibrillation (heart disease), and Dementia (decline in memory). Record review of Resident #97's admission MDS dated 03.17.2026 revealed Section C Cognitive status BIMS score of 3 (severely impaired), Section N Medications-antibiotic-yes. Section O Special treatments, procedures and programs- IV medications-yes, IV access-yes. Record review of Resident #97's care plan dated 03.17.2026 revealed no goals or interventions for use and maintenance of PICC line. No goals or interventions for PICC dressing change. Record review of Resident #97's physician orders dated 04.01.2026 included: EBP (enhanced [NAME] precautions) Tyzavan (antibiotic) intravenous solution 200 mL intravenously every 18 hours for MRSA (methicillin-resistant staphylococcus aureus-bacteria) until 04.08.2026. There were no physician orders for maintenance of PICC line or dressing changes for PICC line. During an observation on 04.07.2026 at 10:30 a.m., Resident #97 was lying in bed with IV antibiotic infusing via gravity to a double lumen PICC line located in the right upper arm. The dressing was clean, dry, and intact and the skin surrounding the dressing was intact and no redness. During an interview with LVN A on 04.09.2026 at 11:19 a.m., she stated she had provided IV medications for Resident #97, he had a double lumen PICC to RUA. She stated she flushed the PICC line before and after use with 10 mL normal saline, she was unable to locate a physician order for PICC line flushes or dressing changes. She stated there should be an order and because it was not on the TAR for PICC dressing changes or on the MAR for flushes of PICC line it could get missed. She stated not flushing the PICC line after each IV ABX dose could cause the PICC line to become blocked or not patent. She stated this could delay treatment for the residents. During an interview on 04.09.2026 at 11:25 a.m., RN B stated she changed the PICC line dressing for Resident #97 every 7 days, she stated she documented this in the progress notes. She stated there should be an order for PICC line dressing changes and for PICC line flushes for maintenance. She stated not having these orders could result in the task not being done. She stated PICC line dressing changes are made to prevent infection at insertion site of PICC and that flushes helped maintain the patency of the PICC line. She stated the resident came from another facility with the PICC line in place. She stated not maintaining patency of PICC line could delay treatment for the resident. During an interview 04.09.2026 at 12:25 p.m., the DON stated there should be physician orders for a PICC line for general maintenance of the PICC line. She stated there should be a physician order for saline flushes and dressing changes for the PICC line. She stated the negative outcome could be the PICC line not being patent, the dressing becoming soiled or loose and cause the resident to get a secondary infection. She stated she was responsible for monitoring physician orders for accuracy. She stated she did not know how this failure occurredShe stated by it not being care planned the care for the PICC line could be missed. During a telephone interview on 04.09.2026 at 12:37 p.m., LVN C stated she had care planned the use of the PICC line for antibiotic therapy. She stated she did not know that wound care for resident had not been care planned or the discharge plans for a resident. Record review of facility's policy titled: Medication Administration-Intravenous Therapy dated 11.01.2025 revealed:Policy StatementLicensed nursing staff shall administer IV medications only through an appropriate vascular access device using aseptic technique, verified medication compatibility, and approved procedures. Definitions.PICC lineMay be used for central-approved medicationsVerify tip placement documentation prior to first useFollow central-line infection prevention practices. Procedure Verify order, medication, and IV accessAssess IV site and patencyScrub hub and administer medication per orderFlush line per protocolReassess resident and IV site. DocumentationMedication name, dose, route, rateIV access typeSite assessment-condition before and after administrationResident response

Based on interview, and record review the facility failed to properly execute the grievance process including review in morning meeting with IDT members, coordinating and developing a plan for resolution, notify complainant about resolution and document all action taken in grievance form and disposition of the grievance will be provided in writing to Executive Director or Designee for 1 out of 5 resident (Resident # 1) review for grievances. The facility failed to investigate Resident #1's grievance of an incident with CNA A yelling and being rude to Resident #1. The facility failed to document all actions taken for the resolution of grievance to include Administrator's investigation. This failure could place residents in the facility at risk for grievances to go unresolved.Record review of Resident #1's detailed summary report/face sheet dated 1.12.26 indicated he was admitted to facility on 4.10.19 with diagnoses of hypertension (high blood pressure, is a common condition where the force of blood against artery walls is consistently too high), reduced mobility, and lack of coordination. Resident # 1's BIMS score was 15, indicating no cognitive impairment. Record review of Facility grievance tracking log dated 11.2025 indicated 11.7.25 reported date of Resident #1's concerns of an incident with CNA A, department nursing. Record review of Facility grievance binder dated 11.2025 had no grievance documentation completed for the incident between Resident #1 and CNA A on 1.7.25. During an interview on 1.9.26 at 3:45 pm Resident #1 stated that she did have an incident a couple months back with CNA A. She stated she cannot remember the exact date, but she turned on her call light for some help and CNA A came into her room and started yelling at her to stop using her call light, she stated that's why all the nurses don't like to help you because you use your call light too much. She stated she exchanged some words with CNA A and finally CNA A left the room. She stated she let SW B know about what happened and her concerns. She stated she never heard anything after that. She stated that CNA A still worked at the facility and still worked on her hall, so I guess nothing really happened. She stated she knows she will yell at CNA A if she comes into her room. During an interview on 1.14.26 at 10:45 am ADMN stated that no resident or employee has come to him at all stating any concerns towards employee CNA A. He stated that he has not received any grievances from Resident #1 regarding anything CNA A has done. He stated the employee, as far as he knew, could work anywhere in the building including hall 100. He stated the process on grievances was, a grievance document would be filled out with the name of resident, perpetrator, date, time, and an overview of what happened. He stated once completed the grievance would be put on the grievance log and at morning meetings the grievance would be submitted to the head of the department in which the grievance was associated too. During an interview on 1.14.26 at 1:15 pm DON stated that no grievance came to her regarding CNA A or an incident that involved Resident #1 or CNA A. She stated she never received anything regarding the incident. She stated that if she were to receive any grievance, she would go first to speak with the resident to find out what happened. She stated depending on what the resident stated she would do an in-service or have a one on one with the staff notated in the grievance. During an interview on 1.14.26 at 1:25 pm SW B stated that yes, she did fill out a grievance for Resident #1 regarding an incident on November 7th, 2025. She stated the grievance was about an incident that happened in which CNA A went into Resident 1's room and yelled at her and told her to stop using her call light and that none of the other nurses liked helping her. She stated due to this being a nursing concern the grievance would have gone to the DON. She stated she had no idea where the grievance document was. She stated the grievance tracking log showed the incident, but the grievance document was not in the binder. Record review of facility policy dated October 2017 titled: Grievances/complaints-staff responsibilities indicated: Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated.

Based on interviews and record review the facility failed to ensure residents were free from neglect for 1 of 7 (Resident $1) reviewed for neglect in that: The facility staff neglected Resident #1 when staff identified Resident #1 as having a cut to the right side of his head after an unwitnessed fall on [DATE], and did not communicate with the nurse to assess resident and begin doing neurological assessments a subdural hematoma (brain bleed) and death on [DATE]. An Immediate Jeopardy (IJ) situation was identified on 8.28.25. The IJ template was provided to the facility on 8.28.25 at 3:05 pm. While the IJ was removed on 8.29.25, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at risk of not being provided services/care while in the facility. The findings included: Record review of Resident #1 face sheet he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1’s diagnoses included encephalopathy (a condition in which the brain does not function properly), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), depression and hypertension. Resident # 1’s BIMS score was 5, indicating severe cognitive impairment. Record review of Resident #1’s care plan dated 8.22.25 indicated: The resident is high risk for falls. Res has spontaneous behaviors and attempts to self-transfer. The resident will be free of falls through the review date. The resident will not sustain serious injury through the review date. 6/19- actual fall, nonskid footwear. 7/5- actual fall, frequent reminders to use call light. 8/13- actual fall, visual reminder in the bathroom. 8/15- actual fall, visual reminder in room. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Encourage resident to ask for assistance with all transfers. Bleeding was also notated in care plan, linked below. Eliquis was not directly named in care plan. Risk for Bleeding Date Initiated: [DATE], Resident Will Be Free of Falls Date Initiated: [DATE], Target Date: [DATE], Resident Will Show No Signs/Symptoms of Bleeding Date Initiated: [DATE] Target Date: [DATE], Avoid unnecessary invasive procedures, punctures or injections Date Initiated: [DATE], Evaluate blood pressure, Date Initiated: [DATE], Evaluate fall risk on admission and PRN Date Initiated: [DATE], Evaluate for blood in stools, Date Initiated: [DATE], Evaluate for change in level of consciousness, Date Initiated: [DATE], Evaluate for hematemesis Date Initiated: [DATE], Evaluate for hematuria, Date Initiated: [DATE], Evaluate heart rate, Date Initiated: [DATE], Evaluate skin for evidence of impaired coagulation (bruising, petechia, bleeding from orifice), Date Initiated: [DATE], If fall occurs, alert provider, Date Initiated: [DATE]. Record review of Resident #1 pharmacy orders indicated Eliquis 5mg (blood thinner used to reduce risk of stroke and blood clots): Give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. Record review of Resident #2’s quarterly MDS assessment dated 8.22.25 revealed a 15 BIMS score was noted but was marked as no impaired under the cognitive skills for daily decision making. During interview on 8.27.25 at 10:15 AM physician A (Hospital ER MD) stated that based on the injury and the combination of Resident #1 being [AGE] years old and on 5mg of Eliquis, along with a cut to the right side of the head reported by family as occurring on Monday [DATE] started the bleed. She stated when she saw the resident in the ER on Wednesday [DATE], he had a small scratch/cut on the top right side of the head. She stated due to Resident #1 being on a blood thinner, and the fact that there was a head injury even anything as minor as a scratch/cut can be an indication of a brain bleed. The resident should have had continued monitoring, even if there was 1 good neurological check, would not mean there was no brain bleed. Often with a blood thinner of any type, there would be a bleed that would not be immediately noticed, and a resident could be talking with you fine at times, then symptoms could be increased tiredness and lethargy. She stated by the time Resident #1 was seen in the ER on [DATE] the bleed was too significant and could not be fixed. She stated this was the resulting factor that caused Resident #1 to pass away on [DATE]. During an interview on 8.22.25 at 10:05 AM Resident #1’s family member stated that on [DATE] she was at the facility and Resident #1 had a fall in his shower. She stated Resident #1 sustained a cut to his right elbow and the top right side of his head. She said he had passed away the morning of [DATE]. She stated that she heard a CNA C tell Resident #1 not to get up off the toilet, she was going to go grab a towel or something. She stated next thing she knew Resident #1 was found on the floor of the shower. She stated a CNA C came to the room that day to get Resident #1 up and into the restroom. She stated she heard CNA C tell Resident #1 do not get up or move from the toilet she had to go get something. She stated that when the CNA came back in, Resident #1 was on the floor in the shower. She stated that not only did CAN A help the resident up but also the RN B came to the room to assess and help the resident up. During an interview on 8.22.25 at 11:15 AM CNA A stated she did notice a scratch/cut approx. 1 inch long to the top right of Resident #1’s head in the afternoon on [DATE]. She stated she was not sure exactly where the cut came from. She stated it could have come from anywhere, so she did not notify anyone of the injury. She stated that on 8.19.25 Resident #1 stayed in bed most of the day and was very lethargic, not acting like himself but she didn’t tell anyone. She stated normally when there was a new injury to a resident, she would let the charge nurse know, but this was so minor of a scratch she did not feel she needed to. CNA A stated she never help Resident #1 up from any fall on 8.18.25, only that she noticed a small scratch to the right side of Resident #1’s head. During an interview on 8.22.25 at 3:05 PM CNA C stated that he noticed that Resident #1 was not himself during the afternoon on Tuesday [DATE]. He stated that normally Resident #1 would hold his hand and try to hug him. He stated Resident #1 did not try any of his normal behaviors and was lethargic as he laid in bed most of the day. CNA C thought he was just tired and didn’t tell the nurse or other nurse aides. CNA C observed the bandage on the top right side of Resident #1’s scalp, but did not have any knowledge of the head injury occurrence from [DATE]. CNA C normally when an injury was observed on a resident, he would let his charge nurse know or at least let the next shift know during shift change, but CNA C did not because the injury was not that large. During an interview on 8.22.25 at 3:15 PM PT D and PT E both stated that they went to Resident #1’s room around 7:35 am on [DATE] to get Resident #1 up for PT. They both stated he would not respond to sternum rub (a medical procedure used to assess a patient's level of consciousness and responsiveness), and they noticed blood around Resident #1’s mouth. They called in the nurse and Resident was sent out to local hospital roughly around 7:55 am by EMS. During an interview on 8.22.25 at 3:45 pm Resident #2 (the roommate of Resident #1) stated he did observe a new cut on the top right side of Resident #1’s head, later in the day on [DATE] around dinner time. Resident # 2’s BIMS score was 15, indicating no cognitive impairment. During an interview on 8.22.25 at 3:45 pm Resident #2 (the roommate of Resident #1) stated he did observe a new cut on the top right side of Resident #1’s head, later in the day on [DATE] around dinner time. During an interview on 8.22.25 at 12:15 PM RN B stated while he was helping Resident #1 off the toilet on [DATE], Resident #1 and his family member told him about a fall on [DATE]. Resident had a cut approximately ¾ to 1 inch on the top right side of his head and on his right arm. RN B put bandages on both. He stated that it was an unwitnessed fall that he charted in his incident report on [DATE]. He stated that due to Resident #1 passing Neuro assessment at that time he did not start Neuro checks. RN B stated that he did not relay the injury to other staff afterwards. RN B stated he was aware that Resident #1 was on Eliquis, that was a blood thinner, however the 1 neuro assessment he did at the time, the resident eyes were not dilated, he could speak to him with memories from the previous day, so Resident #1 passed the neuro check. RN B stated normally when a Resident has a fall with head injury or if the resident hit their head, neuro checks/rounding would be initiated and done for 72 hours. RN B stated he did call the physician the day that he was informed to do an incident report on the fall, which was dated 8.19.25. During interview on 8.29.25 at 3:45 pm Physician B stated that, “yes there was a quapi meeting this morning associated to abuse neglect, non-reporting/communication and neuro checks. He stated was happy with the facility and all the protocols put in place to correct the IJ;s. he stated he had no other concerns with the facility. he did get notified about Resident #1’s fall but could not give the exact date. He stated that any resident that was on a blood thinner he would review before giving the facility the go ahead on what to do. He stated he did not have any concerns with the resident the day he received the call from the facility regarding the fall and the resident being on a blood thinner.” During an interview on 8.25.25 at 12:25 AM the DON indicated on [DATE] that due to state being in the building on [DATE], she asked RN B if anything happened to Resident #1. She stated RN B stated to her that Resident #1 did sustain an unwitnessed fall in the bathroom on [DATE]. She stated she told him to get his incident report completed immediately on the incident. She stated no other communication was done by RN B regarding the incident. She stated no continuous Neuro checks were completed. The DON stated that because there was 1 neuro check and resident was fine on [DATE], there was no need to monitor further. The DON stated her expectation was even with a head injury or unwitnessed fall, if a resident could pass 1 neuro assessment, there would be no need to have continuous monitoring. The DON stated she knew Resident #1 was on blood thinners but due to how minor the scratch was she did not believe neuro rounding was needed. Incident report on Resident #1, dated [DATE], as a late entry for [DATE] Injury type abrasion location top of scalp. no documentation of physician notification and no documentation of Resident #1’s increased lethargy and change in behavior on [DATE] and [DATE]. No measurement of abrasion/scratch to the top of right side of head completed. Review of Resident #1’s hospital records included: CT scan [DATE] was a Large right subdural hematoma (brain bleed) along the entire convexity from anterior-posterior midline measuring up to mostly 15mm in thickness. The result was a midline shift (brain tissue moved) to the left of about 7mm. While in ER on [DATE] Resident #1 had 30-45 second full tonic colonic seizure. ER diagnosis dated 8.20.25 was a Nonsurvivable head bleed. [DATE] Resident #1 passed away at the hospital. Record review of facility policy titled Abuse, neglect, Exploitation and Misappropriation prevention program dated [DATE] indicated: resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents’ symptoms. Record review of facility policy titled Neurological assessment dated [DATE] indicated: The purpose of this procedure is to provide guidelines for conducting a neurological assessment (“neuro checks”) on resident with knowns or suspect head trauma or acute changes in mental or motor function that may be indicative of a neurological event. 13. Neurological checks will be initiated at time of incident-unwitnessed fall or head injury for 72 hours and as ordered by the physician/physician extender. Record review of facility policy titled Assessing Falls and their Causes dated 2021 indicated: Steps in the Procedure After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. lf an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 5. Notify the resident’s attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. b. When fall does not result in significant injury or a condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). 6. Observe for delayed complications of a fall for approximately seventy-two (72) hours after an observed or suspected fall and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed in the electronic health record by the charge nurse on duty at the time. Record review of facility policy titled Falls-Clinical protocol dated 2021 indicated: Monitoring and following up-1. The staff, with the physician’s guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. This was determined to be an Immediate Jeopardy (IJ) on 8.28.25 at 3:05 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 8.28.25 at 3:05 pm. Record review of Plan of Removal accepted on 8.29.25 at 12:45 PM reflected the following: F600 Neglect Plan to Remove Immediate Jeopardy Please accept the following Plan of Removal of Immediate Jeopardy-F600- Failure to ensure residents are free from abuse/neglect/exploitation. 1. On [DATE] at 1510 The facility RN B was suspended immediately pending investigation, by the administrator. This investigation will be completed by [DATE]. 2. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures by the Director of Nursing on [DATE]. For those on who cannot be reached, by phone will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension. 3. The director of nursing was educated on the neurological policy on [DATE] by the VP of Clinical Services. The Director of Nurses was educated by the VP of Clinical Operations, related to the policy stating that neuro checks will be initiated upon any unwitnessed fall or fall with head injury, to continue X72 hours or unless otherwise indicated. 4. All current nursing staff were in-serviced on documentation of Unwitnessed falls and Neuro Check Policy by the Director of Nursing On [DATE]. For those on who cannot be reached by phone, will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension. 5. RN B Will complete all in-services 1:1 with the DON if allowed to return work with residents, by [DATE]. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect is completed by all staff members, by [DATE]. Completion will be reviewed at monthly QAPI meetings. 7. DON is responsible for ensuring that all assigned nursing in-service are completed on [DATE]. For those on who cannot be reached by phone, will not return to work without receiving this in-service prior to anyone working. The administrator will review any new staff to ensure in-services are completed, prior to their first shift on the floor. 8. DON reviewed all other 14 residents on anticoagulants for falls and neuro check documentation on [DATE]. No further injuries were noted on any residents. 9. Social worker completed Safe Surveys on the other 51 interview able residents to ensure they feel safe and free from abuse and neglect. This was completed on [DATE]. No residents reported signs of Abuse or Neglect. 10. Any staff member suspected of committing abuse/neglect will be suspended immediately and/or terminated depending on the outcome of the investigation. 11. Staff who fail to report suspected abuse and change in condition will be educated on the significance of reporting time and disciplined accordingly. 12. Starting [DATE] DON/Designee will conduct random questioning on 3 staff members daily for 4 weeks for staff to ensure they are understanding and retaining the education on abuse and neglect and reporting procedures. 13. Results from random staff questioning will be reviewed during the monthly QAPI meetings with DON, Administrator, and Medical Director. Any incorrect answers will be corrected immediately. Progress will also be monitored during weekly Committee Meetings and Medical Director will be notified of all progress. Monitoring and verification of the facility POR as follows: During a phone interview on 8.29.25 at 11:15 AM Phone interview LVN F work nights-6pm shift yesterday-She stated that she did 4 in-services total yesterday before she was allowed to work. She stated the main one that stands out was falls with head injuries. She stated any fall with a head injuria, an incident report must be completed. She stated that they will no longer use paper copies to do neuro checks but to use the pcc system to get them completed. She stated that neuros must be initiated on all unwitnessed falls, falls in which residents are on anti-coagulants, contact family, don, physician, and administrator. She stated that documentation went hand in hand with the in-services regarding the falls and injuries, and neuros. She stated that that abuse neglect, anything seen or suspected was to be reported to the administrator immediately. She stated that all in-serves were led by the DON. She stated there was a small recall/quiz at the end with information services. During a phone interview on 8.29.25 at 11:30 AM Phone interview LVN G stated there were 4 total in-services. She stated abuse/neglect, documentation, neuros, and falls w/ head injury. She stated that abuse neglect was nothing crazy new. She stated that if you suspect any abuse neglect or witness any sort of abuse neglect let the administrator know and let the don know, the physician and family. She stated documentation wise most importantly was to get the incident report done immediately and to inform all parties about that incident that occurred. She stated for example any resident with a fall that was on an anti-coagulant was to be sent out of the facility via to the ER. She stated then all documentation must be filled out and neuros starts if resident was not on any anti coagulants. She stated neuros really need to be started on all unwitnessed falls and all falls that include head injury that were witnessed. She stated at the end of each in-service there was a recall of knowledge quiz a question-and-answer time for any issues. She stated it was good to hear everything and have the review. During a phone interview on 8.29.25 at 11:45 AM Phone interview CNA H stated that before she was allowed to start work last night at 6pm there were 4 in-services that were completed. She stated that documentation, which was a little more in depth for the nursing side but documentation anytime any abuse/neglect or fall or anything happens in the facility she was to make sure all statements were complete and to always follow her chain of command. She stated that any time abuse or neglect was witnessed, or any sort of injury was seen to be new on a resident, she was to report to her charge nurse. She stated if she were to observe a fall, she would get the charge nurse or get help while another cna stayed with the resident. She stated at the end of the in-services there was a recall of all information that was covered and then a question and answer if any questions. She stated she appreciated her facility going over everything and it was a lot of good information. During a phone interview on 8.29.25 at 12:00 PM Phone interview CNA I stated that there were 4 in-services she had to complete before she was allowed to work last night. She stated that 3 were more to both types of staff while the 4th in-service was more for nursing staff. She stated abuse neglect, to make sure anytime she was to witness any type of abuse/neglect it was to be reported to her chain of command. She stated she would let her nurse/charge nurse know but knows the abuse coordinator was the administrator. She stated when it came to falls, anytime a resident was observed falling or found on the ground she was to report/call for help to have the nurse come and assess the resident. She stated she was not to touch or move the resident in any, way, but only to make sure to get help for the resident and for a nurse to come and assess the resident. She stated neuros were covered but that was more for nurses and not CAN’s. she stated lastly, they covered documentation, again more towards nursing but also if anything abuse/neglect, injury, or fall were observed she would need to document everything and then use the chain of command to communicate everything that she observed. She stated at the end there was a question and answer and then a recall session of the in-services to test retention of education. During a phone interview on 8.29.25 at 12:45 PM Phone interview CNA J stated she was in-service las night before she was allowed to work. She stated due to being a CAN’s she was not allowed to assess any resident given any fall or found on he ground. She stated she was to reach out to the charge nurse or any nurse to come do an assessment on the resident. She stated any new injuries should be identified and communicated to the nurse as soon as possible so that the nurse could notate any changes to the resident or their behavior. She stated that any signs or physically saw abuse of any kind should be reported to the administrator immediately. She stated any changes in condition, if the resident were acting different in anyway should be reported to the nurse. She stated overall all of the in-services had to do with reporting to the nurses, what to report, how to report and to make sure to follow the chain of command. During a phone interview on 8.29.25 at 1:30 pm LVN K stated that there were 4 in-services that she had to complete before she was allowed to work this morning. She stated the main in-service for nursing was the combination of documentation, falls, anticoagulants, and neuro rounding. She stated that the main thing with documentation was that all neuro rounding would be completed in the electronic system and not a paper trail. She stated she believes the facility will honestly use both to make sure everything was completed and accurately. She stated for example if a resident who was on an anti-coagulant has a fall that was unwitnessed the resident will be sent to the ER no questions asked. She stated that but if the fall was witnessed and the resident was not on anti-coagulants then neuro rounding would be triggered, and the resident would be rounded on for a minimum of 72 hours. She stated that abuse neglect in service was very straight forward, what to look for, who to report to (administrator), that sort of thing. She stated but the importance of any head injury with fall with a resident who was on anticoagulants must been sent out or monitored properly. She stated at the end of the in-services there was a recall of knowledge. During a phone interview on 8.29.25 at 1:45 PM LVN L stated there were 4 in-services that she had to complete before she was allowed to start working this morning. She stated that abuse/neglect was one of the very normal abuse/neglects in-services that went over what constitutes abuse neglect, who to report to, how to report and what you are looking for that constitute abuse and neglect. She stated the other 3 in services for the nurses in the building all flowed into each other. She stated the in-services covered documentation, falls, and neuro checks. She stated that if any resident who was on anti-coagulants has an unwitnessed fall the resident was to be sent out immediately. She stated but if a resident has a fall and head injury was suspected and not on anti-coagulant then neuro founding would need to be initiated. She stated all documentation would need to be filled out immediately and neuro checks initiated in the electronic nursing system. She stated that after the in-services were completed a knowledge check was completed for retention. During an interview on 8.29.25 at 2:00 PM CNA M stated there were 4 in-services that he had to complete before he was allowed to start his shift today. He stated that the overall point of all 4 in-services was communication, who to communicate to and what to look for. He stated when it came to abuse/neglect look for any new wounds or injuries on the resident and pay attention to if the resident was acting normal that day. He stated if anything seemed off with the resident you were to report it to the charge nurse. He stated if a resident was found on the floor from a fall, then he would call out for help from another CNA to get the charge nurse or he would have a CNA stay with the resident while he went to get a nurse to come do an assessment of the resident. He stated any abuse/neglect witnessed should be reported to the administrator immediately. During a phone interview on 8.29.25 at 2:00 PM CNA A stated that there were 4 in-services she had to complete before she was allowed to work last night. She stated that 3 were more to both types of staff while the 4th in-service was more for nursing staff. She stated abuse neglect, to make sure anytime she were to witness any type of abuse/neglect it was to be reported to her chain of command. She stated she would let her nurse/charge nurse know but knows the abuse coordinator was the administrator. She stated when it came to falls, anytime a resident was observed falling or found on the ground she was to report/call for help to have the nurse come and assess the resident. She stated she was not to touch or move the resident in any, way, but only to make sure to get help for the resident and for a nurse to come and assess the resident. She stated neuros were covered but that was more for nurses and not CNAs. she stated lastly, they covered documentation, again more towards nursing but also if anything abuse/neglect, injury, or fall were observed she would need to document everything and then use the chain of command to communicate everything that she observed. She stated at the end there was a question and answer and then a recall session of the in-services to test retention of education. During an interview on 8.29.25 at 2:00 PM CNA C stated that he was part of 4 in-services before he was allowed to work. He stated that one of the in-services was more associated to the nursing staff. He stated firs they discussed abuse/neglect and what to look for. He stated look out for any injuries to the resident or new cuts, bruising etc. he stated who to communicated to regarding any information with any injuries or abuse neglect to the charge nurse and the administrator. He stated that even if the injury were to look old or new or not that serious all injuries were to be communicated using the chain of command. He stated another in-service covered what to do as a CNA if you were to find a resident on the floor, weather it was witnessed or not and to not touch the resident but to get the nurse to do an assessment on the resident. He stated all information was good and needed to be heard even as a refresher. Record review of 4 in-services- Abuse/neglect-in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered, abuse, neglect, exploitation, who to report to, how to report and what constitutes as abuse or neglect. Which can include even new injuries. Report to charge nurse, don or administrator. Falls and head injuries in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered what constitutes as a fall, what constitutes as a head injury, who to report to, how to report and what to do if fall was witnessed or not witnessed. Documentation in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered documentation that must be completed such as an incident report the second an incident occurs. What documentation must be completed and started in the electronic system, such as neuro checks and communication to physician, family, chain of command/don and then administrator. Abuse/neglect-in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered what constitutes the injury to start neuro checks vs sending the resident directly to the hospital. Record review of RN B was educated and suspended pending investigation. During interview with DON, RN has been terminated from position at the facility. Signature sheet provided by facility with employee RN signature of report of employee education. Dated 8.28.25. Second Report of education dated 8.27.25 presented by COR to DON with DON signature provided subject covering neuro checks, policy, falls and head injury unwitnessed fall. Record review of 14 residents were reviewed for anticoagulant completed by DON on 8.28.25. Face sheets and dosages provided. &

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 7 (Resident #1) residents reviewed for quality of care in that: The facility staff failed to assess and monitor Resident #1, when Resident #1 was identified [DATE] as having a cut to the right side of his head, after an unwitnessed fall, which resulted in the resident being sent to the emergency room and diagnosed with a subdural hematoma (brain bleed) and death on [DATE]. An Immediate Jeopardy (IJ) situation was identified on 8.28.25. The IJ template was provided to the facility on 8.28.25 at 3:05 pm. While the IJ was removed on 8.29.25 the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures put residents at risk of not receiving treatment/care interventions when needed for changes in resident condition. The findings included: Record review of Resident #1 face sheet he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1's diagnoses included encephalopathy (a condition in which the brain does not function properly), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), depression and hypertension. Resident # 1's BIMS score was 5, indicating severe cognitive impairment. Record review of Resident #1 pharmacy orders indicated Eliquis 5mg (blood thinner used to reduce risk of stroke and blood clots): Give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. Record review of Resident #1's care plan dated 8.22.25 indicated: The resident is high risk for falls. Res has spontaneous behaviors and attempts to self-transfer. The resident will be free of falls through the review date. The resident will not sustain serious injury through the review date. 6/19- actual fall, nonskid footwear. 7/5- actual fall, frequent reminders to use call light. 8/13- actual fall, visual reminder in the bathroom. 8/15- actual fall, visual reminder in room. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Encourage resident to ask for assistance with all transfers. Bleeding was also notated in care plan, linked below. Eliquis was not directly named in care plan. Risk for Bleeding Date Initiated: [DATE], Resident Will Be Free of Falls Date Initiated: [DATE], Target Date: [DATE], Resident Will Show No Signs/Symptoms of Bleeding Date Initiated: [DATE] Target Date: [DATE], Avoid unnecessary invasive procedures, punctures or injections Date Initiated: [DATE], Evaluate blood pressure, Date Initiated: [DATE], Evaluate fall risk on admission and PRN Date Initiated: [DATE], Evaluate for blood in stools, Date Initiated: [DATE], Evaluate for change in level of consciousness, Date Initiated: [DATE], Evaluate for hematemesisDate Initiated: [DATE], Evaluate for hematuria, Date Initiated: [DATE], Evaluate heart rate, Date Initiated: [DATE], Evaluate skin for evidence of impaired coagulation (bruising, petechia, bleeding from orifice), Date Initiated: [DATE], If fall occurs, alert provider, Date Initiated: [DATE]. During interview on 8.27.25 at 10:15 AM physician A (Hospital ER MD) stated that based on the injury and the combination of Resident #1 being [AGE] years old and on 5mg of Eliquis, along with a cut to the right side of the head reported by family as occurring on Monday [DATE] started the bleed. She stated when she saw the resident in the ER on Wednesday [DATE], he had a small scratch/cut on the top right side of the head. She stated due to Resident #1 being on a blood thinner, and the fact that there was a head injury even anything as minor as a scratch/cut can be an indication of a brain bleed. The resident should have had continued monitoring, even if there was 1 good neurological check, would not mean there was no brain bleed. Often times with a blood thinner of any type, there would be a bleed that would not be immediately noticed, and a resident could be talking with you fine at times, then symptoms could be increased tiredness and lethargy. She stated by the time Resident #1 was seen in the ER on [DATE] the bleed was too significant and could not be fixed. She stated this was the resulting factor that caused Resident #1 to pass away on [DATE]. During an interview on 8.22.25 at 10:05 AM Resident #1's family member stated that on [DATE] she was at the facility and Resident #1 had a fall in his shower. She stated Resident #1 sustained a cut to his right elbow and the top right side of his head. She said he had passed away the morning of [DATE]. She stated that she heard a CNA C tell Resident #1 not to get up off of the toilet, she was going to go grab a towel or something. She stated next thing she knew Resident #1 was found on the floor of the shower. She stated a CNA C came to the room that day to get Resident #1 up and into the restroom. She stated she heard CNA C tell Resident #1 do not get up or move from the toilet she had to go get something. She stated that when the CNA came back in, Resident #1 was on the floor in the shower. She stated that not only did CAN A help the resident up but also the RN B came to the room to assess and help the resident up. During an interview on 8.22.25 at 3:15 PM PT D and PT E both stated that they went to Resident #1's room around 7:35 am on [DATE] to get Resident #1 up for PT. They both stated he would not respond to sternum rub and they noticed blood around Resident #1's mouth. They called in the nurse and Resident was sent out to local hospital roughly around 7:55 am by EMS. During an interview on 8.22.25 at 3:45 pm Resident #2 (the roommate of Resident #1) stated he did observe a new cut on the top right side of Resident #1's head, later in the day on [DATE] around dinner time. Resident # 2's BIMS score was 15, indicating no cognitive impairment. During an interview on 8.22.25 at 3:45 pm Resident #2 (the roommate of Resident #1) stated he did observe a new cut on the top right side of Resident #1's head, later in the day on [DATE] around dinner time. During an interview on 8.22.25 at 11:15 AM CNA A stated she did notice a scratch/cut approx. 1 inch long to the top right of Resident #1's head in the afternoon on [DATE]. She stated she was not sure exactly where the cut came from. She stated it could have come from anywhere, so she did not notify anyone of the injury. She stated that on 8.19.25 Resident #1 stayed in bed most of the day and was very lethargic, not acting like himself but she didn't tell anyone. She stated normally when there was a new injury to a resident, she would let the charge nurse know, but this was so minor of a scratch she did not feel she needed to. CNA A stated she never help Resident #1 up from any fall on 8.18.25, only that she noticed a small scratch to the right side of Resident #1's head. During an interview on 8.22.25 at 12:15 PM RN B stated while he was helping Resident #1 off the toilet on [DATE], Resident #1 and his family member told him about a fall on [DATE]. Resident had a cut approximately 3/4 to 1 inch on the top right side of his head and on his right arm. RN B put bandages on both. He stated that it was an unwitnessed fall that he charted in his incident report on [DATE]. He stated that due to Resident #1 passing Neuro assessment at that time he did not start Neuro checks. RN B stated that he did not relay the injury to other staff afterwards. RN B stated he was aware that Resident #1 was on Eliquis, that was a blood thinner, however the 1 neuro assessment he did at the time, the resident eyes were not dilated, he could speak to him with memories from the previous day, so Resident #1 passed the neuro check. RN B stated normally when a Resident has a fall with head injury or if the resident hit their head, neuro checks/rounding would be initiated and done for 72 hours. RN B stated he did call the physician the day that he was informed to do an incident report on the fall, which was dated 8.19.25. During an interview on 8.22.25 at 11:45 PM LVN N stated that the normal fall protocol was to go in and assess the resident for any injuries. She stated where everything changes was based on if the fall was witnessed or not. She stated if a fall was witnessed by any staff and the resident did not hit their head then neuro rounding would not be needed to be done on the residents. She stated but if the resident fall was witnessed and head was hit then 72 neuro checking would need to be completed pending the assessment of the resident. She stated if the assessment shows neuro issues the resident would be sent out right then and there. She stated but any injury to the head indicates the head was hit then neuros should be initiated. She stated in the case of Resident #1, even if it was a small scratch that notates as a head injury and especially since he was on Eliquis neuro checks should have been initiated. During interview on 8.29.25 at 3:45 pm Physician B stated that, yes there was a quapi meeting this morning associated to abuse neglect, non-reporting/communication and neuro checks. He stated was happy with the facility and all the protocols put in place to correct the IJ;s. he stated he had no other concerns with the facility. he did get notified about Resident #1's fall but could not give the exact date. He stated that any resident that was on a blood thinner he would review before giving the facility the go ahead on what to do. He stated he did not have any concerns with the resident the day he received the call from the facility regarding the fall and the resident being on a blood thinner. During an interview on 8.25.25 at 12:25 AM the DON indicated on [DATE] that due to state being in the building on [DATE], she asked RN B if anything happened to Resident #1. She stated RN B stated to her that Resident #1 did sustain an unwitnessed fall in the bathroom on [DATE]. She stated she told him to get his incident report completed immediately on the incident. She stated no other communication was done by RN B regarding the incident. She stated no continuous Neuro checks were completed. The DON stated that because there was 1 neuro check and resident was fine on [DATE], there was no need to monitor further. The DON stated her expectation was even with a head injury or unwitnessed fall, if a resident could pass 1 neuro assessment, there would be no need to have continuous monitoring. The DON stated she knew Resident #1 was on blood thinners but due to how minor the scratch was she did not believe neuro rounding was needed. Incident report on Resident #1, dated [DATE], as a late entry for [DATE] Injury type abrasion location top of scalp. no documentation of physician notification and no documentation of Resident #1's increased lethargy and change in behavior on [DATE] and [DATE]. No measurement of abrasion/scratch to the top of right side of head completed. Record review of facility policy titled Assessing Falls and their Causes dated 2021 indicated: Steps in the ProcedureAfter a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.2. Obtain and record vital signs as soon as it is safe to do so.3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.4. lf an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standingposition, and then document relevant details.5. Notify the resident's attending physician and family in an appropriate time frame.a. When a fall results in a significant injury or condition change, notify the practitioner immediately byphone.b. When fall does not result in significant injury or a condition change, notify the practitioner routinely(e.g., by fax or by phone the next office day).6. Observe for delayed complications of a fall for approximately seventy-two (72) hours after an observedor suspected fall and will document findings in the medical record.7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreasedmobility; and any changes in level of responsiveness/consciousness and overall function. Note thepresence or absence of significant findings.8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed in the electronic health record by the charge nurse on duty at the time.Record review of facility policy titled Falls-Clinical protocol dated 2021 indicated: Monitoring and following up-1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Review of Resident #1's hospital records revealed:CT scan [DATE] was a Large right subdural hematoma (brain bleed) along the entire convexity from anterior-posterior midline measuring up to mostly 15mm in thickness. The result was a midline shift (brain tissue moved) to the left of about 7mm. While in ER on [DATE] Resident #1 had 30-45 second full tonic colonic seizure. ER diagnosis dated 8.20.25 was a Nonsurvivable head bleed. [DATE] Resident #1 passed away at the hospital. This was determined to be an Immediate Jeopardy (IJ) on 8.28.25 at 3:05 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 8.28.25 at 3:05 pm. Record review of Plan of Removal accepted on 8.29.25 at 12:45 PM reflected the following: F684 Quality of LifePlan to Remove Immediate JeopardyThe facility failed to provide treatment and care for Resident #1 when Resident #1 was identified [DATE] as having a cut to the right side of his head, which resulted in a subdural hematoma (brain bleed) and death on [DATE].Facility C NAs failed to report the scratch/cut to the top right of resident #1's head on [DATE] to charge nurse or other nursing staff. Facility staff did not report resident #1 being lethargic on [DATE], to the charge nurse or other nursing staff.The facility RN failed to begin neurological checks or complete an incident report after family had reported that resident #1 fell on [DATE], this was reported to facility RN on [DATE]. Facility RN put bandages on both the skin tear to right elbow and right side of head on [DATE]. Facility RN did not report fall or injuries to other nurses, or nursing administration. The facility medical director was notified of Immediate Jeopardy by the facility Administrator on [DATE].Resident #1 expired in the hospital on [DATE]. The director of nursing reviewed all residents to ensure no other unreported injuries or falls had occurred that had not been addressed. None were found. This was completed on [DATE].The charge nurse that did not report the fall, was suspended, investigation pending on [DATE] by the director of nursing and administrator. This investigation will be completed no later than [DATE].The CNA that failed to report the skin alteration on resident #1's right side of head to the charge nurse will have a 1:1 in-service and have a documented letter of counseling by the Director of Nursing on [DATE] regarding reporting any abnormalities with residents immediately. The CNA that failed to report the lethargy related to resident #1, to the charge nurse will have a 1:1 in-service on reporting suspected change of conditions to the to the charge nurse and have a documented letter of counseling by the Director of Nursing on [DATE] regarding reporting any abnormalities with residents immediately. The director of nursing was educated on the neurological policy, specifically related to any fall that is unwitnessed or a fall with head involvement, the nurse will begin neuro checks to continue for 72 hours or extended if the practitioner orders extension, on [DATE] by the VP of Clinical Services. All nurses were in-serviced by the Director of Nursing on [DATE] regarding documentation of change in condition, incident reporting process, neurological check policy, fall policy. All nurses will be in-service in person or on the phone, prior to the nurse working the next shift. The nurses' signature on in-service indicate understanding. All nursing staff were in-serviced on notification of change in resident condition, falls, injury of unknown origin, assessment and treatment, beginning on [DATE], and will be completed on [DATE]. The DON will track completion utilizing a staff roster to ensure a 100% of nursing staff are completed prior to them working with residents. The staff members that are unavailable will be taken off any scheduled shifts until the in-service is completed. The staff will notify the charge nurse/designee of a change in resident condition when it is noted. The charge nurse/designee will notify the resident representative and physician/physician extender except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical condition or status.All CNAs, TCNAs and hospitality aides will be educated on notifying the charge nurse/designee when a resident presents with a change in condition. DON/designee will monitor by randomly questioning 5 staff members per week starting [DATE] for 4 weeks on changes in conditions and who to notify. The DON/designee will document staff comprehensive on a monitoring form.Nursing administration will round in the morning all resident rooms. Focus will be ensuring there is no evidence injuries or change in resident condition, daily M-F X4 weeks. The DON/ADON will contact nursing staff during the weekends to ensure if any changes in condition occurred, all proper steps have been followed and all notification have been made. If there is any evidence of a change of condition, the CNA will notify the nurse who will notify the DON, Medical Director, Responsible party of the change in condition and will follow physician direction on next course of action. Nursing administration will be educated on this practice by the administrator on [DATE]. DON and the Administrator will interview 3 staff daily related to their understanding of the in-service education provided, for the next 4 weeks. An Ad Hoc QAPI was held by the Facility Administrator, Director of Nursing, and Asst. Director of Nurses on [DATE] to review the alleged deficiency and plan. Monitoring and verification of the facility POR as follows: During a phone interview on 8.29.25 at 11:15 AM Phone interview LVN F work nights-6pm shift yesterday-She stated that she did 4 in-services total yesterday before she was allowed to work. She stated the main one that stands out was falls with head injuries. She stated any fall with a head injuria, an incident report must be completed. She stated that they will no longer use paper copies to do neuro checks but to use the pcc system to get them completed. She stated that neuros must be initiated on all unwitnessed falls, falls in which residents are on anti-coagulants, contact family, don, physician, and administrator. She stated that documentation went hand in hand with the in-services regarding the falls and injuries, and neuros. She stated that that abuse neglect, anything seen or suspected was to be reported to the administrator immediately. She stated that all in-serves were led by the DON. She stated there was a small recall/quiz at the end with information services. During a phone interview on 8.29.25 at 11:30 AM Phone interview LVN G stated there were 4 total in-services. She stated abuse/neglect, documentation, neuros, and falls w/ head injury. She stated that abuse neglect was nothing crazy new. She stated that if you suspect any abuse neglect or witness any sort of abuse neglect let the administrator know and let the don know, the physician and family. She stated documentation wise most importantly was to get the incident report done immediately and to inform all parties about that incident that occurred. She stated for example any resident with a fall that was on an anti-coagulant was to be sent out of the facility via to the ER. She stated then all documentation must be filled out and neuros starts if resident was not on any anti coagulants. She stated neuros really need to be started on all unwitnessed falls and all falls that include head injury that were witnessed. She stated at the end of each in-service there was a recall of knowledge quiz a question-and-answer time for any issues. She stated it was good to hear everything and have the review. During a phone interview on 8.29.25 at 11:45 AM Phone interview CNA H stated that before she was allowed to start work last night at 6pm there were 4 in-services that were completed. She stated that documentation, which was a little more in depth for the nursing side but documentation anytime any abuse/neglect or fall or anything happens in the facility she was to make sure all statements were complete and to always follow her chain of command. She stated that any time abuse or neglect was witnessed, or any sort of injury was seen to be new on a resident, she was to report to her charge nurse. She stated if she were to observe a fall, she would get the charge nurse or get help while another cna stayed with the resident. She stated at the end of the in-services there was a recall of all information that was covered and then a question and answer if any questions. She stated she appreciated her facility going over everything and it was a lot of good information. During a phone interview on 8.29.25 at 12:00 PM Phone interview CNA I stated that there were 4 in-services she had to complete before she was allowed to work last night. She stated that 3 were more to both types of staff while the 4th in-service was more for nursing staff. She stated abuse neglect, to make sure anytime she was to witness any type of abuse/neglect it was to be reported to her chain of command. She stated she would let her nurse/charge nurse know but knows the abuse coordinator was the administrator. She stated when it came to falls, anytime a resident was observed falling or found on the ground she was to report/call for help to have the nurse come and assess the resident. She stated she was not to touch or move the resident in any, way, but only to make sure to get help for the resident and for a nurse to come and assess the resident. She stated neuros were covered but that was more for nurses and not CAN's. she stated lastly, they covered documentation, again more towards nursing but also if anything abuse/neglect, injury, or fall were observed she would need to document everything and then use the chain of command to communicate everything that she observed. She stated at the end there was a question and answer and then a recall session of the in-services to test retention of education. During a phone interview on 8.29.25 at 12:45 PM Phone interview CNA J stated she was in-service las night before she was allowed to work. She stated due to being a CNA she was not allowed to assess any resident given any fall or found on he ground. She stated she was to reach out to the charge nurse or any nurse to come do an assessment on the resident. She stated any new injuries should be identified and communicated to the nurse as soon as possible so that the nurse could notate any changes to the resident or their behavior. She stated that any signs or physically saw abuse of any kind should be reported to the administrator immediately. She stated any changes in condition, if the resident were acting different in anyway should be reported to the nurse. She stated overall all of the in-services had to do with reporting to the nurses, what to report, how to report and to make sure to follow the chain of command. During a phone interview on 8.29.25 at 1:30 pm LVN K stated that there were 4 in-services that she had to complete before she was allowed to work this morning. She stated the main in-service for nursing was the combination of documentation, falls, anticoagulants, and neuro rounding. She stated that the main thing with documentation was that all neuro rounding would be completed in the electronic system and not a paper trail. She stated she believes the facility will honestly use both to make sure everything was completed and accurately. She stated for example if a resident who was on an anti-coagulant has a fall that was unwitnessed the resident will be sent to the ER no questions asked. She stated that but if the fall was witnessed and the resident was not on anti-coagulants then neuro rounding would be triggered, and the resident would be rounded on for a minimum of 72 hours. She stated that abuse neglect in service was very straight forward, what to look for, who to report to (administrator), that sort of thing. She stated but the importance of any head injury with fall with a resident who was on anticoagulants must been sent out or monitored properly. She stated at the end of the in-services there was a recall of knowledge. During a phone interview on 8.29.25 at 1:45 PM LVN L stated there were 4 in-services that she had to complete before she was allowed to start working this morning. She stated that abuse/neglect was one of the very normal abuse/neglects in-services that went over what constitutes abuse neglect, who to report to, how to report and what you are looking for that constitute abuse and neglect. She stated the other 3 in services for the nurses in the building all flowed into each other. She stated the in-services covered documentation, falls, and neuro checks. She stated that if any resident who was on anti-coagulants has an unwitnessed fall the resident was to be sent out immediately. She stated but if a resident has a fall and head injury was suspected and not on anti-coagulant then neuro founding would need to be initiated. She stated all documentation would need to be filled out immediately and neuro checks initiated in the electronic nursing system. She stated that after the in-services were completed a knowledge check was completed for retention. During an interview on 8.29.25 at 2:00 PM CNA M stated there were 4 in-services that he had to complete before he was allowed to start his shift today. He stated that the overall point of all 4 in-services was communication, who to communicate to and what to look for. He stated when it came to abuse/neglect look for any new wounds or injuries on the resident and pay attention to if the resident was acting normal that day. He stated if anything seemed off with the resident you were to report it to the charge nurse. He stated if a resident was found on the floor from a fall, then he would call out for help from another CNA to get the charge nurse or he would have a CNA stay with the resident while he went to get a nurse to come do an assessment of the resident. He stated any abuse/neglect witnessed should be reported to the administrator immediately. During a phone interview on 8.29.25 at 2:00 PM CNA A stated that there were 4 in-services she had to complete before she was allowed to work last night. She stated that 3 were more to both types of staff while the 4th in-service was more for nursing staff. She stated abuse neglect, to make sure anytime she was to witness any type of abuse/neglect it was to be reported to her chain of command. She stated she would let her nurse/charge nurse know but knows the abuse coordinator was the administrator. She stated when it came to falls, anytime a resident was observed falling or found on the ground she was to report/call for help to have the nurse come and assess the resident. She stated she was not to touch or move the resident in any, way, but only to make sure to get help for the resident and for a nurse to come and assess the resident. She stated neuros were covered but that was more for nurses and not CNA's. she stated lastly, they covered documentation, again more towards nursing but also if anything abuse/neglect, injury, or fall were observed she would need to document everything and then use the chain of command to communicate everything that she observed. She stated at the end there was a question and answer and then a recall session of the in-services to test retention of education. During an interview on 8.29.25 at 2:00 PM CNA C stated that he was part of 4 in-services before he was allowed to work. He stated that one of the in-services was more associated to the nursing staff. He stated firs they discussed abuse/neglect and what to look for. He stated look out for any injuries to the resident or new cuts, bruising etc. he stated who to communicated to regarding any information with any injuries or abuse neglect to the charge nurse and the administrator. He stated that even if the injury were to look old or new or not that serious all injuries were to be communicated using the chain of command. He stated another in-service covered what to do as a CNA if you were to find a resident on the floor, weather it was witnessed or not and to not touch the resident but to get the nurse to do an assessment on the resident. He stated all information was good and needed to be heard even as a refresher. Record review of 4 in-services- Abuse/neglect-in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered, abuse, neglect, exploitation, who to report to, how to report and what constitutes as abuse or neglect. Which can include even new injuries. Report to charge nurse, don or administrator. Falls and head injuries in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered what constitutes as a fall, what constitutes as a head injury, who to report to, how to report and what to do if fall was witnessed or not witnessed. Documentation in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered documentation that must be completed such as an incident report the second an incident occurs. What documentation must be completed and started in the electronic system, such as neuro checks and communication to physician, family, chain of command/don and then administrator. Abuse/neglect-in-service provided by the facility. Signature pages for all staff provided. Signatures of all employees were observed on signature pages. In-service dated 8.28.25. presented by DON. Subjects covered what constitutes the injury to start neuro checks vs sending the resident directly to the hospital. Record review of RN B was educated and suspended pending investigation. During interview with DON, RN has been terminated from position at the facility. Signature sheet provided by facility with employee RN signature of report of employee education. Dated 8.28.25. Second Report of education dated 8.27.25 presented by COR to DON with DON signature provided subject covering neuro checks, policy, falls and head injury unwitnessed fall. Record review of 14 residents were reviewed for anticoagulant completed by DON on 8.28.25. Face sheets and dosages provided. Record review of Safe surveys completed for all residents in the building with 1-4 questions: 1. Do you feel safe here at [facility]?2. Do you feel your rights are upheld here at [facility]?3. Does the staff treat you with respect?4. Have you had any issues with staff recently? 14 pages with 4 residents per page were completed with all questions being answered as yes, yes, yes, no for all residents. Record review of Actual/Alleged abuse monitoring completed starting 8.29.25 at 9am by administrator and 3 random times per day completed with administrator signature provided. Times were 9am, 10:30am and 8am. Three employees random selected were CNA Q, CNA R, and CNA S, no concerns notated. Record review of Ad

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food stored in the kitchen were sealed and/or labeled properly in the facilities refrigerator #1 and freezers (#1, #2, and #4). These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 2/3/25 at 10:05 AM of facility kitchen revealed; Refrigerator #1: 1 bag of shredded cheese was unsealed and open to air. Freezer #1: 1 box of hamburger patties was unsealed and open to air. Freezer #2: 1 box of egg omelets was unsealed and open to air. Freezer #4: 1 box of mixed vegetables was unsealed and open to air. Sheet tray of red velvet chocolate chip cookies was open to the air. During an observation and interview on 2/5/25 at 3:15 PM, freezer #4 had an opened box of egg rolls. The DM stated that she would not consider that box to be sealed and open to the air. There were 3 trays of rolls sitting out, DM stated the rolls should be covered even if they are coming to room temperature. She stated she understood that all foods need to be covered and sealed and that an open box did not count as being covered or sealed. DM stated this should be done so the residents do not get sick from any contaminants that could be getting on the food . During an interview on 01/16/25 at 5:12 PM, the ADMN stated he did not know the food was exposed in the kitchen. He stated it was his responsibility as well as the DM to keep all food covered and safe. He stated the kitchen staff should have followed the facility's policies for food storage. He stated the negative impact on residents was residents could have ate contaminated foods resulting in residents getting sick. He stated that all residents ate from the kitchen. Review of the Food Safety and Sanitation Plan, dated 07/22/2021, revealed - Foods are stored off the floor .and covered. - All cooked or prepared foods shall be protected at all times from cross contamination Review of FDA Food Code 2022: Full Document accessed on 01/31/2025 in annex 7 page 37, 38 revealed: Applicable Code Sections: 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #97, Resident #78, and Resident #74) reviewed for accident hazards. The facility failed to follow the smoking policy with Resident #97 leaving her unsupervised while smoking, smoking at undesignated smoking times, and allowing her to have her cigarettes and lighter with her. The facility failed to follow the smoking policy with Resident #78 leaving him unsupervised when smoking and smoking at undesignated times. The facility failed to follow the smoking policy with Resident #74 leaving him smoking already smoked cigarettes, smoking unsupervised, and smoking at undesignated times. These failures could place residents at risk for injuries and fire hazards. Findings included: Resident #97 Review of Resident #97's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: artificial hip joint, high cholesterol, and tobacco use. Review of Resident #97's MDS assessment, dated 01/14/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment. Review of Resident #97's Comprehensive Care Plan, revised 1/16/25, revealed: Focus: Nicotine addiction- I am a smoker. I have been assessed to be a supervised smoker. I smoke traditional cigarettes. Goal: The resident's desire to smoke will be honored daily and will smoke in designated area. Interventions: . Ensure I am aware of smoking times and assist if needed if on supervised smoking schedule. I will be aware and practice safe smoking techniques: A. Designated smoking area, B. safe use of lighter, C. Safely extinguishing cigarettes, D. Cigarettes will be kept locked up with nurses . Review of Resident #97's smoking assessment, dated 01/19/25, revealed in part, that Resident was capable of understanding Facility Smoking Policy, Resident verbalized understanding of the Facilities Smoking Policy, Resident needed facility to store lighter and cigarettes, and Resident had no limitations to prevent her from smoking without assistance or supervision. Review of Resident #97's electronic chart revealed no evidence of a signed smoking agreement. Review of Resident 97's progress notes from 01/10/25 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the smoking policy. During an observation on 02/04/25 at 09:00 AM, Resident #97 was outside smoking and had her own pack of cigarette with her. No staff supervision was present. Resident #74 was wheeling around with a lighter asking residents for a cigarette. Resident #97 gave him a cigarette. No staff supervision was present. Resident #74 lite the cigarette and smoked it. Red trash can in smoking area was filled with trash and a lighter. No obvious burns or injuries from smoking noted to Resident # 97 or Resident #74. During interview on 02/04/25 at 09:15 AM, Resident #97 stated she did not sign or go over any admission paperwork regarding the smoking policy. She stated she was not aware of any smoking policy and that she had her cigarettes and lighter and smoked whenever she wanted to. During observation on 02/04/25 at 03:00 PM, Resident #97 was outside in the smoking area with her own cigarettes and lighter with her. Resident #78 Review of Resident #78's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: blood infection, heart valve replacement, and lung disease. Review of Resident #78's MDS assessment, dated 02/02/25, revealed his BIMS score was 15 of 15 reflective no cognitive impairment. Review of Resident #78's Comprehensive Care Plan, revised 02/03/25, revealed nothing related to smoking. Review of Resident #78's electronic chart revealed no evidence of a smoking assessment. Review of Resident #78's electronic chart revealed no evidence of a signed smoking agreement. Review of Resident #78's progress notes from 01/30/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the smoking policy. During an observation and interviews on 02/03/25 at 11:17 AM, Resident #78 and Resident #97 were outside smoking with no supervision. No obvious burns or injuries from smoking noted to Resident # 97 or Resident #78. Resident #78 stated the staff had his cigarettes and they gave him one and let him smoke because he missed smoke break. Resident #97 stated she kept her own cigarettes and lighter with her and she smoked whenever she wanted to. During an observation and interview on 02/04/25 at 09:10 AM, Resident #78 stated the facility had his cigarettes but gave them to him whenever he asked for them. He stated he was allowed to smoke whenever he wanted to. Resident #78 stated he did not go over or sign any paperwork when he was admitted regarding the smoking policy. Resident #74 Review of Resident #74's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: lung disease, depression, anxiety, and tobacco use. Review of Resident #74's Admission MDS assessment, dated 12/25/24, revealed his BIMS score was 02 of 15 reflective of severe cognitive impairment. Review of Resident #74's Comprehensive Care Plan, revised 12/30/24, revealed: Focus: I am able to use tobacco products independently without adaptations or supervision. Goal: I will follow the tobacco policy of the community without injuring self or others. Interventions: I can smoke unsupervised. Review of Resident #74 smoking assessment, dated 10/08/24, revealed in part, that Resident was capable of understanding Facility Smoking Policy, Resident verbalized understanding of the Facilities Smoking Policy, Resident needed facility to store lighter and cigarettes, and Resident had no limitations to prevent her from smoking without assistance or supervision. Evaluation: Resident requires supervision while smoking. Comments: Resident understands the policy but is non-compliant with rules. Residents smoking material will be put in a locked area and will be given out during smoke break and has to be a supervised smoker. Review of Resident #74 electronic chart revealed no evidence of a signed smoking agreement. Review of Resident #74's progress notes from 12/25/24 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the smoking policy. During an observation and interview on 02/04/25 at 02:12 PM, Resident #74 stated that he was a smoker. He stated that he went out and smoked any chance he could get. He stated that there have been times where he was outside and smoking by himself. He stated he did not have a lighter, but he got them from another resident because a few of them had lighters. He stated he got cigarettes from other residents or traded for them if he needed to. He stated he smoked cigarettes that were half smoked from other residents that he found. Review of document, not dated, posted at the nurses' station revealed Smoking Times: 10:30 AM, 1:30 PM, 3:30 PM, 7:30 PM, and 9:00 PM. During an observation and interview on 02/03/25 at 03:16 PM, multiple residents were on the smoking patio with cigarettes but no lighter to light them. Resident #74 was wheeling around with an already smoked cigarette butt asking people for a lighter. CNA A stated smoke break did not start until 3:30 but they had already passed out cigarettes. She stated all cigarettes and lighters were kept by staff and that no resident should have their own on them. CNA then lite the residents' cigarettes and started the smoke break early. During an interview on 02/04/25 at 11:47 AM, LVN B stated her only concern with the facility was the smoking. She stated there were multiple residents that had cigarettes, lighters and vapes on them. She stated the residents were not supposed to go outside and smoke unless a CNA or nurse was present. LVN B stated there were multiple residents that went outside and smoked on their own. She stated there was a smoking schedule, but it was not followed. During an interview on 02/05/25 at 10:06 AM, Admission/Marketer stated she did not know anything about who informed the residents of the smoking policy. During an interview on 02/05/25 at 02:51 PM, the Administrator stated the smoking policy was addressed and explained to all admits with the admission packet and paperwork. He stated he was not aware that it was not part of the packet. He stated no resident should have cigarettes or lighters on them. He stated he was not aware that any residents had their own or that residents were not aware of the smoking policy. He stated it was the Marketer/Admissions responsibility to ensure that residents were aware of the smoking policy on admission. He stated it was a system failure. He stated not reviewing the smoking policy on admission could lead to residents not knowing their rights and not knowing the expectations of the facility. He stated resident having their own cigarettes and lighters could cause many negative or harmful situations. Review of facility policy titled, Resident Smoking, dated 2024, revealed in part: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation .3.) All residents and family members will be notified of this policy during the admission process, and as needed. 4.) All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 5.) Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all. 6.) Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking area, at designated times, and in accordance with his/her care plan.

Based on interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, including but not limited to the right to make choices about aspects of his or her life in the facility that are significant to the resident, for 3 of 3 Rresidents (Resident #97, Resident #78, and Resident #304) who was reviewed for resident rights. The facility failed to inform Resident #97 of smoking policies, resulting in resident having her cigarettes taken away and restrictions added to her smoking times. The facility failed to inform Resident #78 of smoking policies, resulting in restrictions added to his smoking times. The facility failed to allow Resident #304 to sit outside on the patio due to other residents not following the facility's smoking policy. These failures could affect any resident who was a new admission to the facility and could result in residents not knowing their rights regarding smoking. The findings include: Resident #97 Review of Resident #97's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: artificial hip joint, high cholesterol, and tobacco use. Review of Resident #97's MDS assessment, dated 01/14/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment. Review of Resident #97's Comprehensive Care Plan, revised 1/16/25, revealed: Focus: Nicotine addiction- I am a smoker. I have been assessed to be a supervised smoker. I smoke traditional cigarettes. Goal: The resident's desire to smoke will be honored daily and will smoke in designated area. Interventions: . Ensure I am aware of smoking times and assist if needed if on supervised smoking schedule. I will be aware and practice safe smoking techniques: A. Designated smoking area, B. safe use of lighter, C. Safely extinguishing cigarettes, D. Cigarettes will be kept locked up with nurses . Review of Resident #97's electronic chart revealed no evidence of a signed acknowledgement of smoking policy. Review of Resident 97's progress notes from 01/10/25 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the smoking policy. Review of Resident #97's smoking assessment, dated 01/19/25, revealed in part, that Resident was capable of understanding Facility Smoking Policy, Resident verbalized understanding of the Facilities Smoking Policy, Resident needed facility to store lighter and cigarettes, and Resident had no limitations to prevent her from smoking without assistance or supervision. Resident #78 Review of Resident #78's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: blood infection, heart valve replacement, and lung disease. Review of Resident #78's MDS assessment, dated 02/02/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Review of Resident #78's Comprehensive Care Plan, revised 02/03/25, revealed no evidence related to smoking or resident rights. Review of Resident #78's electronic chart revealed no evidence of a acknowledgement of smoking policy. Review of Resident #78's progress notes from 01/30/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the smoking policy. Review of Resident #78's electronic chart revealed no evidence of a smoking assessment. Resident #304 Review of Resident #304's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: heart failure and lung disease. Review of Resident #304's MDS assessment, dated 01/25/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Further review of MDS indicated resident is not on oxygen therapy. Review of Resident #304's Comprehensive Care Plan, revised 1/23/25, revealed: Focus: I have altered respiratory status/difficulty breathing .Goal: I will maintain normal breathing pattern .Interventions: .Oxygen settings 3 liters via nasal cannula. Review of document posted at the nurses' station revealed Smoking Times: 10:30 AM, 1:30 PM, 3:30 PM, 7:30 PM, and 9:00 PM. Review of facility document titled, Admission Agreement, had no evidence of anything regarding smoking or smoking policy for the facility. During observation and interviews on 02/03/25 at 11:17 AM, Resident #78 and Resident #97 wasere outside smoking with no supervision. Resident #78 stated the staff had his cigarettes and they gave him one and let him smoke because he missed smoke break. Resident #97 stated she kept her own cigarettes and lighter with her and she smoked whenever she wanted to. During observation and interview on 02/03/25 at 03:12 PM, Resident #304 was outside on the patio relaxing in her wheelchair. Resident was wearing oxygen via nasal cannula with portable oxygen tank on wheelchair. Staff came outside and told her she had to go inside because residents were about to smoke, and she had on oxygen. Resident #304 stated she did not go over or sign any admission paperwork. She stated no one had discussed resident rights or grievances with her. She stated she did not think it was fair for her to not be able to sit on the patio especially when it was not even a designated smoking time. She stated it made her feel as if her rights and wants to sit outside were not important. She stated she did not know who to speak to about her concerns nor how to file a grievance. During observation on 02/03/25 at 03:16 PM, multiple residents were on the smoking patio with cigarettes but no lighter to light them. CNA A stated smoke break did not start until 3:30 but she had already passed out cigarettes. She stated all cigarettes and lighters were kept by staff and that no resident should have their own on them. CNA A then lit the residents' cigarettes and started the smoke break early. During observation on 02/04/25 at 09:00 AM, Resident #97 was outside smoking and had her own pack of cigarettes with her. No staff supervision was present. During observation on 02/04/25 at 09:10 AM, Resident #78 stated the facility had his cigarettes but gave them to him whenever he asked for them. He stated he was allowed to smoke whenever he wanted to. Resident #78 stated he did not go over or sign any paperwork when he was admitted regarding the smoking policy. During an interview on 02/04/25 at 09:15 AM, Resident #97 stated she did not sign or go over any admission paperwork regarding the smoking policy. She stated she was not aware of any smoking policy and that she had her cigarettes and lighter and smoked whenever she wanted to. During an interview on 02/04/25 at 11:47 AM, LVN B stated her only concern with the facility was the smoking. She stated there were multiple residents that had cigarettes, lighters and vapes on them. She stated the residents were not supposed to go outside and smoke unless a CNA or nurse was present. LVN B stated there were multiple residents that went outside and smoked on their own. She stated there was a smoking schedule, but it was not followed. During observation on 02/04/25 at 03:00 PM, Resident #97 was outside in the smoking area with her own cigarettes and lighter with her. During an interview on 02/05/25 at 10:06 AM, the Admission/Marketer stated she did not know anything about who informed the residents of the smoking policy. During an interview on 02/05/25 at 02:51 PM, the Administrator stated the smoking policy was addressed and explained to all admits with the admission packet and paperwork. He stated he was not aware that it was not part of the packet. He stated no resident should have cigarettes or lighters on them. He stated he was not aware that any residents had their own or that residents were not aware of the smoking policy. He stated it was the Marketer/Admissions responsibility to ensure that residents were aware of the smoking policy on admission. He stated it was a system failure. He stated not reviewing the smoking policy on admission could lead to residents not knowing their rights and not knowing the expectations of the facility. He stated residents having their own cigarettes and lighters could cause many negative or harmful situations. During observation and interview on 02/05/25 at 03:30 PM, Resident #97 and Resident #78 were sitting on the patio smoking. Resident #97 stated the administrator confiscated her cigarettes and lighter and reviewed the smoking policy and times with her. She stated she felt this should have been discussed on admission and not after she had already been in the facility for a month. Resident #78 stated the smoking policy was reviewed with him also and that he felt it was against his rights to restrict his smoking times since he was not informed of the policy on admission. Review of facility policy titled, Resident Smoking, dated 2024, revealed in part: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation .3.) All residents and family members will be notified of this policy during the admission process, and as needed. 4.) All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 5.) Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all. 6.) Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking area, at designated times, and in accordance with his/her care plan.

Based on interview and record review, the facility failed to ensure an admission policy was implemented for 3 of 3 residents (Resident #97, Resident #78, and Resident #304), reviewed for admissions. The facility failed to ensure that Resident #97 reviewed and signed her admission paperwork per facility policy. The facility failed to ensure that Resident #78 reviewed and signed her admission paperwork per facility policy. The facility failed to ensure that Resident #304 reviewed and signed her admission paperwork per facility policy. These failures could place residents at risk who are not being informed of the admission requirements, services, and processes. Findings Include: Resident #97 Review of Resident #97's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: artificial hip joint, high cholesterol, and tobacco use. Review of Resident #97's MDS assessment, dated 01/14/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment. Review of Resident #97's electronic chart revealed no evidence of a signed admission agreement. Review of Resident 97's progress notes from 01/10/25 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the admission agreement. During an interview on 02/04/25 at 09:15 AM, Resident #97 stated she did not sign or go over any admission paperwork. Resident #78 Review of Resident #78's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: blood infection, heart valve replacement, and lung disease. Review of Resident #78's MDS assessment, dated 02/02/25, revealed his BIMS score was 15 of 15 reflective no cognitive impairment. Review of Resident #78's electronic chart revealed no evidence of an admission agreement. Review of Resident #78's progress notes from 01/30/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the admission agreement. During an interview on 02/04/25 at 09:10 AM, Resident #78 stated he did not go over or sign any paperwork when he was admitted . Resident #304 Review of Resident #304's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: heart failure and lung disease. Review of Resident #304's MDS assessment, dated 01/25/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Review of Resident #304's electronic chart revealed no evidence of an admission agreement. Review of Resident #304's progress notes from 01/20/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the admission agreement. During an interview on 02/03/25 at 03:12 PM, Resident #304 stated she did not go over or sign any admission paperwork. She stated no one had discussed resident rights or grievances with her. She stated she did not know who to speak to about her concerns nor how to file a grievance. During an interview on 02/05/25 at 10:06 AM, Admissions/Marketer stated she brought all residents into her office when they were admitted and went through all the admission paperwork and resident rights. She stated she did not know why these were not signed. She stated she must have missed these admissions. She stated she did not know the policy as to when the paperwork needed to be signed and that she did not see any negative outcome to not doing it. During an interview on 02/05/25 at 02:51 PM, the Administrator stated he was not aware that the admission agreement was not being signed and reviewed on admission. He stated it was the Marketer/Admissions responsibility to ensure that this was being done. He stated it was a system failure. He stated not reviewing the admission agreement could lead to residents not knowing their rights and not knowing the expectations of the facility. Administrator stated the faility did not have an admissions policy. Record review of the facility document titled Admission Agreement, not dated, stated Preamble: This Admission Agreement is a legally binding contract that defines the rights and obligations of each person who signs it .If you are able to do so, you must sign this agreement in order to be admitted to this center. If you are not able to sign this agreement, your legal representative, who has been given authority by you to admit you to the center, must sign it on your behalf .

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that can be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 5 residents reviewed for generic comprehensive person-centered care plans. The facility failed to update care plans with personalized interventions for Resident #1, Resident #2, and Resident #4 in areas such as fall prevention. The facility failed to implement care plan interventions for Resident #3 in areas such as fall prevention. These failures could affect the residents by placing them at risk for not receiving care and services to meet their individual needs. Findings included: Resident #1 Record review of Resident #1's electronic face sheet dated 11/02/2024 revealed an [AGE] year-old female admitted to the facility on [DATE] and originally admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, urinary tract infection (infection in the urine), repeated falls, abnormalities of gait and mobility, lack of coordination, and muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed: no BIMS score because the resident was rarely understood. Further review revealed Resident #1 had behavior of wondering, she used wheelchair, she required supervision with eating, she required partial assistance with toileting hygiene, she needed substantial assistance with oral hygiene, showers, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. She had no falls since prior assessment and received SLP and PT. Record review of Resident #1's Comprehensive Care Plan dated 11/05/2024 revealed Focus I am at risk for falling related to repeated falls, poor balance, poor safety awareness, muscle weakness, poor coordination, unstable gait, unaware of limitations. I had an actual fall on 11/2/2024 Goal Resident #1 will remain free from major injury through next review. Interventions: Educate resident to allow staff to pick items up from floor. Date Initiated: 07/03/2023 Revision on: 10/06/2023. Encourage resident to use environmental devices such as hand grips, handrails, etc. PRN Date Initiated: 03/15/2021 Revision on: 10/06/2023 Keep bed in lowest position with brakes locked, call light, personal, and frequently used items within reach at all times. Date Initiated: 02/23/2023 Revision on 10/06/2023. Orient resident when there has been new furniture placement or other changes in environment. Date Initiated: 02/23/2023. Revision on: 10/06/2023. Provide resident an environment free of clutter Date Initiated: 02/23/2023 Revision on 10/06/2023. Provide supervision during showering to minimize risk for falls. Date Initiated: 02/23/2023 Revision on 10/06/2023 Remind resident to remove blankets/items from chairs/recliners and utilize the handrails before going from standing to sitting. Date Initiated: 10/17/2023 Revision on 10/06/2023 Review medications Date Initiated: 03/13/2021 Therapy to complete fall screen and treat if needed. Date Initiated: 03/15/2021 Revision on: 03/22/2021 There was no evidence that care plan interventions had been updated since 10/06/2023. Record review of Resident #1's progress notes dated 10/22/2024 revealed she had been found lying in left side on the floor at bedside. She had spilled her boost drink and reported that she had slipped when trying to get up. Record review of Resident #1's progress notes dated 11/02/2024 revealed she had been found lying on the floor with personal small fridge next to her. Record review of Resident #1's fall investigation tool dated 10/22/2024 revealed recommendations to IDT for fall prevention included resident on therapy, refuses staff help with transfers, continue current interventions, perform urine analysis to follow up once antibiotics had been completed for 72 hours. Fall investigation completed by the DON. Record review of Resident #1's fall investigation tool dated 11/2/2024 revealed recommendations to IDT for fall prevention included continue current therapy. Fall investigation completed by the DON. During an observation and interview on 11/02/2024 at 8:42 a.m., entered the secured unit and no staff members were seen in the hallway. Heard a crash and female voice calling out help me, someone help me. Observed Resident #1 lying on the floor in her room. It appeared that she had knocked the refrigerator over and fell in the process. Two bottled waters seen around the resident and fridge lying to Resident #1's right side. After two minutes, two staff members entered the resident's room and shut her door. During an interview on 11/04/2024 at 2:06 p.m., CNA B stated Resident #1 had not fallen recently. CNA B stated the resident had behavior of putting herself onto the floor and staff would pick her up and put her back into her wheelchair when that happened. CNA B stated Resident #1 usually fell when she had an infection and she needed at least one staff to assist with transfers and showers. During an interview on 11/04/2024 at 2:08 p.m., CNA C stated Resident #1 had not fallen recently. CNA C stated staff watched Resident #1 and assisted her with transfers to help prevent her from falling. CNA C stated Resident #1 would transfer herself when staff were not watching. During an interview on 11/04/2024 at 3:00 p.m., LVN A stated Resident #1 had fallen twice in the last 3 weeks. LVN A stated interventions to prevent falls would be found in the fall risk assessment and care plan, but staff would intervene or assist as needed. LVN A stated prior to Resident #1's fall on 10/22/2024, staff would encourage the resident to use her wheelchair. LVN A stated interventions after the fall included more supervision and more assessments for urinary tract infections because the resident would get them chronically. During a telephone interview on 11/04/2024 at 4:54 p.m., Resident #1's RP stated staff had put Resident #1 in her wheelchair to help prevent her from falling. He stated she was ambulatory most of the time but the ability to ambulate changed when she had a urinary tract infection and staff must focus on her more. He stated she did not suffer injury from falling and to the best of his knowledge she was trying to get something out of her fridge when she fell last. He stated he did attend care plan meetings via telephone and did give his opinion when he felt he needed to. During a telephone interview on 11/05/2024 at 9:19 a.m., the MD stated he was notified of Resident #1's fall. He stated he did get invited to post fall care plan meetings but did not make it to all the care plan meetings. He stated not all care plans needed to be updated and that depends on the resident and their condition. He stated historically Resident #1 falls when she had a urinary tract infection, and he may order for her to have a UA later this week since she just finished treatment for a UTI. Resident #2 Record review of Resident #2's electronic face sheet dated 11/04/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: blindness left eye and fall on same level. Record review of Resident #2's admission MDS assessment dated [DATE] revealed: BIMS score of 00 which indicated severe cognitive impairment. Further review of the MDS revealed Resident #2 needed supervision with eating, oral hygiene, and personal hygiene. She needed partial assistance with upper body dressing and substantial assistance with toileting hygiene, showers, lower body dressing, and putting on footwear. Resident #2 did not use walker or wheelchair and received PT, OT, and SLP. Resident had fall prior to admission and fall with injury after admission. Record review of Resident #2's comprehensive care plan dated 11/06/2024 revealed: Focus I am at risk for falls r/t balance problems, confusion, and history of falls. Date Initiated: 10/31/2024 Revision on: 11/06/2024 Goal: My fall risk will be minimized. Date Initiated: 10/31/2024 Target Date 01/20/2025. Interventions: Encouraged me to stay in common areas to promote more supervision Date Initiated 10/31/2024 Encouraged my participation in activities that will increase strength and mobility Date Initiated 10/31/2024 Ensure I am wearing appropriate-fitting clothing and footwear (SPECIFY and describe footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks) that fits well when ambulating or mobilizing in w/c . Date Initiated: 10/31/2024. Care plan did not reflect intervention for staff to stop guiding Resident #2 with touch. Record review of Resident #2's progress note dated 10/13/2024 revealed Resident #2 was found on the floor beside her bed. Assessment found hematoma and laceration to right eyebrow. Record review of Resident #2's fall investigation tool dated 10/13/2024 revealed recommendations to IDT for fall prevention included orientation to location, new admission to facility. Fall investigation completed by the DON. During an observation on 11/04/2024 at 12:22 p.m., Resident #2 was sitting at a dining room table in a dining room chair. Two bruises to her right side of face observed. Resident #2 was feeding self and had slip on shoes that were worn on both feet. During an interview on 11/04/2024 at 2:06 p.m., CNA B stated interventions in place to prevent falls included keeping a close eye on Resident #2. CNA B stated Resident #2 would start screaming and hollering if staff attempted to assist her. CNA B stated staff would let Resident #2 calm down and attempt to assist her again after she had calmed down. During an interview on 11/04/2024 at 3:00 p.m., LVN A stated staff knew that interventions to prevent falls would be found in the fall risk assessment and care plan, but staff would intervene or assist as needed. LVN A stated Resident #2 had fallen about a month ago and had been sent to the ER following the fall. LVN A stated Resident #2 had stiches to her right temple area at the ER. LVN A stated prior to the fall there were no interventions in place. LVN A stated the facility staff were still trying to learn Resident #2 at that time and Resident #2 would freak out, shook, and got more unsteady if staff attempted to guide her with touch. LVN A stated that new interventions put in place after the fall included for staff to stop guiding Resident #2 with touch. During a telephone interview on 11/04/2024 at 5:20 p.m., Resident #2's RP stated she had not been invited to any care plan meetings. She stated she and family member were notified of Resident #2 falling and went with her to the ER. She stated she was unaware of what the facility was doing to prevent Resident #2 from falling. She stated she felt anxiety may have played a role in the resident falling and voiced concerns that the secured unit did not have staff stationed at both ends of the hall. She stated Resident #2 did get dizzy when standing up at times. During a telephone interview on 11/05/2024 at 9:19 a.m., the MD stated he was notified of the fall Resident #2 had on 10/13/2024. He stated one reason she had falls was due to being on benzodiazepines for anxiety. He stated the medication treated her anxiety but did increase her risk for falls. He stated he had not changed any of her medications because Resident #2 was on a low dose of antianxiety medication and anxiety could lead her to falling also. During a telephone interview on 11/05/2024 at 9:56 a.m., Physician D stated he would not know if Resident #2 had a fall on 10/13/2024 because his nurses handled that information. He stated he did not expect to be invited to care plan meetings and was not sure if the resident's family was invited to care plan meetings. He stated the care plan probably needed to be updated after a resident had a fall but there was no good way to prevent falls in patients with dementia and stated Resident #2 had dementia. Physician D stated Resident #2 had fallen for different reasons and would fall even if staff were walking next to her. During an interview on 11/06/2024 at 4:25 p.m., the DON stated care plan interventions (SPECIFIC) did not need to be filled in. She stated she would just remove that verbiage if she was doing a care plan. She stated there basically was non-skid socks and shoes that were standard for every resident. She stated she did not believe the area needed to be filled in with more specific information. She did not feel that not filling in that area caused any negative effect on Resident #2. Resident #3 Record review of Resident #3's electronic face sheet dated 11/04/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease. Record review of Resident #3's quarterly MDS dated [DATE] revealed: no BIMS assessment score because the resident was rarely understood. Further review of the MDS revealed Resident #3 needed setup assistance with eating. She needed supervision with oral hygiene and toileting. She needed partial assistance with upper body dressing, lower body dressing putting on footwear, and personal hygiene. Resident #3 was dependent on staff for shower. Resident #3 used no walker or wheelchair. She frequently was incontinent of urine and bowel. She took anticoagulant medications. Resident #3 did not receive therapy. Record review of Resident #3's care plan dated 11/04/2024 revealed Focus: Potential for injury R/T [x] Actual falls [x] HX of falls and is at risk for further falls R/T: [x]cognitive impairment D/T short term memory deficit [x] impaired safety awareness Date Initiated: 06/13/2024 Revision on 06/13/2024; Goal Goal [x] I will have decrease in the # of fall events through the next review date. Date Initiated: 06/13/2024 Revision on: 06/13/2024 Target Date: 12/30/2024; Interventions: Ensure staff aware of safety needs of the resident Date Initiated: 06/13/2024 Provide proper, well-maintained footwear Date Initiated: 06/13/2024 Provide resident an environment free of clutter Date Initiated: 06/13/2024. No evidence that care plan interventions had been updated since 06/13/2024 for fall prevention. Care plan did not include intervention to physically guide her or frequent toileting. Record review of Resident #3's progress notes dated 08/16/2024 revealed Resident #3 was ambulating in the hall and fell on to the left side hitting her left posterior scalp, left shoulder, and left knee. Nurse observed fall and resident reported I got dizzy. During an observation on 11/04/2024 at 12:13 p.m., Resident #3 was sitting at dining room table with socks on and no shoes. The socks did not have slip resistant grips on them. During a telephone interview on 11/04/2024 at 8:04 p.m., Resident #3's RP stated that he was notified of fall, and he did get invited to care plan meetings. He stated he will join via telephone and did give his input. He stated her dementia and bad knee was what he felt caused the fall. He stated no concerns with how the facility cared for Resident #3. During an interview on 11/04/2024 at 2:06 pm, CNA B stated Resident #3 had not fallen on their shift. CNA B stated the resident was very confused and roamed in and out of rooms. CNA B stated staff tried to keep Resident #3 in the main areas to help prevent her roaming and decrease fall risk by more supervision. During an interview on 11/04/2024 at 3:00 p.m., LVN A stated Resident #3 had fallen on their shift, and they observed the fall. LVN A stated Resident #3 had been ambulating in the hall towards the dining area when she got weak and fell hitting her arm on the railing. LVN A stated they attempted to get to Resident #3 but could not reach her in time before she fell . LVN A stated interventions prior to Resident #3 were to physically guide her places, and frequent toileting to help prevent Resident #3 from using the restroom anywhere when the urge occurred. LVN A stated that after recent fall, interventions included more frequently toileting resident. During a telephone interview on 11/05/2024 at 9:19 a.m., the MD stated he had been notified of Resident #3's fall on 08/16/2024. He stated he had addressed her dizziness and nausea which he felt led to the fall. He stated she had low blood pressure on 08/27/2024 and medications were addressed. During an interview on 11/05/2024 at 2:21 pm, the DON stated that Resident #3's risk factors for a fall were evaluated quarterly and upon an event. She stated the last fall Resident #3 had, was on 08/16/2024. The DON stated Resident #3 had gotten dizzy and the facility sent her to the ER for an evaluation. The DON stated no fractures had occurred but was diagnosed with elbow contusion (deep bruise) in the ER and was sent back to the facility with an order to give over the counter pain medication. She stated interventions prior to the fall were for staff to maintain needs, proper footwear to be worn, and keep the environment free of clutter. She stated no new interventions were added to the care plan after the fall. She stated Resident #3 was tested for urinary tract infection in the ER and was treated for infection in the hospital. Resident #4 Record review of Resident #4's electronic face sheet dated 11/02/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: dementia, muscle weakness, unsteadiness on feet, lack of coordination, history of falling, age-related physical debility, and macular degeneration (impaired vision). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed: BIMS score of 02 which indicated severe cognitive impairment. Further review of MDS assessment revealed the resident needed set up assistance with oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. Resident #4 needed supervision assistance with eating, showering, and lower body dressing. Resident #4 needed partial assistance with putting on and taking off footwear. She used a walker and had no rejection of care behaviors. She had occasional urinary incontinence and was always incontinent to bowel. She had 3 falls, with minor injury with 2 falls. Record review of Resident #4's care plan dated 08/08/2024 revealed she was risk for falls related to balance problems, confusion, deconditioning, gait problems, and history of falls. The goal was for fall risk will be minimized. The interventions listed were Encourage me to stay in common areas to promote more supervision .Encourage my participation in activities that will increase strength and mobility. Further review of care plan revealed no evidence that the care plan was updated after 08/08/2024 and did not include the interventions of: placing a mattress on the floor, therapy, or change in ambulation from walker to wheelchair. Record review of Resident #4's progress notes dated 08/13/2024 revealed Resident #4 fell in the hallway and was witnessed by 2 staff. Record review of Resident #4's progress notes dated 08/28/2024 revealed Resident #4 was found on the floor of her bathroom. Record review of Resident #4's progress notes dated 09/07/2024 revealed Resident #4 was lying on the floor on her right side. Record review of Resident #4's progress noted dated 09/14/2024 revealed Resident #4 was lying on the floor leaning on her left side and had blood on the right side of her face and in hair. Record review of Resident #4's fall investigation tool dated 09/07/2024 revealed recommendation to IDT for fall prevention were for frequent reminders and to continue current interventions. Record review of Resident #4's fall investigation tool dated 09/14/2024 revealed recommendation to IDT for fall prevention were for increased frequency of checks and family wanted a camera in her room but have not provided a camera. During a telephone interview on 11/04/2024 at 12:43 p.m., Resident #4's RP stated she did get invited to care plan meetings. She stated Resident #4 was using a walker until July of 2024 then she was changed to a wheelchair. Resident #4's RP stated her opinions were not gathered during care plan meetings and staff just discussed what was going on with Resident #4. She did not know of any other interventions that had changed to help prevent Resident #4 from falling. She stated Resident #4 did go on hospice services in September and in September both her and another family member saw Resident #4 lying on the floor next to a mattress that was lying beside her bed. During an interview on 11/04/2024 at 2:06 p.m., CNA B stated Resident #4 never fell during their shift. CNA B stated staff put a mattress on the floor beside her bed and would put her in her wheelchair to help keep her from falling when she did not use a walker anymore. CNA B stated Resident #4 had a lot of swelling in her hands that was new and swelling in her legs that was not new. CNA B stated the resident did refuse showers at times and staff would let her calm down and ask her again to get her to take showers. During an interview on 11/04/2024 at 2:08 p.m., NA C stated Resident #4 had gotten more confused and after staff laid her down, she would try to get up on her own. NA C stated Resident #4 had behaviors of taking her clothes off and moving clothes around. NA C stated staff put Resident #4's bed in low position but she was able to get the remote and use it to raise the bed up. NA C stated staff put a mattress beside Resident #4's bed to help prevent falls. NA C stated Resident #4 would refuse showers and staff would circle back around and offer again and she would change her mind sometimes. During an interview on 11/04/2024 at 3:00 p.m., LVN A stated interventions to prevent falls included toileting often because Resident #4 would try to toilet without assistance. LVN A stated Resident #4 had a will to do things without assistance and did not like to be touched. LVN A stated interventions after falls included a mat at her bedside. During a telephone interview on 11/05/2024 at 9:19 a.m., the MD stated he had been notified of Resident #4's falls. He stated he believed one of the reasons she had been falling was because of the edema to her legs that was being addressed. He stated the fall on September 14th with bruising and swelling around nasal bone did not warrant ER evaluation. During an interview on 11/05/2024 at 2:21 p.m., the DON stated Resident #4's risk factors for falling were dementia, deconditioning, gait imbalance, and medication use. She stated risk factors were assessed quarterly and upon an incident. The DON stated interventions in place prior to August 13th fall were for encouragement to remain in common areas, and to use wheelchair and therapy services. She stated interventions in place prior to August 28th fall was for therapy services, encouragement to remain in common areas, and use of wheelchair. She stated interventions after falling included therapy and Resident #4 started therapy services on [DATE]th and remained on therapy for the remainder of time she was at the facility. She stated after August 28th fall new interventions included continuous reminder to use wheelchair and reiterating what therapy was enforcing. The DON stated after September 7th fall interventions included continue on therapy services and reminders to use wheelchair. She stated after September 14th fall new interventions of non-skid footwear and continue on therapy was listed in progress notes. She stated every staff that had access to care plan had access to progress notes and progress notes were where staff could find those interventions. She stated nurses and CNAs were notified of interventions verbally during shift report from staff that were leaving. She stated her expectation would be for new interventions to be added into the care plan. She denied any negative outcome occurred to residents due to staff able to find information in progress notes rather than reference care plan. She stated she did not know why interventions were not added into the care plan. She stated she did write important care items on a daily sheet that was kept at the nurses' station after the IDT has morning meetings to help pass along information. She stated she leaves sheets for the night shift at the nurses' station as well. During an interview on 11/05/2024 at 3:40 p.m., the ADMN stated the facility had identified that the care plans needed work. He stated the DON and a remote MDS nurse were working on the care plans. He stated the facility had just hired a new onsite MDS nurse that will start working on updating care plans. He expected for care plans to be up to date with current interventions and the MDS nurse was to bring a laptop to morning meetings to start updating care plans. He expected for charge nurses to relay information to nurse assistants so that staff would know what interventions to do to take care of residents. He stated staff were able to perform emergency interventions but would expect placing a mattress on the floor to be in the care plan. Admn would not stated how the failure could affect the residents. During a follow up interview on 11/06/2024 at 4:20 p.m., the DON stated she expected to be notified if staff were using a mattress on the floor beside the bed as fall prevention intervention. She stated the care plan should have been updated with such an intervention. She agreed that mattress on the floor was better than Resident #4 falling but she was not aware of staff doing so. She denied any negative outcome occurred to residents due to staff able to find information in progress notes rather than reference care plan. Review of facility's policy titled Fall Prevention Program dated 07/01/2022 revealed Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. Review of facility's policy titled Comprehensive Care Plans dated 07/2023 revealed The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.

Based on interviews and record review the facility failed to allow residents to obtain a copy of their records or any portions thereof upon request and 2 working days advance notice to the RP for 1 of 5 (Resident #4) residents reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #4 to her RP within two working days of a request on 10/29/2024. This failure could place residents and their representatives at risk by not having information about resident's care that was provided under the care of the nursing facility. Findings included: Record review of Resident #4's electronic face sheet dated 11/02/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: dementia. Further review of Resident #4's electronic face sheet revealed family member was Resident's responsible party. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed: BIMS score of 02 which indicated severe cognitive impairment. Record review of Resident #4's admission agreement dated 4/28/2024 revealed Resident's family signature as legal representative. Further review of the admission agreement revealed: Upon an oral or written request to the facility, you have the right to access your records, including current clinical records. The nursing home must provide you access within 24 hours of your request (excluding weekends and holidays). After receiving your records for inspection, you have the right to purchase photocopies of your records at a cost that is not more than the standard rate in your community. The nursing home must provide you with the photocopies, upon request, within two working days advance notice to the facility . Right to Inspect and Copy. With limited exceptions, you have the right to inspect and copy protected health information that may be used to make decisions about your care. To inspect and copy protected health information maintained by the Center you must submit your request in writing to the Administrator or Medical Records Department. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy your protected health information in certain limited circumstances. If you are denied access to medical information, you will receive a written denial. You may request that the denial be reviewed. Thereafter, another licensed health care professional chosen by the Center will review your request and the denial. The person conducting the review will not be the person who originally denied your request. We will comply with the outcome of the review. We may charge you reasonable fees for copying your PHI. During an interview on 11/06/2024 at 1:50 p.m., the ADMN stated the procedure for releasing medical records was the resident or the POA would fill out a request for release of medical records form. He stated the form was then sent to corporate and the facility would wait for a response before releasing medical records. During a telephone interview on 11/06/2024 at 3:04 p.m., Resident #4's representative stated after she received Resident #4's death certificate, she went around to get health records. She stated she went to the facility and was told by the ADMN she didn't have to fill out any paperwork to receive medical records. She was unsure how long ago that was when she had originally asked the ADMN for medical records. She stated she did not hear back from the facility, so she spoke to the ADMN again who directed her to speak to MR. MR had her fill out a form to submit for medical record release. Resident #4's representative stated she was told it could take up to 2-3 weeks to get medical records. She denied getting a letter requesting payment for medical records or denial of medical record release. She stated she was upset that it had taken so long to get medical records and did not understand why she was not instructed to fill out a form requesting release of medical records from the beginning. During an interview on 11/06/2024 at 3:09 p.m., the MR stated she had received the request for release of medical records from Resident #4's responsible party on 10/29/2024. She stated she sent the request to corporate on 10/30/2024. She stated that she had a conversation with the responsible party that it could take up to two weeks before medical records were released. She stated that she thought the facility had 14 days to get medical records to a resident or their representative. She stated she had not gotten approval from corporate to release the medical records and the ADMN would know more about where facility was in releasing records. She stated that if the medical records were large, the family would be asked to pay a fee for those records but denied that she had requested money for medical records at this time. During an interview on 11/06/2024 at 3:20 p.m., the ADMN stated he believed the facility had 15 days to release medical records based on the Texas Administrative Code. He did not know why the medical records would be denied to a resident's representative. He stated he knew MR had sent a request to corporate but had not been given any information on when the medical records would be released. He stated the resident representative had not been waiting for more than 15 days at this point. He denied any negative impact to the resident or her representative from not receiving medical records. Record review of the facility policy titled Release of Medical Records undated revealed: Request for records should be referred to the Director of Nursing or Administrator, or another staff member previously designated by the facility. Upon request to access or obtain copies of the medical record, the facility should review the authorization to ascertain access rights o that person. Authority to access or release records is only granted by the resident or the resident's legal representative. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records .The corporate office/risk manager should be notified of the request for records. Records should not be released prior to discussion with the corporate office/risk manager, to further validate authenticity of the request. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that records are available 2 days after receipt of payment for the copies. Copies should not be released prior to the receipt of payment for copying charges. Record review of facility policy titled Confidentiality of Personal and Medical Records undated revealed: If there is information considered too confidential to place in the records used by all staff, it may be retained in a secure place in the facility. These confidential records can be formally requested. Once formal request has been received facility staff should gather information requested. The facility has 14 business days to gather requested information. The information will be reviewed at the corporate level before final records will be released to the requesting party. Unauthorized persons are permitted to review records only with the signed permission of the resident or a legal document allowing such assess. Each requested record must be listed on formal document request.

Based on observations, interviews, and record review the facility failed to ensure a resident received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (Resident #4) reviewed for quality of care. Resident #4 did not see a podiatrist despite having thickened and long toenails and the request of the resident's RP. This failure could place residents at risk of pain, toenail injury, difficulty wearing socks and or shoes, and could result in embarrassment, frustration, anxiety, and a decreased quality of life. The findings were: Record review of Resident #4's electronic face sheet dated 11/02/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: dementia, muscle weakness, unsteadiness on feet, lack of coordination, history of falling, age-related physical debility, and macular degeneration (impaired vision). Further review revealed Resident #4 was discharged from facility on 09/27/2024. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed: BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS assessment revealed the resident needed set up assistance with oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. Resident #4 needed supervision assistance with eating, showering, and lower body dressing. Resident #4 needed partial assistance with putting on and taking off footwear. She used a walker and had no rejection of care behaviors. She had occasional urinary incontinence and was always incontinent to bowel. She had 3 falls with minor injury, with 2 falls. Record review of Resident #4's care plan dated 08/08/2024 revealed no mention of podiatry services or of thickened and long toenails. Record review of Resident #4's electronic physician orders with revision date of 12/18/2023 revealed May be seen by Podiatrist as needed. Record review of Resident #4's shower sheets revealed long nails documented on September 27, 2024, September 6, 2024, September 2, 2024, August 26, 2024, August 19, 2024, August 31, 2024, July 24, 2024, July 22, 2024, July 19, 2024, July 17, 2024, July 12, 2024, July 10, 2024, July 3, 2024, July 1, 2024, June 26, 2024, June 21, 2024, June 17, 2024, June 7, 2024, June 3, 2024, May, 15, 2024, May 10, 2024, May 6, 2024, and May 1, 2024. Further reviewed of shower sheets revealed on August 7, 2024, refused emery board, and refused nail/toenail care, and refused nail care on June 17, 2024, June 12, 2024, and June 3, 2024. Record review of Resident #4's EHR revealed no documentation, appointments, or recommendations for Podiatry or toenail trimming or general foot and nail care . During an interview on 11/04/2024 at 12:43 p.m., Resident #4's RP stated that she was told by the SW, the facility podiatrist would see Resident #4 sometime around February 29th, 2024. Resident #4's RP stated she was never told after that if Resident #4 had been seen by podiatrist, but her toenails never got cut. She said she was upset that Residnet #4's nails were thick and long. RP said she felt Resident #4 lost her toenail because her toenails were long and may have gotten caught on something. During an interview on 11/06/2024 at 9:09 a.m., NA E stated NAs were allowed to perform toenail care if the resident's toenails were not complicated or the residents did not have diabetes. NA E stated the last day they took care of Resident #4, her great toenail on one of her feet had been cracked but did not remember for sure. NA E stated they circled the area on the shower sheet when nail issues observed so that the charge nurse and wound care nurse would be notified. NA E stated Resident #4's toenails were complicated, and they were not able to perform foot care on her. During an interview on 11/06/2024 at 9:34 a.m., the SW stated she went around the whole building and asked residents if they wanted a podiatry visit. The SW stated she would make a list of residents that needed to be seen by podiatry based on residents wants and needs voiced by nurses and family. She stated the list was separated up by halls and the podiatrist would go see those residents and his wife would document if a resident refused podiatry services. She stated she would document in EHR the visit or the refusal after the podiatrist finished seeing residents. She stated if a resident refused the podiatry, the podiatrist would attempt to see that resident again in 3 months. She stated she would look through Resident #4's EHR and see if there was documentation of podiatry visit or refusal. During an interview on 11/06/2024 at 10:03 a.m., LVN F stated Resident #4's RP mentioned toenails needed to be cut but Resident #4 would not let staff or family cut her nails. LVN F stated the podiatrist came to the building about every 3 months. She stated she would notify the SW if a resident needed podiatry services. LVN F stated she had attempted to perform foot care by using emery board to file down toenails but Resident #4 would pull away and say, no don't. LVN F stated Resident #4 was agitated after the attempt. She had no knowledge of any toenails being missing. During an interview on 11/06/2024 at 11:03 a.m., the MR stated she would upload documents into the EHR after receiving them. She stated there were no outstanding podiatry visit notes that needed to be uploaded into the EHR system. During an interview on 11/06/2024 at 11:17 a.m., the DON stated she expected for podiatry visits to be provided to residents who needed podiatry and that staff were unable to provide foot care for. She stated the SW would refer to the podiatrist when foot care was needed. She stated she was looking for podiatry notes or documentation about Resident #4 but could not provide anything at this time. During an interview on 11/06/2024 at 1:59 p.m., LVN G stated she had witnessed attempted foot care to Resident #4. She stated Resident #4 would slap and attempt to pinch staff when trying to do fingernail care. She stated Resident #4 would try to kick staff and pull away when attempting to perform toenail care. During a follow up interview on 11/06/2024 at 3:04 p.m., the SW stated she had not been able to locate documentation on Podiatry visit notes for Resident #4 . During exit conference, the facility was not able to provide any documented podiatry visit notes on Resident #4. Record review of the facility policy titled Podiatry Services with no date revealed: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health .Foot care that is provided in the facility, such as toe nail clipping for residents without complicating disease processes, should be provided by staff who have received education and training to provide this service. Residents requiring foot care who have complicating disease processes will be referred to qualified professionals such as a Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy. Foot disorders which may require treatment include, but are not limited to: corns, neuromas, calluses, hallux valgus (bunions), digiti flexus (hammertoe), heel spurs, and nail disorders. Employees should refer any identified need for foot care to the social worker or designee. The social worker or designee will assist residents in making appointments and arranging transportation to obtain needed services.

Based on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 1 resident (Resident #1) reviewed for resident rights. Resident #1 had no consents for the antianxiety medication, Clonazepam, Ativan, Divalproex and Temazepam. Resident #1 had no consents for the antipsychotic medication Risperidone, Aripiprazole, and Haloperidol. These failures could place the resident, who received care at the facility, at risk of not being informed of their health status, to make informed decisions regarding their care. The findings included: Record review of Resident #1's Electronic Admission Record dated 04/05/2024 revealed she was a [AGE] year-old female originally admitted to the facility 01/11/2024 with a most recent admitted [DATE]. She had diagnoses which included Cerebral Palsy, Bipolar disorder with psychotic features, Depression, Anxiety, and Autistic Disorder. Record review of Resident #1's MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 0 out of 15 (severe impairment), short and long-term memory problems, severely impaired cognitive skills for daily decision making, inattention and disorganized thinking. Section D-Mood revealed; Trouble falling or staying asleep, or sleeping too much nearly every day, being short-tempered and easily annoyed 7-11 days out of a two-week period. Social Isolation being the resident is unable to respond. Section E-Behaviors revealed; Physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others, with rejection of care and wandering present. Section GG-Functional Abilities and Goals revealed; substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for eating, oral hygiene, and toileting hygiene, upper/lower body dressing, taking on/off footwear and personal hygiene. Shower and bathing herself had not been attempted. Resident also needed Substantial/maximal assistance for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfers, toilet transfer, walk 10 feet, walk 50 feet, and walk 150 feet. Section N-Medications-High-Risk Drug Classes: Use and Indication revealed: Medications received were antipsychotic 7/7 days, antianxiety 7/7 days, and antidepressant 7/7 days. Section N-Medications-Antipsychotic Medication Review revealed; Antipsychotics were received on a routine basis only. Section Q - Participation in Assessment and Goal Setting (Identifying all active participants in the assessment process) revealed; Family and Legal guardian. Record review of Resident #1's Electronic Order Summary on 04/04/2024 at 3:07pm revealed the following physician orders; ARIPiprazole 5mg at bedtime for behaviors related to bipolar disorder, current episode mixed, severe, with psychotic features (initial start date 01/11/2024; discontinue date 04/02/2024) Ativan 1mg every 4 hours as needed for agitation (initial start 01/20/2024; discontinue date 04/02/2024) ClonazePAM 1mg three times a day for anxiety (initial start date 01/11/2024, discontinue date 03/19/2024) ClonazePAM 1mg four times a day related to anxiety disorder, autistic disorder (initial start date 03/19/2024, discontinue date 04/02/2024) Divalproex Sodium Delayed Release Spring 250mg two times a day related to seizures (initial start date 01/24/2024, discontinue date 04/02/2024) Haloperidol Lactate Oral Concentrate 2.5mg every 4 hours as needed for agitation/aggressiveness for 2 days (initial start date 01/14/2024, discontinue date 01/15/2024) Haloperidol Lactate Oral Concentrate 6mg STAT for extreme agitation related to cerebral palsy (initial start date 01/13/2024, discontinue date 01/13/2024) medroxyPROGESTERone Acetate Intramuscular Suspension 150mg one time a day every 3 month(s) starting on the 28th for 1 day(s) for behaviors (initial start date 01/28/2024, discontinue date 04/02/2024) Perseris Subcutaneous Prefilled Syringe 120mg one time a day every 1 month(s) starting on the 26th for 1 day(s) related to bipolar disorder with psychotic features (initial start date 01/26/2024, discontinue date 04/02/2024) Risperidone 2mg two times a day related to anxiety disorder and autistic disorder (initial start date 01/11/2024, discontinue date 04/02/2024) ZyPREXA Intamuscular Solution 10mg every 24 hours as needed for agitation (initial start date 03/16/2024, discontinue date 04/02/2024) ZyPREXA 5mg one time a day related to bipolar disorder with psychotic features (initial start date 03/16/2024, discontinue date 04/02/2024) Record review of Resident #1's Electronic Medical Record revealed no evidence of signed consents for ARIPiprazole, Ativan, ClonazePAM, Diavalproez, Haoperidol, medroxyprogesterone, Perseris, Risteridone, and ZyPREXA. During an interview on 04/08/2024 at 11:16 AM, the DON stated Resident #1 was not a patient of the Psychiatric doctor but of the facility Medical Director. She stated she could not guarantee there were consents filled out because Resident #1's Representative lived in a different town. She stated the consent would have been a verbal consent. She stated regional management told her had to be wet signature (signature on a physical paper document with penned signatures rather than electronic or digital signatures) for psych meds. During an interview on 04/08/2024 at 11:27 AM, MR stated she did not have any signed consents available to be uploaded for Resident #1. She stated the ADON and DON monitored those. Once they had the consents completed, they would have provided them to her to be uploaded into the resident's electronic chart. During an interview on 04/08/2024 at 11:30 AM, the ADON stated she had been out sick and had gotten behind on consents. She then provided an undated and unsigned 3713 consent form with all of Resident #1's antipsychotics and antianxiety medications (Aripiprazole, 5 mg, Clonazepam 1mg, Risperidone2 mg/ml, Ativan 1 mg, Divalproex Sodium, Temazepam 15 mg). The ADON stated the 3713 had been filled out on 03/15/2024 but was not signed by the Resident Representative or MD. She stated this form provided was the only consent form she had for Resident #1. The ADON stated the MD came to the facility weekly and signs the forms. She stated she does not know why this form has not been signed since the MD had been at the facility weekly. She stated there were no other consents for antipsychotics and antianxiety medications. During a follow-up interview on 04/08/2024 at 11:35 AM, the DON stated she did not know why Resident #1's consent form 3713 was not signed and did not want to make a guess. She stated since the MD had been to the facility several times since the 3713 forms had been printed, the MD should have signed the form as well as having had the Representatives signature. During a follow-up interview on 04/08/2024 at 11:37 AM, MR stated the nurses filled out the consent forms and then would go to her for filing and uploading. She stated she had not seen this consent form (3713), but usually would not get them until they were completed. During an interview on 04/08/2024 at 2:20 PM, the MD stated he visited this facility on a weekly basis and made sure all signed consents for each resident were completed while there. He stated for Resident #1 he had not signed her consents as she was in the hospital and was not physically there at the facility. The MD stated he did have consents at his office and not at the facility, but only had his signature on them and not the representatives. He stated for the medications being prescribed, the consents were supposed to have all signatures in place which also included the RR's signature. During an interview on 04/08/2024 at 4:12 PM, Resident #1's Representative stated she had not signed any consents concerning Resident #1's medications. She also stated she had not received any emails or phone calls concerning consents. She stated the only paperwork she had signed since Resident #1's admission was the admission packet. During a follow-up interview on 04/09/2024 at 3:48 PM the DON stated she had thought Resident #1's representative would come visit at the facility and had not sent or used any other means of communication to get the consents signed. The DON stated herself as well as the ADON monitored the consent forms and making sure they were signed either by the resident or RR. She stated once signed; the consent forms should go to MR for them to upload in the EMR. The DON stated the negative impact to residents could have been, the RR not knowing and/or understanding what their loved one's medications may have been as well as a negative side effect. She stated the failure occurred in not having the consents signed where needed, as well as not documenting and not having other means of communication with the RR to get that completed. She stated she had not tried alternate methods of completing the consent forms with the RR, and that would have been her expectation in doing that as well as being available in the resident chart. During a follow-up interview on 04/09/2024 at 5:45 PM, the DON stated to her Corporate Office that she had not reached out to Resident #1's representative by any other means such as email and/or phone, nor had any documentation of doing so. The facility provided the Texas HHSC Long-Term Care Regulatory Provider Letter Titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022 revealed: 2.0 Policy Details & Provider Responsibilities Under 26 TAC S554.1207, a resident receiving antipsychotic or neuroleptic medications must provide written consent. Written consent can also be given by a person authorized by law to consent on the resident's behalf. Consent for antipsychotic and neuroleptic medications must be documented on Texas Health and Human Services Commission (HHSC) Form 3713. 2.2 The prescriber of the medication, the prescriber's designee, or the NF's medical director must complete Section I of Form 3713 . .The resident or the resident's legally authorized representative must sign Section II of Form 3713. The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF cannot sign on behalf of the resident. The original Form 3713 or a copy of the completed form must be kept in the resident's clinical record to meet the consent requirement. Copies could be mailed, faxed, or securely emailed if all parties are unable to sign the form in one sitting. Any copy or original consent form must be accurately completed and contain all required information applicable signatures. 2.3 The person prescribing the medication, the prescriber's designee, or the NF's medical director must provide the resident, and if applicable, the person authorized to consent on behalf of the resident, the following information: The condition being treated; The beneficial effects on that condition expected from the medication; The potential side effects of the medication; The associated risks of the medication; and The proposed course of medication Record Review of Facility Action Plan dated 12/26/2023 revealed: Problem: Psychotropic Consent Form 3713 has not been completed for all resident receiving atypical antipsychotic medication. Appropriate DX is not present for all residents receiving antipsychotic medication. Goal: 1. All residents that receive antipsychotic medications will have completed form 3713 in their EMR. Goal date: 01/31/2024 2. All residents that receive antipsychotic medications will have appropriate CMS approved DX to justify antipsychotic medications. Goal date: 01/31/2024 Approaches: 1. DON or designee will review order summary daily. If new order for antipsychotic is received, DON or designee will ensure proper 3713 form is completed and CMS approved DX is present for medication. Responsible person(s) DON or designee 2. If appropriate DX is not present, DON or designee will contact provider to request appropriate DX or ask for new order for medication that is appropriate for resident's DX, making sure schizophrenia and schizoaffective DX's have supporting documentation following CMS guidelines. Responsible person(s) DON or designee 3. DON or designee will perform an audit of all residents in facility, with antipsychotic medications, to ensure that each resident with antipsychotic orders, has a form 3713 in place, and DX is appropriate for medication order. Responsible person(s) DON or designee 4. DON or designee will speak with pharmacy consultant to request an audit upon each visit, to ensure proper DX is in place and form 3713 is in place for any residents on antipsychotic medication. Responsible person(s) DON or designee 5. DON or designee will notify providers for residents with antipsychotic medication orders, that do not have CMS approved diagnosis, to request appropriate DX, or new order more appropriate for current diagnosis. Responsible person(s) DON or designee 6. DON or designee will ensure DDR attempts continue at least quarter for residents who receive antipsychotic medications. Responsible person(s) DON or designee 7. Form 3713 will be scanned into EMR for all residents who receive antipsychotic medications with wet RP signature and physician signature. Responsible person(s) DON or designee 8. Pharmacy consultant to review all current antipsychotics and make recommendations to adjust antipsychotic medication for resident without appropriate DX for medications. Responsible person(s) **Monitoring: DON and discussed monthly in QAPI

Based on observation, interview and/or record review the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of new pressure ulcers/injuries for 1 of 6 residents (Resident #61) reviewed for pressure injuries, in that: 1. The facility failed to assess Resident #61 for skin abrasions, pressure ulcer &/or wounds. 2. The facility failed to ensure Resident #61 did not develop pressure ulcer/wounds. This failure could place residents at risk for [CONDITION(S)] and hospitalization . The findings include: Interview with Family Member S of Resident #61 on 09/28/21 at 7:50 pm, Family Member S of Resident #61 stated of two wounds on Resident #61's mid right back side area. Family Member S of Resident #61 stated told the DON aware of the wounds on 09/19/2021 at 1:19 pm. DON stated, Yes sir. Record Review of Resident #61's active record, revealed that there were no treatment orders in place for the two wounds on the right mid back area or treatment documentation. There were no interventions in place. Record reviewed skin assessment document created by RN A on 09/11/2021 revealed Upper-Mid back area, abrasions with no measurements or staging. Observations on 09/29/2021 at 9:20 am, RN B helped Resident #61 to turn to the right side and there were two wounds fully exposed with no bandage, there was blood on the sheets from the wounds. Observations of the two wounds on the mid left back area revealed that the two wounds were shallow and open with a red wound bed and bleeding. Observed RN B measure the two wounds prior to treatment. The wound on the mid left middle back area measured to be 2 inches wide and 1 inch in length. The second wounds on the left lower back area measured to be 6 inches wide and 1.25 inches long. RN B nurse began treating the wound, once had gathered supplies and failing to wash his hands prior to gathering supplies. RN B continued to treat the wound without washing his hands prior to treating the wound, he then put a small amount of hydrogel on a cotton tip stick and applied to the wounds; he then placed a foam padded 4 x 4 over each wound and initialed and dated the foam bandage. Observations on 09/29/2021 at 9:29 am, RN B removed left boot after the resident #61 was complaining of it hurting, that there was a wound on the left backside heel area. Observed the wound to be open with red wound bed around the edging of the wound with a black center and bleeding. Observed Resident #61 in distress with face grimacing and stating, My foot hurts. Observation on 09/29/2021 9:32 am RN B gathered supplies to treat the wound to the left backside of the heel. RN B failed to wash his hands after cleaning wounds on Resident #61's middle and lower back before treating the wound on the heel. RN B donned clean gloves, cleansed right heel with wound cleanser, placed hydrogel on a long q-tip and then placed on wound. RN B placed 4 x 4 foam padded bandage over the back of the heel, initialed and dated the bandage, and wrapped pink 3 mm coban wrap around the heel and foot to secure the bandage. Interview on 09/29/2021 at 9:45 am, RN B stated he was the wound care nurse. He said he did not know Resident #61 had the wounds on his back and right heel. RN B stated that he had only been the wound care nurse for three weeks. RN B stated that he had been so busy and has had no time to complete the initial skin assessments. RN B stated that the wounds would likely worsen and possibly cause infection if not assessed and treated. RN B denied being informed of the wounds by anyone. RN B stated that he was not aware of the wound on the right heel as well because he did not see any other skin assessment sheets when he took the position. RN B stated, I have been basically having to play catch up since I have been here and unfortunately, I had not had the chance to get to this resident (Resident #61). Interview on 09/29/2021 at 10:28 am, CNA Q stated they had knowledge of the wound during giving a shower and CNA Q stated that he had reported it to LVN H. CNA Q stated that he does get the opportunity to provide skin assessments while giving a shower and if there is something that has not been there before then, I will report it. CNA Q stated that he learned about the wounds on Resident #61 mid left back area a couple of days ago when he gave Resident #61 a shower. CNA Q could not specify exactly what day. CNA Q stated that he gives showers every other day. There were no interventions in place for resident #61 wounds. Observation on 09/30/2021 at 10:15 am, an open wound on the right back of Resident #61's right heel that was uncovered and bleeding on the floor. The bandage RN B had placed on Resident #61's foot had fallen off and was lying on the floor. There was pink coban wrapped around the ankle. LVN F was made aware of Resident's #61 right back heel was bleeding on the floor. LVN F had placed a towel under the resident's #61 right foot and went to gather supplies to treat and cover the wound. LVN F washed hands and then LVN F placed gloves on hands, had a few 2 x2 gauze pads in a cup and sprayed wound cleaner on the pads. LVN F then proceeded on cleaning the wound with the drenched gauze pads. LVN F put some hydrogel on a cotton tip stick and placed on the wound. LVN F placed a 4 x4 foam bandage over the wound and then initialed and dated the bandage. Interview on 09/30/2021 at 10:28 am, LVN F stated they was unaware of the wound on the back of the heel. LVN F stated that normally the wound care nurse takes care of all the wounds. LVN F stated that the wound would probably get worse if it were not being treated. When LVN F was asked how she knows what to treat the wound with. LVN F stated that the doctor places orders in the computer and she will follow the instructions. When LVN F was asked if Resident #61 had orders for these wounds. LVN F stated, Honestly I did not check because Resident #61 heel was bleeding badly so when I saw that I just grabbed what I thought I would need to treat the wound. It is undetermined when Resident #61 developed the wounds because there was no documentation for the back-right heel area. Interview with DON on 09/30/2021 at 10:45 am revealed that she had no knowledge of the wounds. DON stated that this was not brought to her attention. DON stated that an initial skin assessment should be completed upon admissions, during showers, during incontinent care, and when the wound care nurse is treating wounds. DON stated the wounds could get worse if they are not assessed or treated. DON stated to treat the wound staff follow doctor's orders in knowing what and how to treat the wound. DON stated the wounds could be treated incorrectly if there were no physician orders for staff to follow. DON stated that they are in the process of finding a new medical director and have taken the necessary steps in doing this. Record Review of Resident #61's active physician orders were dated on 09/30/2021 at 4:05 pm revealed: A. Heel-cleanse wound with NS or wound cleanser, pat dry, apply hydrogel, cover with padded dressing. Repeat EOD (Monday, Wednesday, Friday) and as needed r/t soiling. Start date 09/30/2021 at 12:00, Revision date 09/30/2021. B. Cleanse wound on left back with NS or wound cleanser, pat dry, apply hydrogel, cover with padded dressing. Repeat EOD (Monday, Wednesday, Friday) and PRN r/t soiling. Start date 09/30/2021 at 12:00, Revision date 09/30/2021. Record Review of CNA Shower Check Point showed that for resident #61 revealed that Resident #61 had a wound on the right back heel with black scabs dated 09/11/2021 signed by RN #3. RN #3 was unavailable for interview. Record Review of Resident #61's comprehensive assessment dated on 09/08/2021 revealed moderate risk on the Braden Scale for predicting Pressure Sore Risk. Decreased cognitive level. Record Review of facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol from the Nursing Services Policy and Procedures Manual for Long Term Care Revised April 2018 states: Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: Full assessment of pressure sore including location stage, length, width and depth, presence of exudates or necrotic tissue. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Treatment/Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc) and application of topical agents. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors, for example: A. Healing or Prevention likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. Record Review of facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol from the Nursing Services Policy and Procedures Manual for Long Term Care Revised April 2018 states: Assessment and Recognition: Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Record review of facility policy labeled, Wound Care, revised October 2010 indicated: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to access for any special needs of the resident. For example: the resident may have PRN orders for pain medication to be administered prior to wound care. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc. with alcohol pledget before opening, as necessary (Note: this may be performed at the treatment cart)

Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the current threat of COVID-19. 1. The facility failed to ensure screening/or screening prior to entry of essential visitors and all staff including the Investigator (essential visitor) and for 11 of 79 employees reviewed for entry screening. 2. The facility staff failed to prompt the investigator to complete hand hygiene before entry into the facility. 3. The facility failed to ensure all staff wore face masks and properly wore face masks at all times. 4. The facility failed to ensure residents were wearing mask when out of their rooms or were social distancing. 5. The facility failed to monitor Resident #3 for signs and symptoms of COVID-19 (May 2020) and ensure the residents (Resident #1 and #2) were being monitored three times a day. 6. The facility failed to frequently disinfect high-touch surface areas. An Immediate Jeopardy (IJ) situation was identified on 5/29/20. While the IJ was lowered on 5/30/20, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of widespread, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure could place residents at a greater risk of being exposed to the COVID-19 virus and result in serious illness and/or death. Findings: In an observation on 5/28/20 at 10:00 pm three staff were observed 1 (CNA B) of the 3 were not wearing their masks properly. Certified Nurse Aide (CNA) B was walking by the nurse station with his mask below his nose. In an observation and interview on 5/28/20 at 10:09 pm entry by the investigator was allowed by CNA A and no entry screening was completed, no hand hygiene was requested, and no visitor teaching was offered. In an observation and interview on 5/28/20 at 10:15 pm LVN A arrived in the facility foyer to greet the investigator. No entry screening was completed, no hand hygiene, was requested, and no visitor teaching was offered. LVN A did not do an entry screening of investigator until prompted and she never requested hand hygiene of the investigator. LVN A stated she had been in serviced on entry screening, but no one had in serviced her on essential visitor education. In an interview on 5/28/20 at 10:25 pm CNA B stated when he was not in resident rooms he wears his mask below his nose because he has asthma. In an observation on 5/28/20 at 10:25 pm an unidentified female staff in black scrubs at a medication cart moved her mask to below her chin while at the medication cart. In an observation and interview on 5/28/20 at 10:29 pm CNA C was observed walking through the halls with her mask down at her neck. CNA C stated it was down because she was hot and on her way to the breakroom where it was acceptable to remove the face mask. In an interview on 5/28/20 at 11:22 pm CNA C and an unidentified staff stated they were wiping down commonly touched surfaces twice a night, but they often do not have the time just like tonight they were a CNA short. In an observation on 5/29/20 at 10:00 am Employee J allowed the Investigator entry with the Administrator observing. A screening was completed but no hand hygiene was requested by Employee J or the Administrator. Record of review of employee clock in times provided by the Administrator compared to the facility entry screening tool for 5/28/20 and 5/29/20 revealed the following: 5/28/20- Employee I clocked in at 4:47 am but was not identified on the screening log; Business Office Manager (BOM) clocked in at 9:00 am but was not identified on the screening log; Dietary Manager (DM) clocked in at 8:00 am but was not identified on the screening log; the Administrator clocked in at 7:30 am but her spot on the screening log was between an employee who clocked in at 8:00 am and one who clocked in at 8:30 am; the Social Worker clocked in at 8:00 am but the employee on the screening log before her clocked in at 8:33 am and the one after her was the DON who clocked in at 7:30 am the employee whose entry screening was after the DON's clocked in at 8:12 am. There were several examples of employee screening not coordinating with the time of clocking in on the May 28th, 2020. 5/29/20- Employee E clocked in at 1:42 pm and was never identified on the screening log; BOM clocked in at 9:00 am and was never identified on the screening log; 4 out of 49 employee screenings did not follow in a logical and reasonable clock in to screening time on 5/29/20 such as with Employee G who clocked in at 8:00 am but the person who's screening was before hers clocked in at 2:00 pm. In total on day 5/28/20 3 employees did not have a screening and 10 employee screenings did not fall within a chronologically reasonable time frame compared to clock in times, and on 5/29/20 starting at 12:00 and ending at 2:00 pm 2 employees did not have a screening and 5 employee screenings did not within a chronological reasonable time frame compared to clock in times. In an interview on 5/29/20 at 12:25 p.m. the Administrator said that the employees should be coming in at the main entrance to be screened then go to the back of the building to clock in. In an observation on 5/29/20 at 10:09 am several residents were not in their rooms moving about the halls, dining area, sitting areas, and activity room. None of the residents had a mask on or even on their person. In an observation on 5/29/20 at 10:15 am 3 residents were observed in the activity room with no mask on. In an observation on 5/29/20 at 10:19 am Resident #4 and Employee A were in the sitting room at the end of hall 400 not observing social distancing by sitting 2-3 feet apart. In an observation on 5/29/20 at 10:30 am two residents were in the dining room with no mask on. In an observation on 5/29/20 at 10:50 am 3 residents were gathered at the nurse station and one resident was using the phone. No social distancing was observed. The DON and two other staff were in observance of this and gave the residents no encouragement or reminder to practice social distancing. After the resident was done using the phone a home health nurse was observed using the same phone as the resident. The phone was not cleaned in between users. In an observation on 5/29/20 at 11:13 am staff assisted 4 female residents in wheelchairs moving them to a sitting area by the nurse's station. All four residents were sitting together less than 6 feet apart around a square table that was approximately three feet by three feet. In an observation on 5/29/20 at 11:19 am 7 residents were in the activity room with Employee B eating popcorn and watching a movie 6 of the seven residents were within two feet of one another. In an interview on 5/29/20 at 11:21 am Employee B was aware residents are to be observing social distancing. Employee B stated that not all the residents are 6 feet apart. In an observation on 5/29/20 at 11:50 am another staff and resident used the same phone at the nurse station as used previously. The phone was not cleaned in between users. In an interview on 5/29/20 at 11:54 am Employee C who was in housekeeping stated they are to be wiping down frequently touch surfaces every hour and that is assigned by halls. Employee C stated she had not wiped down the nurse station or the foyer today (5/29/20). In an interview on 5/29/20 at 12:01 pm Employee D who was in housekeeping said she was aware commonly touched surfaces should be wiped down every hour and even though the nurse station was assigned to her she had not cleaned the nurse station today, and the only time she was aware it was cleaned today was around 8:00 am by Employee H. Employee D stated she had not been able to keep up the cleaning of commonly touched surfaces because they were short staffed in housekeeping. Employee D stated housekeeping works an 8:00 a.m. to 4:00 p.m. shift with a one-hour lunch break. In an observation and interview on 5/29/20 at 12:08 pm CNA F was observed with her mask below her nose. CNA F stated she was aware her mask should cover her nose and mouth and only be removed in the break room, but her mask will not stay up. While CNA F was talking she kept pulling her mask down to talk. In observations on 5/29/20 from 10:00 am until 12:10 pm residents were not wearing masks when out of their rooms, no social distancing was being observed, masks were not being worn properly by staff working the floor, and masks were not being worn properly by administration on the floor and in their offices. Administration would remove their masks to talk on the phone or to one another, and food and drinks were observed sitting on their desk. No cleaning or disinfecting of commonly touched surface was observed. In an interview on 5/29/20 at 2:45 pm the Administrator stated they have been doing cleaning of commonly touched surfaces but could not provide any documentation to assignments of cleaning commonly touched surfaces or having staff have sign off as completing the task. Residents: Resident #3 Record review of Resident #3 electronic face sheet accessed on 6/1/20 revealed a [AGE] year-old female admitted on [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #3 most recent quarterly Minimum Data Set (MDS) revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating a severely impaired cognition. A severely impaired cognition placed Resident #3 at a higher risk of not being able to identify and report signs and symptoms of any illness including COVID-19. Record review of Resident #3 electronic care plan accessed on 6/1/20 revealed COVID-19 was care-planned. Record review of Resident #3 electronic orders accessed on 6/1/20 revealed the following orders: Daily temperature three times a day with a start date of 5/30/20. (Note there is no order for assessing respiratory status.) Record review of Resident #3 Medication Administration Record [REDACTED]. In an observation on 5/28/20 at 11:22 pm Resident #3 was resting in bed. In an interview on 5/29/20 at 2:06 pm the DON stated they have not been doing COVID-19 screening on Resident #3, and she must have gotten missed. Resident #1 Record review of Resident #1 electronic face sheet accessed on 6/1/20 revealed a [AGE] year old female admitted on [DATE] with the following Diagnosis: [REDACTED]. Resident #1 face sheet revealed Family Member A was her guardian. Record review of Resident #1 most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had unclear speech with difficulty communication some words or finish thoughts and misses some part/intent of a message. Resident #1 was not able to complete a Brief Interview for Mental Status (BIMS) and problems with both short term and long-term memory. Resident #1 difficulty with communication and memory issues placed her at a higher risk of not being able to report signs and symptoms of illness which could have led to a late detection of any illness including COVID-19. Record review of Resident #1 electronic orders accessed on 6/1/20 revealed the following orders: Assess every shift respiratory status: Shortness of breath, cough or sore throat every shift for Screening for COVID-19 with a start date of 3/16/20 and Daily temperature every day and night shift for Screening for COVID-19 with a start date of 3/16/20. Record review of Resident #1 Medication Administration Record [REDACTED]. Record review of Resident #1 electronic care plan accessed on 6/1/20 revealed COVID-19 was care-planned. In an observation on 5/28/20 at 11:15 pm Resident #1 who shared a room with Resident #2 had a small camera sitting on her over bed light. It appeared to be placed to capture her side of the room and not just her bed. In an interview on 6/1/20 at 7:30 pm Family member A stated since his wife's admission in to the facility he has had a camera in her room. Family member A stated it had brought him great comfort having the camera after being married for [AGE] years to Resident #1, he can leave the camera on at night and hear her breathing and getting to ensure she is ok during the COVID-19 event has brought him peace of mind. Family member A stated he has had issue with staff not wearing mask, and some general care concerns. Family member A stated the Administrator when he had brought his concerns to the attention of the Administrator. Resident #2 Record review of Resident #2 electronic face sheet accessed on 6/1/10 revealed an [AGE] year-old female admitted on [DATE] with the following Diagnosis: [REDACTED]. Resident #2 face sheet also revealed Family Member B was the power of attorney for financial and care and was listed as the next of kin. Record review of Resident #2 most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated a moderately impaired cognition. A moderately impaired cognition placed Resident #2 a risk of not being able to identify and report signs and symptoms of any illness including COVID-19. Record review of Resident #2 electronic orders accessed on 6/1/20 revealed the following orders: Assess every shift respiratory status: Shortness of breath, cough or sore throat every shift for Screening for COVID-19 with a start date of 3/16/20 and Daily temperature every day and night shift for Screening for COVID-19 with a start date of 3/16/20. Record review of Resident #2 Medication Administration Record [REDACTED]. Record review of Resident #2 electronic care plan accessed on 6/1/20 revealed COVID-19 was care-planned. In an observation on 5/28/20 at 11:00 pm Resident #2 had a small camera sitting on top of her over bed light that was directed at her bed. In an interview on 5/31/20 at 7:55 pm Family member B stated she has had a camera in her mother's room since she moved into the facility. Family member B stated that during the COVID-19 changes the camera was a way to ensure the care and treatment of [REDACTED]. Family member B stated she would report those events to the Administrator and they would improve for a bit but then go back to what it was before. Family member B stated she had screen shots of staff not wearing masks properly or not at all. Family member B shared the photographs with the investigator and stated she was concerned with the facility's infection control practices. Record review of photos shared by Family Member B on 6/1/20 revealed 4 out of 6 facility staff on different occasions at different times in Resident #2's room with no mask or not properly wearing a mask. The photos were not date and time stamped, but the family member hand-wrote the dates and times on each of the pictures. The dates on the pictures ranged from 5/15/20-5/27/20. In an interview on 5/29/20 at 10:36 am the DON stated to protect the residents during the COVID-19 threat they were isolating residents on [MEDICAL TREATMENT]. She said that the facility was isolating new and readmissions for 14 days. She said they had in room dining for those whom it is appropriate. She said the residents had in room activities or if the activity room was used less than 10 people would be in the room. She said the staff were doing temperature checks and oxygen saturation checks twice daily on all residents. (Note: the DON never stated they were having residents wear mask when out of their room, assessing resident three times a day, or having the residents social distance.) Recorded review of facility policy dated 3/2/20 with a most recent revision date of 4/20/20 revealed the following: Coronavirus, COVID-19- Infection Prevention strategies for Long-term care facilities .The purpose of the updates is to provide direction to our facilities and help improve the infection control and prevention practices to prevent the transmission of COVID-19 .A healthcare personnel will screen all visitors (those allowed to enter based on above exception) at each visit .A screening tool is placed to monitor for compliance according to HHS, to include temperature checks for each healthcare personnel .We are following CMS, CDC, state and local guidance on who to screen and who may not enter our Center .All visitors will be instructed to follow respiratory hygiene and cough etiquette precautions .Screening visitors for symptoms of acute respiratory illness before enter the facility .Standard cleaning and disinfection procedure (e.g., using cleaners and water to preclean surfaces prior to applying disinfectants to frequently touched surfaces or objects for indicated contact times) will be used for [MEDICAL CONDITION] environmental control in all setting within the facility, including those resident-care areas in which aerosol-generating procedures are performed. Record review of Texas Health and Human Services (HHS) COVID-19 Response For Nursing Facilities 3.0 dated 5/22/20 revealed the following . VI. To Do's for Nursing Facilities .Comply with all CMS and CDC guidance related to infection control. (NFs need to frequently monitor CDC and CMS guidance, as it is being updated often.)For the duration of the state of emergency, all NF personnel should wear a facemask while in the facility .Actively screen, monitor, and surveil everyone who comes into the facility .Immediate Prevention Measures .Active screening - The CDC and CMS recommend NFs screen all staff prior to entering the facility at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, and sore throat .Environmental cleaning and disinfection .High-touch surfaces include items like doorknobs, light switches, handrails, countertops - clean and disinfect frequently. Workstations include items like computers, chairs, keypads, common-use items - clean and disinfect frequently .Monitoring - Ask residents to report if they feel feverish or have symptoms of respiratory infection. Actively monitor all residents upon admission and at least three times daily for fever and respiratory symptoms (including shortness of breath, new or change in cough, sore throat, and oxygen saturation). If the resident has fever or symptoms, implement recommended infection prevention and control (IPC) measures .Source control - Ill residents should wear a surgical mask when health care or other essential personnel enter the resident's room .All residents who are not ill should wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments .Social distancing - Remind residents to practice social distancing and perform frequent hand hygiene. Social distancing means avoiding unnecessary physical contact and keeping a distance of at least 6 feet from other people. Cancel communal dining and all group activities, such as internal and external activities .Control Measures for Staff Active screening - The CDC and CMS recommend NFs screen all staff prior to entering the facility at the beginning of their shift for fever and other symptoms consistent with COVID-19. The Administrator was notified on 5/29/20 at 12:15 pm an IJ had been identified due to the above failures. The IJ template was provided to the Administrator and signed at 12:25 pm. The facility's Plan of Removal was accepted on 5/29/20 at 9:50pm and revealed the following: 1.Facility initiated Texas Health and Human Service- COVID 19 Responses 3.0 2.Facility will allow only essential visitors in the facility; such as: employees, consultants, hospice nurse, attending physicians, medical director, First Responders EMT, phlebotomist, X-ray technician, HHS Surveyors, etc. All must enter the facility through the front entrance and participate in COVID-19 screen, proper sanitizing of hands and wear a mask while in the facility. 3.All residents that leave the facility must have a mask on upon leaving the facility and their mask is encouraged to remain on until they return to their assigned room and on until the return to the facility. Upon return each resident will be encouraged to shower and at a minimum hand will be washed and sanitized and temperatures will be monitored every shift. New admission/readmission's will be placed on 14 days droplet precaution quarantine and if no sign of COVID-19, they will be transferred out of quarantine into general population after day 14. 4. All employees or visitors will enter the facility through the front door and will be screened per CDC guideline. The screening process questionnaire will be completed, signed, temperature checked, hands sanitized, if screening is passed, they will be deemed safe to enter the facility with a mask. 5.PPE- All facility staff will wear a mask; all residents will be offered a mask when out of their rooms and care planned if they don't meet criteria or refuse to wear a mask. 6. In-services have been initiated with the facility staff on hand washing, COVID-19 screening process, infection control, Employee use of face mask, residents use of face mask, cleaning high touch areas and check list usage will be completed by their next shift. All employees will complete education prior to working their next scheduled shift. 7. Cleaning and Disinfecting- High touch surfaces including (doorknob, light switches, handrails, countertops, workstations, equipment and phones will be cleaned with Peroxide Multi-surface cleaners and disinfect. Housekeeping department is being in-serviced on cleaning high touch areas, chemicals that are to be used and technique to ensure a thorough cleaning of each area and housekeeping supervisor will ensure compliance with random audits of scheduled check off. 8. Facility will screen residents for sign and symptom three times a day. Investigator monitoring of the facility's plan of removal: In an observation on 5/30/20 at 8:30 am upon entry to the facility there was black tape that had been added on the floor to indicate not to move beyond that point until you are screened. The screener's desk had been moved closer to the door. The investigators screening was completed, and hand hygiene was requested by the Administrator. In an observation on 5/30/20 8:50 am housekeeping was cleaning and disinfecting at the nurse station counter tops and commonly touched surfaces. In an interview on 5/30/20 at 9:40 am Employee H stated they are increasing cleaning of commonly touched surfaces at night. It is currently being done by CNAs and LVNs but the company has given him the ok to hire a night cleaning person. Employee H could tell me the current changes in policy for the COVID-19 threat. In an interview on 5/30/20 at 10:50 the Administrator stated they now have 69 of 74 employees in-serviced on recent policy changes and she was actively calling all employees to come in to be in-serviced and they would not be allowed to work until the completed training on the policy changes. Record review of facility in servicing revealed on 5/29/20 about 44 of 74 employees had been in serviced on the following: Being a COVID-19 screener; All Residents are to wear a mask; Infection control; Personal Protective Equipment (PPE); Hand washing; All employees are to wear mask at all times and it also included the proper way to wear a mask; COVID screening on All employees; Abuse, Neglect, and Dignity; and Customer services. Interviews on 5/30/20 with Employee F, CMA A, and LVN C revealed they had been in-serviced and knew the recent changes in policy in place to protect the residents such as properly wearing mask and where it is ok to remove a mask, screening of residents and staff, social distancing, and cleaning/disinfecting of commonly touched surfaces. In an observation on 5/30/20 at 9:09 am administration offices just off the foyer no longer had food and drinks on their desk and no one was removing their mask inside their office. In an interview on 5/30/20 at 9:10 am the DON could explain to the current changes in policy to protect residents such as screening employees, proper wearing of face mask for employees and residents, resident assessments 3 times a day, and frequent cleaning of commonly touched surfaces. In an observation on 5/30/20 at 9:33 am residents outside of their rooms were wearing masks. In an observation on 5/30/20 at 10:49 am Residents in the activity room were observed wearing mask and observing social distancing. In an observation on 5/30/20 at 11:17 am an employee was seen cleaning nurse station with disinfectant wipes. The dining room, activity room, and all sitting areas have been set up to promote social distancing. In observation 5/30/20 from 8:30 am - 11:56 am staff and residents were properly wearing masks; disinfecting of commonly touched surfaces was observed often and all over the building; areas were set up to promote social distancing and social distancing was observed; and the screening area had been moved closer to the door and 6 employees were able to tell the investigator there was no entry unless you are screened. On 5/30/20 at 12:00 pm the Administrator was informed the IJ was lowered; however, the facility remained out of compliance at a severity level of potential for more than minimal harm and scope of widespread, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal.

Based on observation, interview, and record review the facility failed to ensure two of three residents (#1 & #5) with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing for 2 of 3 residents reviewed for pressure ulcers in that Resident #1 developed a Stage II pressure ulcer to her second toe that will have to amputated and was being treated as a small scabbed area and did not provided treatment as ordered by physician. LVN C failed to provide Resident #5 pressure ulcer treatments as prescribed by the physician. The facility failed to report (document) changes to integumentary system to physician when changes occurred to obtain treatment orders. These failures could place residents at risk for developing new pressure ulcers or worsening of existing pressure ulcers. The findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] indicated a BIMS score of 11 out of 15 indicating her cognitive skills for daily decision making were impaired. Further review of MDS revealed the resident was at risk of developing pressure ulcers. Record review of Local Wound Care Clinic progress note indicated Resident #1 had a Diabetic Ulcer to Left Dorsal foot on 2/9/17 and Soft Tissue Necrosis of Left Dorsal second toe on 3/9/17. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk on 1/10/18 indicated a score of 17.0 (low risk) with no further Braden Scale assessments available. Record review of Resident #1's revised care plan dated 1/23/19 indicated that resident was at risk for circulatory impairment due to [MEDICAL CONDITION] disease and risk for frequent infections/pressure sores due to Type II Diabetes. Interventions include skin assessment weekly and PRN (as needed); monitor skin for changes, redness, circulatory problems, breakdown and report to physician and family; perform finger stick blood sugars and report any abnormalities and/or trends to physician. Observation and interview on 07/12/19 at 9:20am, resident's ulcer to Left second toe was covered with clean, dry, intact gauze. Resident #1 does not recall details of how injury to Left second toe occurred and stated she was upset that she is losing another toe. Resident stated she had recently seen her primary physician and was informed she had an infection in the bone of toe. Record review of Resident #1's Skin Observation Assessment indicated on 5/9/19 LVN C documented, small blanching area to Left second toe 0.2cm x 0.2cm. with no documentation that physician was notified. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Skin Observation Assessment indicated on 5/16/19 LVN C documented small scabbed area to Left second toe Record review of Resident #1's Nurses Progress notes indicated that an entry regarding Left second toe was not entered until 5/31/19 with LVN C documenting, continues to have scab to 2nd toe on left foot, slight redness around scabbed area. Cleansing with wound cleanser, applied TAO and covered with band aid (which is not a foam dressing). LVN C did not document if physician was notified. Record review of Resident #1's Nurses Progress note on 6/14/19 indicated that charge nurse on duty documented, Medical director at facility, started antibiotic for Left second toe, orders for wound care-clean with soap and water, apply Hydrogel and cover with Opti foam. Antibiotic was taken from 6/14/19 to 6/24/19. Record review of Resident #1's Skin Observation Assessment revealed on 6/17/19 LVN C documented scabbed area to Left second toe some bleeding noted and scant white pus-like drainage. LVN C did not document if physician was notified. Record review of Resident #1's Skin Observation Assessment revealed on 6/24/19 LVN C documented open area to Left second toe. Record review of Facility Infection Control Log dated (MONTH) 2019 indicated Resident #1 started antibiotic for [MEDICAL CONDITION] of Left second toe on 6/14/19 with infection resolved on 6/24/19. Record review of Resident #1's Primary Physician Office Visit Progress Note dated 6/27/19 revealed primary physician ordered lab work and x-ray of Left second toe, Antibiotic and documented referral to local wound care clinic for aggressively managed treatment with high probability to lose another toe. Record review of Resident #1's Nurses Progress Notes on 7/1/19 revealed resident was seen at local wound care clinic with the following orders for dressing to Left second toe: dressing is to remain intact, if dressing comes off cleanse area with wound cleanser, apply Alleyne and cover with Medi-pore tape. Nurses Progress Notes for 7/1/19 also revealed that primary physician contacted facility and reported X-ray of Left second toe indicated Abnormal findings with infection and orders to discontinue current antibiotic and start different antibiotic. Record review of Resident #1's revealed the first and only Pressure Ulcer Assessments was completed on 7/4/19 by treatment LVN C who documented, Left second toe diabetic ulcer measuring 1.2cm x 1.5cm x 0.2cm, light serosanguineous drainage with 100% slough noted. Documentation revealed section of form with Support Devices check boxes indicated the following interventions were not being performed (Float feet, bed cradle, footboard, etc.) No boxes were checked, and Plan of Care was not updated. Review of Resident #1's follow up visit with wound care clinic on 7/8/19 revealed the following: Left, dorsal second toe is an acute Wagner Grade 2 Diabetic ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.5cm length x 1.5cm width x 0.2cm depth. Joint and bone are exposed. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a scant amount of sero-sanguineous drainage noted which has no odor. The wound margins are flat and intact. Wound bed has 26-50% slough, 26-50% pink, firm granulation. The wound is deteriorating. The peri wound skin moisture is normal. The peri wound skin exhibited: [MEDICAL CONDITION], [DIAGNOSES REDACTED]. The temperature of the peri wound skin is WNL. Peri wound skin does not exhibit signs or symptoms of infection. General notes: toe is boggy, results show osteo[DIAGNOSES REDACTED]. The wound is still large and open, no purulence, no odor noted, the wound does not appear to extend to the foot, no signs [MEDICAL CONDITION] outside the toe, appears chronic in appearance. Plan to continue previous orders and have patient follow up in 10 days. Record review of Resident #1's Primary Physician Office Visit Progress Note dated 7/9/19, physician documented [DIAGNOSES REDACTED] of Left 2nd toe, has been on antibiotic, wound care recommends amputation, refer to local surgeon, plan to continue antibiotic. Recored review of Resident #1's MAR's (Medicine Administration Record) and TAR's (Treatment Administration Record) from 4/1/17 to 7/12/19 revealed no finger sticks with blood sugar readings. Interview on 7/12/19 at 8:55 a.m., LVN C stated Resident #1's wound to Left second toe had been going on for a while and had improved and then worsened. Stated that Resident #1's wound appeared around 6/14/19 and was a scab when first noted. Stated that she is un-aware how injury occurred to Left second toe. Stated wound started as a scab then she noted [MEDICAL CONDITION] of toe and then scab opened with wound present. Stated that she had informed Medical Director and DON of wound. LVN C stated she did not contact resident's primary physician. LVN C stated that when she see's a new wound she reports changes to DON and assessment of wound will be done by DON. Stated she does wound care checks daily and DON does rounds once a week. LVN C stated Resident #1 was seen by her primary care physician and had orders for labs and x-rays, stated that when x-rays returned primary physician provided orders for resident to be seen at local wound care clinic and referred to a surgeon for possible amputation of Left second toe. Stated that resident has been seen at wound care clinic and has orders to keep bandage intact with wound care clinic to change. LVN C stated that wound care clinic is responsible for Resident #1's wound care. Interview on 7/15/19 at 9:30 a.m. Administrator stated that medical director does not assess/treat a resident if they have a primary care physician outside the facility. Stated that resident is transported to their physician if changes of condition occur. Resident #5 Record review of Resident #5's facesheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Admission MDS dated [DATE] revealed a BIMS score of 07 out of 15 indicating her cognitive skills for daily decision making were impaired. Further review of MDS revealed the resident was at risk of developing pressure ulcers. Record review of Resident #5's care plan dated 4/07/19 revealed that resident is at risk for UTI (urinary tract infection) and Skin Breakdown related to incontinence of bladder with added comment of Left Heel Blood Blister. Interventions include skin assessment weekly per facility schedule and perform treatment as ordered until healed. Interview on 07/15/19 at 2:10 p.m. Resident #5 stated that she was admitted to facility for skilled services due to hip replacement. Stated that two days after arriving at facility the aides were putting on her shoe and were rubbing the back of her shoe back and forth on her heel trying to put shoe on. Stated she is not sure why staff was doing this since her shoes are not hard to put on. Stated that is how she received the wound to the back of her heel. Stated she will be glad when this wound heals since she has not been able to wear her shoes since the wound was acquired. Resident #5 stated that she has been having wound care to left heel daily. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 3/19/19 indicated a score of 15.0 (low risk). Record review of Resident #5's Skin Observation on 3/21/19 revealed LVN C documented fluid filled blister to Left heel with no documentation of physician notified. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 3/26/19 indicated a score of 15.0 (low risk). Record review of Resident #5's Skin Observation on 3/29/19 revealed LVN C documented slightly red boggy area to Left heel with no documentation of physician notified. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 4/2/19 indicated a score of 15.0 (low risk). Record review of Resident #5's Nurse's Progressive Notes revealed on 4/3/19 LVN C documented Blister noted to left heel. Non-fluid filled, Unstageable per RN-DON. New order to clean with Normal Saline, pat dry, cover with dry foam dressing Monday-Wednesday-Friday Until healed. Documentation did not indicate that physician was notified. Physician order [REDACTED]. Record review of Resident #5's Skin Observation on 4/5/19 revealed LVN C documented unstageable blister to Left heel with no documentation of physician notified. Record Review of Resident #5's Pressure Ulcer assessment dated [DATE] revealed charge nurse documented Unstageable 2.5cm x 3.5cm onset 4/5/19, within the comment section noted blister to left heel, closed, no drainage. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 4/9/19 indicated a score of 15.0 (low risk). Record review of Resident #5's Nurse's Progressive Notes revealed on 4/12/19 charge nurse documented at 10:55am out to doctor appointment with ortho and then at 7:11 p.m. documented Received new wound care orders for resident. Clean left heel with 1/2 peroxide 1/2 water solution, pat dry, apply [MEDICATION NAME] to wound bed, keep dressing dry and intact, clean q day. Nurses documentation did not indicate which physician ordered new wound care or reason for changes to wound care. Record review of Resident #5's Nurse's Progressive Notes revealed on 4/19/19 LVN C documented, Resident continues to have blister to Left heel. scant drainage noted. Blister cleansed, and [MEDICATION NAME] and new foam dressing applied. Documentation is unclear if orders were followed. Record review of Resident #5's Nurse's Progressive Notes revealed on 5/3/19 LVN C documented, Wound to left heel healing well. No openings, no drainage. Record review of Resident #5's Skin Observation on 5/9/19 charge nurse documented unstageable blister to Left heel 2.5cm x 3.5cm. Record review of Resident #5's Skin Observation on 5/10/19 LVN C documented unstageable blister to Left heel 1.5cm x 2.4cm. Record review of Resident #5's Nurse's Progressive Notes revealed on 5/10/19 LVN C documented New orders per medical director to cleanse left heel with wound cleanser, apply wet to dry with Dakins solution and secure with tape. Slight drainage noted. Nurses documentation did not indicate reason for treatment changes to wound care. Record review of Resident #5's Skin Observation on 5/17/19 LVN C documented Unstageable 1.5cm x 2cm, and within the comment section documented, blister to left heel, hard area came off, eschar. No documentation that physician was notified. Record review of Resident #5's Skin Observation on 5/21/19 LVN C documented unstageable with light serosanguineous drainage and slough. No documentation that physician was notified. Record review of Resident #5's Nurse's Progressive Notes revealed on 5/31/19 LVN C documented, Wound to left heel continues to heal. No odor noted. Slough noted on half of wound, half granulation tissue. Continue to eval and treat. Doctor and family aware. Record review of Resident #5's Skin Observation on 6/21/19 LVN C documented, Wound to left heel measures 1cm X 2.3cm slight drainage noted. No odor. Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 7/9/19 indicated a score of 18.0 (low risk). Observation on 07/15/19 at 2:23 p.m. LVN C removed old bandage (gauze to left heel with foot and ankle wrapped with kerlix and secured with tape) with no drainage observed to old bandage. Pressure ulcer to left heel appeared to be stage two (partial thickness with red wound base) no drainage or odor noted. LVN cleansed area with wound cleanser applied a wet gauze (soaked with Dakins solution) and then secured wet gauze with tape. Interview on 07/15/19 at 2:42 p.m. LVN C stated, this is how I always change Resident #5's bandage. Stated that other nurses use the kerlix and doesn't understand why they wrap foot. Interview on 7/16/19 at 3:00 p.m., DON stated training with LVN C had been done when he started at facility (March 2019) that any new wounds needed to be assessed by himself for staging since he had noticed LVN C would document Unstageable or was inconsistent with staging of pressure ulcers. Stated he is unsure what an unstageable blister is, and his expectations are that nurses do not document a blister and/or wound as unstageable. DON stated that his expectations are for nurses to document when a new wound is found, document when and who was contacted with change of condition (physician and family). Stated that all diabetics should have blood sugars checked four times a day (before meals and at bedtime) unless physician orders [REDACTED].#1's blood sugars are not being checked and stated it may be because resident only takes oral medication once a day for her diabetes. DON stated that he expects nurses to know what orders mean when read and stated he expects his nurses to ask for help if they are unsure of an order. DON stated that a wet to dry dressing is when a wet dressing is applied to wound a with a dry dressing applied on top of wet dressing and then secured. DON stated that when orders call for packing of a wound his expectations are that the wound has enough packing inside to have slight pressure against the walls of the wound and expects his nurses to know the meaning of packing of wound. DON stated that currently the facility does not have an MDS coordinator and is in the process of updating care plans but has not been able to complete this. Stated he is unsure why the TAR's (treatment assessment record) would have the wrong location of wound (wrong side). DON stated that his expectations are that nurses complete an SBAR form when a resident has a change of condition to have information available for all staff involved with resident's care. DON stated that if wound care is done daily then documentation should be done with weekly skin observation/pressure ulcer assessment unless there is a change, the nurses are to initial the TAR's on all other days. Record review of the facilities policy titled Wound Care, revised (MONTH) 2010 revealed in part purpose of this procedure is to provide guidelines for the care of wounds to promote healing verify physician's orders [REDACTED].any changes in the resident's condition,,, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound . Record review of the facilities policy titled Skin Program/System not dated, revealed in part the treatment nurse will observe and assess the resident's skin and depending on their findings complete necessary forms apply treatment to resident's wounds if observation shows that skin in not intact, contact physician immediately for the appropriate treatment, the resident will be treated; the family notified nurse will document thoroughly in the medical record the chain of events .treatment nurse will complete a Braden evaluation the week of admission then quarterly and with change of condition update care plan and have interventions related to skin condition .input all resident's with pressure ulcers on the weekly pressure ulcer QI log and complete pertinent information all residents will have a weekly skin assessment completed every seven days, any abnormal findings will be documented, reported to physician and family .revised care plan will be generated and all staff members involved in the care of resident will be updated .treatment nurse will audit daily to assure all weekly skin assessment is done DON will complete weekly skin audit form . Record review of the facilities policy titled Acute Charting Guidelines updated 8/15/15 revealed in part, acute charting must include vital signs, physician/resident/family notified New treatment order chart why treatment order was needed, initial treatment was performed and follow up . According to the National Pressure Ulcer Advisory Panel website (http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/) searched on 7/22/19 revealed: Pressure Injury Prevention Points: Risk Assessment: 1 Consider bedfast and chairfast individuals to be at risk for development of pressure injury . 8 Continue to reposition an individual when placed on any support surface. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Basics of Staging: .Do not reverse stage, instead identify as a healed Stage 4, for example .

Based on interview and record review, the facility failed to ensure that a resident who had respiratory needs was provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (ID #1) reviewed for [MEDICAL CONDITION] (Continuous Positive Airway Pressure). Resident #1 was not provided assistance with his [MEDICAL CONDITION] resulting in an emergency hospital admission. This failure could affect residents by increasing the risk of hospitalization . The findings included: Review of Resident #1's closed computerized record revealed he was admitted to the facility on [DATE] and discharged on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Review of Resident #1's referral information from a local hospital with a print date of 03/25/19 indicated that the resident was to be on a BIBAP (Biphasic Positive Airway Pressure) nightly. Review of Resident #1's transfer orders from a local hospital dated 03/27/19 had an ancillary order dated 03/27/19 circled for [MEDICAL CONDITION]. Per the National Institutes of Health's U.S. National Library of Medicine at Medline Plus, accessed on 05/03/2019: Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by [MEDICAL CONDITION] (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems Continuous positive airway pressure ([MEDICAL CONDITION]) provides a gentle and steady pressure of air in your airway to keep it open.Bilevel positive airway pressure ([MEDICAL CONDITION] or [MEDICAL CONDITION]) has a higher pressure when you breathe in and lower pressure when you breathe out. https://medlineplus.gov/ency/article/ 6.htm Review of Resident #1's facility Admission assessment dated [DATE] revealed: shortness of breath with activity, upper right lung sounds diminished, and upper and lower left lung sounds diminished. Review of Resident #1's five day MDS (Minimum Data Set) dated 03/29/19 indicated positive for the resident being on [MEDICAL CONDITION]/[MEDICAL CONDITION]. Review of Resident #1's baseline care plan dated 03/27/19 indicated he was on oxygen 2 liters via nasal cannula and [MEDICAL CONDITION] at 14/10 with 2 liters of supplemental oxygen. Review of Resident #1's computerized records revealed the only O2 sats (oxygen saturation level) documented were on 03/28/19 at 8:28 PM and 9:38 PM indicating a saturation level of 94% on oxygen via nasal cannula. Review of Resident #1's nursing progress notes dated 03/29/19 9:49 AM revealed he complained of distress with slightly labored breathing. He and his wife requested that the resident be transferred to a local hospital and he left the facility at 10:45 AM. Review of Resident #1's progress notes, computerized orders, and treatment records for the month of (MONTH) 2019 had no mention of [MEDICAL CONDITION]/[MEDICAL CONDITION]. Review of the nursing 24 hour report dated 03/27/19 revealed Resident #1 was a new admission at 3:00 PM. Review of the nursing 24 hour report dated 03/28/19 revealed Resident #1's [MEDICAL CONDITION] and oxygen concentrator arrived on the 03/27-28/19 night shift. Review of the facility Daily Assignment sheets for 03/27/19 and 03/28/19 revealed that LVN A and LVN B were assigned to work on Resident #1's hall. Review of Resident #1's (MONTH) medication administration records revealed LVN A signed out as giving medications to the resident on 03/27/19 and 03/28/19. In a telephone interview with Resident #1 and his wife on 04/23/19 at 1:18 PM, he said he was supposed to have worn his [MEDICAL CONDITION] during his two nights at the facility, but that it was never put on because when he asked the staff for help, they said they didn't know how. Resident #1's wife said that when the resident was admitted to the facility on [DATE] there was a [MEDICAL CONDITION] machine in the room when she got there. She said that the nurse said she didn't know how to hook it up. In a telephone interview with LVN A on 04/26/19 at 10:02 AM, she said she worked with Resident #1 one night. She said she only works from 5:30 PM to 9:30 PM and passes medications. She said Resident #1 was there one night when she worked and then was gone the next night. She said she had helped the CNA get him to bed and had given his medications, but had not put on his [MEDICAL CONDITION] mask because he was not ready to go to sleep yet. In a telephone interview with LVN B (who took over the hall when LVN A left for the night) on 04/26/19 at 10:15 AM, she stated that when the resident's equipment came in on 03/27/19 she set it up and helped the resident put on the [MEDICAL CONDITION] mask. She stated she did not document this anywhere. She did not recall working with him a second night. In an interview with the ADON on 04/26/19 at 10:57 AM she confirmed that LVNs A and B would have worked with Resident #1 during the two nights he was a resident. She said that the admission procedure was that the nurse working on the hall transferred admission orders [REDACTED]. In an interview with the MDS coordinator on 04/26/19 at 11:18 AM, she said that the ADON checked new orders on admission and she checked diagnoses, and to make sure the MDS and the initial care plan were completed. In an interview with the ADON on 04/26/19 at 2:43 PM, she said she didn't find instructions from the hospital for Resident #1 to have a [MEDICAL CONDITION]. She didn't know how he would have gotten one. She said if the order whet directly to the medical supply company, the facility might not have the order. The ADON said that if a [MEDICAL CONDITION] machine showed up the nurse should have clarified the orders with the physician. Review of Resident #1's Emergency Department Physician documentation dated 03/29/19 revealed the following: He started physical therapy yesterday and then last night became short of breath. Patient does use 2-3 L (liters) of oxygen on a daily basis but they have had to increase that since the symptoms began. Review of Resident #1's Emergency Department Physician documentation dated 03/29/19 also revealed the resident was admitted to the Intensive Care Unit. Review of Resident #1's hospital Discharge Summary dated 04/01/19 revealed the following: On evaluation in the ER (emergency room ) .ABG (arterial blood gas) showed both [MEDICAL CONDITION] and hypercapnia. Patient was admitted for acute on chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] and hypercapnia secondary to acute exacerbation of [MEDICAL CONDITIONS]. Patient was placed on [MEDICAL CONDITION]. He was started on breathing treatment, IV (intervenous) steroids and IV [MEDICATION NAME] for atypical coverage. Patient improved with baseline treatment. Suspect non-compliance with home [MEDICAL CONDITION] at night likely contributed to patient's acute on [MEDICAL CONDITION]. Counseled patient the importance of wearing [MEDICAL CONDITION] at night. Patient also received extensive education regarding how to use [MEDICAL CONDITION] at home. Patient did not want to return to the nursing home for continued physical therapy. Review of the facility policy on [MEDICAL CONDITION]/[MEDICAL CONDITION] Support dated 03/2015 revealed the following: Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. General Guidlelines 4. [MEDICAL CONDITION] may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. Steps in the Procedure 1. Explain the procedure to the resident. Ask his/her permission to continue 9. Attach pulse oximeter to the resident. 10. Holding the mask to the resident's face, turn on the machine and allow him/her to become acclimated to the pressure. 11. Once the resident is acclimated, secure mask on his/her face. a. The mask should fit firmly but does not need to be airtight b. Placing the mask on too tightly increases the chance of aspiration and skin breakdown. 13. Monitor the oxygen saturation of the resident. Documentation Document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; 2. Time [MEDICAL CONDITION] was started and duration of therapy; 3. Mode and settings for the [MEDICAL CONDITION]/IPAP/EPAP; 4. Oxygen concentration and flow, if used; 5. How the resident tolerated the procedure; and 6. Oxygen saturation during therapy.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services that assured accurate administering of drugs to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services. LVN B failed to transcribe Physician A's order to hold Resident #1's [MEDICATION NAME]; LVNs B, C, and D failed to communicate to LVN A that Resident #1's [MEDICATION NAME] was to be held and LVN A administered the [MEDICATION NAME] to Resident #1 earlier than it was scheduled to be given. The next day Resident #1 was hospitalized with rectal bleeding. This was determined to be past-noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure placed the residents at risk for complications due to errors in medication administration. Findings included: Review of Resident #1's Admission Record printed 1/29/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 14-day Minimum (MDS) data set [DATE] revealed she had a Brief Interview for Mental Status score of 10 which indicated her cognitive function was moderately impaired and she required extensive assistance with her activities of daily living. Review of Resident #1's Care Plan dated 2/21/19 revealed: potential for alteration in bleeding tendencies and increased bruising r/t use of anticoagulants/antiplatelet therapy for [DIAGNOSES REDACTED].Administer medication as ordered, monitor for side effects and report findings to MD (medical doctor). In an observation and interview on 3/7/19 at 1:30 p.m., Resident #1 was dressed and groomed, sitting in her wheelchair in her room watching television. She was receiving oxygen via nasal cannula. Resident #1 said she went to the hospital because they found blood in her rectum. She said her blood was too thin because they had given her too much [MEDICATION NAME]. Resident #1 said the [MEDICATION NAME] was stopped for a couple of days and she was back on it now. Observation of exposed areas of Resident #1's face, neck, hands, arms and lower legs revealed no signs of bruising or bleeding. Review of a Lower Extremity Venous Report performed at Hospital B's cardiology services dated 1/11/19 revealed Resident #1 had a non-occlusive chronic [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot) in the left popliteal vein; a non-occlusive hyperechoic thrombus suggestive of chronic [MEDICAL CONDITION] in the right femoral vein; a non-occlusive chronic [MEDICAL CONDITION] in the right popliteal vein; a [MEDICAL CONDITION] in the right peroneal vein; and a [MEDICAL CONDITION] in the right posterior tibial vein. Review of Resident #1's Nurse Progress Notes, physician's orders [REDACTED]. Following the result of the lab draw on 1/14/19, Physician A discontinued the [MEDICATION NAME] 5 mg and increased the dosage to 7.5 mg at bedtime for two days for [MEDICAL CONDITION]. On 1/17/19, Physician A renewed the order for [MEDICATION NAME] 7.5 mg at bedtime related to acute embolism and [MEDICAL CONDITION] of unspecified veins of unspecified lower extremity until 1/24/19. Review of a lab result for Resident #1 drawn at 1:15 a.m. on 1/24/19 revealed the PT was 56 which was high according to the range of 12.0-14.7; and the INR was 6.2 which was high high according to the range of 0.9-1.1. Documentation on the lab result indicated the critical result was called to and read back by LVN C on 1/24/19 at 14:16 (2:16 p.m.). According to the Mayo Clinic, a PT is a [MEDICATION NAME] time test to measure how quickly blood clots. [MEDICATION NAME] is a protein produced by the liver and is one of many factors that help blood to clot appropriately. If a blood-thinning medication such as [MEDICATION NAME] ([MEDICATION NAME]) is being taken the [MEDICATION NAME] time test results will be expressed as a ratio. called the international normalized ratio (INR). In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking [MEDICATION NAME] ([MEDICATION NAME]) for disorders such as [MEDICAL CONDITION] or a blood clot in the leg or lung .When the INR is higher than the recommended range, it means that the blood clots more slowly than desired, and a lower INR means the blood clots more quickly than desired .[MEDICATION NAME] side effects that require immediate medical attention: Severe bleeding, including heavier than normal menstrual bleeding Red or brown urine Black or bloody stool Severe headache or stomach pain Joint pain, discomfort or swelling, especially after an injury Vomiting of blood or material that looks like coffee grounds Coughing up blood Bruising that develops without an injury you remember Dizziness or weakness Vision changes Accessed on 3/11/19 at https://www.mayoclinic.org/tests-procedures/[MEDICATION NAME]-time/about/pac- 661?p=1 Review of the following Nurse Progress Note for Resident #1 revealed: 1/17/19 at 17:32 (5:32 p.m.) Per Physician A, Resident is to stop [MEDICATION NAME] and continue on [MEDICATION NAME] 7.5 mg and repeat PT/INR in 1 week (01/24/2019) . Signed by LVN E Review of Resident #1's active, completed and discontinued physician's orders [REDACTED]. In interview on 3/9/19 at 2:15 p.m., when asked what she did after she wrote the Nurse Progress note to discontinue the [MEDICATION NAME] and draw the PT/INR on 1/24/19, LVN E said I'm pretty sure I discontinued the [MEDICATION NAME] and put the lab slip in the lab book. When asked if she usually entered the physician's orders [REDACTED]. In observation and interview on 3/9/19 at 2:50 p.m., the ADON reviewed the electronic physician's orders [REDACTED]. In an interview on 3/9/19 at 2:55 p.m. the DON said lab orders were the same as any telephone order and should be entered into the computer. He said the procedure was to take the order, put it into the computer which generated a print-out of the order which was to be faxed with the lab slip to the lab. Put the lab slip in the binder for the lab to check-that is the proper procedure. The DON said LVN E failed to put the lab order into the computer. Review of the following Nurse Progress Notes for Resident #1 revealed: 1/24/19 at 14:26 (2:26 p.m.): Received call from lab with critical PT result of 56 and INR result of 6.2. Called to Physician A's office with results and had to leave a message. Signed by LVN C 1/24/19 at 16:22 (4:22 p.m.): Physician A's nurse called stating .hold [MEDICATION NAME] 3 days due to elevated PT/INR and recheck PT/INR on 1/27/19 STAT order . Signed by LVN B 1/24/19 at 16:29 (4:29 p.m.): Call (Physician A) at (phone number) for lab result obtained STAT. Signed by LVN B Review of Resident #1's paper and electronic current, completed and discontinued physician's orders [REDACTED]. Review of the following Nurse Progress note for Resident #1 revealed: 1/24/19 at 19:35 (7:35 p.m.): Physician A called back due to night nurse (LVN A) gave [MEDICATION NAME] when it was on hold. This nurse told Physician A that there was a communication error. Physician A stated to discontinue the [MEDICATION NAME] now and resident is to be bed rest until further orders and to call Physician A stat when lab is obtain (sp). This nurse relay the messages to night nurse (LVN D) . Signed by LVN B Review of Resident #1's MAR dated 1/1/19-1/31/19 indicated LVN A did not document she administered the [MEDICATION NAME] on 1/24/19, after Physician A ordered it to be held. Review of a STAT lab result drawn on 1/24/19 at 22:39 (10:39 p.m.) revealed the PT was 58.9 and the INR was 6.6. Documentation on the lab result was as follows: Tried calling results not able to after three attempts. Will fax and leave for AM to call. 1/24/19 23:29 (11:29 p.m.). Critical result. Results called to and read back by (LVN E's name) RN on 1/25/19 at 08:24 (8:24 a.m.). Review of the Nurse Progress Notes revealed they did not contain a note by LVN E that indicated she called or communicated Resident #1's critical lab result to Physician A. In an interview on 3/8/19 LVN E said she did not remember taking a phone call from the lab about Resident #1's STAT lab result. This surveyor provided LVN E with a copy of the result to review. LVN E said, I know that if I had a critical lab I would have called Physician A immediately. She said, if I called the doctor, I would document in the nurse's notes-I know I would have called her on a critical value. LVN E reviewed the Nurse Progress notes but did not find documentation that she had called Physician A. LVN E said, I know that I messed up by failing to document that I called her (Physician A). Review of the following Nurse Progress Notes revealed: 1/25/19 at 08:45 (8:45 a.m.): Rec'd call from (Physician A's nurse's name) in regards to lab results. Informed her that results were not in from STAT lab draw last night. Called Lab and spoke with (lab staff), she stated all PT/INR are sent to Hospital A. Explained to her order was STAT and we needed the results for Physician A. She then stated she would call Hospital A and send lab to us ASAP (as soon as possible). Signed by the ADON. 1/25/19 11:30 a.m.: Called Physician to report PT/INR of 58.9/6.6 reported that the [MEDICATION NAME] has been discontinued per orders. Received new order for PT/INR in the AM and call Physician A with result. Signed by the DON 1/25/19 15:43 (3:43 p.m.): Notified resident's niece to ensure notification of [MEDICATION NAME] administered last night in error. Also reported no physical harm to resident .Signed by ADON 1/25/19 19:55 (7:55 p.m.): called into (Resident #1's) room by aide for bleeding in the rectal area. Called PCP (primary care physician-Physician A) new order send to ER (emergency room ) for evaluation. Niece called and updated. 911 called and arrived at 2000 (8:00 p.m.) . Signed by the MDS Coordinator 1/28/19 12:12 p.m.: Resident returned back to the facility from Hospital A via facility van. Resident is alert and oriented .Resident's vital signs all are within normal limits .Signed by LVN E Review of a history and physical from Hospital A dated 1/25/19 dictated by Physician B revealed: Chief complaint: bright red blood per rectum. History of present illness: .female with [DIAGNOSES REDACTED] as well as recently diagnosed right lower extremity [MEDICAL CONDITION], currently on [MEDICATION NAME] for anticoagulation, who presents to our emergency room with complaints of bright red blood per rectum. She reports that earlier today while being changed after having a bowel movement, the nursing staff at the facility had noticed that she had bright red blood in her stools. It is unclear the quantity of blood, but the patient reports that she has been more so constipated over the last few days, but this is the only time she has been told that she had blood in her stools. She has denied any hematemesis, denied any abdominal pain. Additionally, denies any recent NSAID use .Initially, she was on Eliquis; however, she was found to have a [MEDICAL CONDITION] while on Eliquis and was switched over to [MEDICATION NAME] earlier this year. Records from the facility indicate that she recently had her [MEDICATION NAME] dose increased from 5 mg to 7.5 mg.Assessment: 1. Probable lower GI bleed 2. Supratherapeutic INR 3. [DIAGNOSES REDACTED] 4. History of recent right lower extremity [MEDICAL CONDITION] .Plan: we will admit the patient to a medical-surgical floor. At this time, she has no active signs of bleeding and is hemodynamically stable. Additionally, H and H (hemoglobin and hematocrit) appear to be stable .For now, we will hold her [MEDICATION NAME] and hold off on any reversal agents; although, I do believe she got 10 mg dose of vitamin K .she has been bedridden for the last couple of weeks per instructions after being diagnosed with [REDACTED]. Review of Resident #1's discharge summary from Hospital A dated 1/28/19 revealed: The patient was admitted to the hospital and observed. Because she was on [MEDICAL CONDITION] and had a previous [MEDICAL CONDITION], we elected not to give her anything to reverse her anticoagulation. She was not hemodynamically unstable. She was given IV fluids and did well. Her [MEDICATION NAME] gradually corrected and her bleeding stopped. We are unsure of the etiology, but because of her overall state and fact that she had a normal colonoscopy within the past year, we elected not to perform a repeat colonoscopy .She is discharged back to the facility .She is to take [MEDICATION NAME] 5 mg 1 tablet once a day .We stopped her multiple vitamin, stopped her [MEDICATION NAME], decreased her [MEDICATION NAME], and for now held her losartan as her blood pressure was low normal .Final Diagnoses: [REDACTED]. Acute blood loss [MEDICAL CONDITION] 3. Over-anticoagulated with [MEDICATION NAME] 4. [DIAGNOSES REDACTED]-currently in sinus rhythm . Review of Resident #1's lab result on 1/31/19 following her discharge from the hospital on [DATE] revealed her PT was 16.4 and her INR was 1.3. Review of the facility's Provider Investigation Report dated 1/25/19 revealed LVN A administered medication prior to scheduled administration time . Based on our investigation we concluded that one nurse failed to enter order in timely manner and another nurse failed to follow medication administration schedule. Resident back to facility in 72 hours .Alleged perpetrators: LVN B and LVN A. In a telephone interview on 3/7/19 at 1:07 p.m., LVN A said she worked from 6:00 p.m. to 10:00 p.m. on 1/24/19 passing medications. She said she did not get report that day from the previous shift nurse that the 8:00 p.m. dose of [MEDICATION NAME] was to be held because Resident #1's PT/INR was too high. LVN A said she gave the dose early and then LVN C came down the hall to tell her that the [MEDICATION NAME] was supposed to be held. LVN A said she notified the DON (Director of Nursing) and the physician was notified. She said the physician ordered a STAT (Latin word meaning immediate) PT/INR and it was higher than the first result. LVN A said the next two to three days, no bleeding or bruising was noted, but on Friday (1/25/19) Resident #1 had blood in her bottom area and was sent to the emergency room . LVN A said she did not remember the result of the ER visit, but she said Resident #1 had been fine since. LVN A said a medication error report was completed and the DON counseled her on not giving medications too early. She said the process for handling/managing held or discontinued medication was that the nurses were supposed to tell each other and document it on the (computerized) medication administration record (MAR). LVN A said she did not know which nurse took the order to hold the [MEDICATION NAME] and it was not documented on the MAR. She said the nurses gave each other report, but she did not get a report on Resident #1; she said she remembered LVN A told her about a new admission on hall 1. She said the nurses did not refuse to give report, but it was a busy day, and nurses did not make resident rounds during report. Review of a witness statement signed by LVN A on 1/28/19 revealed: I came on shift around 5:30 p (p.m.), was told by charge report nurse hall 100 had 2 new patients. No other information was given. I gave [MEDICATION NAME] to patient. Then charge nurse came down the hall and asked if I had given Pt. (patient) her [MEDICATION NAME] I said yes. She stated it was to be held. I told her I was not told and at that tim (time) the medication was still showing on the EMAR (electronic MAR). In a telephone interview on 3/7/10 at 5:12 p.m., LVN A said the reason she gave the [MEDICATION NAME] early was because the staff was really busy and she was trying to get medications administered and help the aides/CNAs (Certified Nurse Assistants/Aide). LVN A said, it was my fault, I shouldn't have given it that early. She said she gave the medication around 6:45 p.m. She said she should have waited 15 minutes, but resident #1 wanted to go to bed. Review of a witness statement signed by LVN B on 1/28/19 revealed: this nurse recieved (sp) phone call from (Physician A's nurse) of res's (Resident #1's) n/o (new order) around 1600 (4:00 p.m.). (Physician A's nurse) stated that she would like to talk to the nurse taking care of (Resident #1). This nurse stated that the nurse is passing out meds at the moment et. (and) ask her for what messages she would like me to give to (LVN C). She stated .HOLD [MEDICATION NAME] for 3 days d/t PT/INR is elevated. On Saturday (1/26/19) to draw PT/INR STAT et. to call MD (Physician A) direct cell phone when lab result is obtained. This nurse gave a note pad to (LVN C) of the orders that was taken by this nurse et. directly verbalize the orders to her et. (LVN C) accepted et. understand the orders. On shift report as what (LVN C) told this Nurse that (LVN A) gave [MEDICATION NAME] to (Resident #1). And ask this nurse of what to do. (LVN C) has stated that she gave (LVN D) night shift nurse the reports of (Resident #1) situations. On night shift, (LVN A) give meds to 100/200 halls. (LVN C) came back to this nurse et. stated that she went down 100 hall et. ask (LVN A) if she has given Warferin (sp) to (Resident #1) et. said that she did. (LVN C) ask this nurse what should be done? This nurse told (LVN C) to call (Physician C) d/t the error. (LVN D) called (Physician A) cell phone with no answer et. left a messages (sp). Around 1900 (7:00 p.m.) (Physician A) called back et. this nurse spoke to (Physician A). This nurse explained to (Physician A) that the messages did not completely relaid (sp) to all the nurse that was taking care of (Resident #1). (Physician A) was upset et. gave this nurse a n/o: STAT PT/INR, D/C'd (discontinued) Warferin (sp) now, (Resident #1 is to be bed rest until further orders, et. to call (Physician A) when result is obtain (sp) STAT. This nurse gave the orders to (LVN D) et. LVN C) is aware of the n/o. (LVN D) wrote the n/o, called lab d/t STAT orders. Around 2030 (8:30 p.m.) lab (lab staff's first name) draw PT/INR. In an interview on 3/7/19 at 2:53 p.m. LVN B said he had worked at the facility for approximately a year and worked the 200 and 400 halls. He said on 1/24/19 he received a call from Physician A and he put it in a progress note. LVN B was not able to tell this surveyor the specific order. Surveyor provided LVN B with his witness statement to refer to. LVN B said he took a call from Physician A's nurse about 4:00 p.m., but he was not taking care of the hall that Resident #1 was on. Physician A's nurse wanted to talk to LVN C but LVN C was busy at the moment so she gave LVN B the message. LVN B said he told LVN C to hold the [MEDICATION NAME] for three days due to an increase in Resident #1' PT/INR and on Saturday to call Physician on her cell phone after another PT/INR had been drawn. He said LVN C had it all on her note pad and she carried it to LVN D the night charge nurse on Resident #1's hall and told him about the order to hold the [MEDICATION NAME]. LVN B said LVN A was not in report at the shift change and was passing medications earlier than usual. LVN C asked LVN A if she had given the [MEDICATION NAME] to Resident #1 and she said yes. LVN B said he told LVN D who called Physician A's cell phone but she didn't answer. When Physician A called back LVN B said he answered the phone and told Physician A what had happened. LVN B said Physician A was pretty upset and gave an order for [REDACTED].#1 on bed rest until further notice. LVN B said the procedure to give report from one shift to the next was to usually just give report to the one scheduled to work on that hall at the nurse's station. He said the nurses would tell each other what was going on with the residents and if needed they would go to the specific resident. LVN B said he did not know why LVN A did not get report. LVN B said at that time, the process for transcribing telephone orders into the computerized system had been that each charge nurse transcribed for their own residents, just because they didn't know the status of other residents, so he gave LVN C a sticky note with the order for Resident #1. LVN B said Resident #1 took the [MEDICATION NAME] at night. Review of a witness statement signed by LVN C (date not visible on copy of statement) revealed: On 1/24/19 I received a phone call from the lab with critical PT/INR results on (Resident #1) at 2:26 (p.m.). Results immediately called to (Physician A's) office and had to leave a message. I went to lunch at 2:45 (p.m.). When I returned from lunch I went down to do feeding on a resident. Shortly after I came out of this resident (sp) room (LVN B) came down the hall and handed me a sticky note with a message written on it and he said, this is for you. It said (Physician B) wouldn't see (Resident #1) while on SNF (skilled nursing facility) and then below this was about holding [MEDICATION NAME] and having lab drawn. I went on to pass 5 pm meds for hall 100 and 300 and check blood sugars. The [MEDICATION NAME] was on schedule to be given at 8 pm. I then gave report to (LVN D) and in report I told him the [MEDICATION NAME] was to be held-that the order wasn't in (computer) yet and I would put it in as soon as report was finished. As I was starting to put order in I noticed (LVN A) at the end of hall 100 and went down to her and asked if (LVN D) had told her (Resident #1's) [MEDICATION NAME] was to be held. She (LVN A) said she had already given the med to (Resident #1) and no one had told her not to. At this time it was 6:15 p.m. and I went back to nurses station and told (LVN B) then (LVN D) med was given. (LVN D) immediately called (Physician A) on cell phone and left a message. (Physician A) called at 7 pm and (LVN B) spoke with her. (LVN B) then relayed to (LVN D) what (Physician A) said/ordered. In an interview on 3/7/19 at 3:13 p.m., LVN C said she had gone to lunch late and when she came back LVN B brought her a sticky note that had some stuff written on it. She said she was administering medications at that time and doing a tube feeding that was due at 3:30 p.m., so it was around 4:00 when LVN B handed her the sticky note. LVN C said the information at the top of the sticky note was about moving Resident #1 to another hall. She said she showed the ADON (Assistant Director of Nursing) the information about the move and they discussed it. LVN C said later she noted the information about the medication change at the bottom of the sticky note. LVN C said she gave report to LVN D (the night charge nurse for halls 100 and 400) and told him the [MEDICATION NAME] was on hold, that Resident #1 was not to get any. LVN C said she told LVN D she had not put the order into the computer yet, but she was getting ready to do it. She said LVN D arrived at 5:45 p.m. and between 5:45 p.m. and 6:00 p.m. was when she gave LVN D report. LVN C said she went to enter the order into the computer and LVN D went to hall 400 to do meds and LVN A was doing meds on hall 100. LVN C said she saw LVN A at the end of hall 100 (Resident #1's hall) around 6:00 p.m. passing medications. LVN C said she went to LVN A and asked her if she gave Resident #1 the [MEDICATION NAME] and LVN A said yes and that LVN D did not tell her (LVN A) not to give it. LVN C said she went to LVN D to ask if he told LVN A not to give the medication and LVN D said no. LVN D immediately called Physician A. LVN C said the medication was scheduled to be given at 8:00 p.m. LVN C said the lab came out an drew blood work again. LVN C said LVN B wrote a progress note when he received the telephone order but did not enter the order into the computer. Review of a witness statement signed by LVN D on 1/29/19 revealed: During change of shift report I was informed by day shift nurse that resident (Resident #1's name) [MEDICATION NAME] was going to be put on hold due to a critical lab value. I was informed that the order was just given and that the nurse was still working on the residnets (sp) orders in the system at that time. Once report was finished, I headed down the 400 hall to make my initial rounds and see the residnets (s). Within only a few minutes at approximately 1825 (6:25 p.m.) the day shift nurse came down the hall to inform me that she noticed the med aid (sp) (LVN A) down 100 hall and that she got up to go make sure she was not going to give the [MEDICATION NAME] to (Resident #1) but that it had already been given. At this time (Physician A) was called and message was left about the residnet (sp). In a telephone interview on 3/7/19 at 4:17 p.m. LVN D said he was the charge nurse for hall 100 on which Resident #1 had resided and on hall 400. He said he administered medications on 400 while LVN A administered medications on hall 100, then he took over hall 100 when LVN A left at 10:00 p.m. LVN D said he was coming on shift when LVN C was working on putting the medication ([MEDICATION NAME]) order into the computer. He said he went down to the 400 hall to check on his residents after report. LVN D said LVN A was not in report and he did not know why. LVN D said LVN A usually was up at nurse's station during report. LVN D said after he went down hall 400 around 6:15 or 6:20 p.m., LVN C came down the hall and told him that LVN A had already given the [MEDICATION NAME] to Resident #1 after the facility had an order to hold, and LVN C reported that LVN A gave the [MEDICATION NAME] early. LVN D said he called Physician A and left a message. He said Physician A called back and gave the order to discontinue the [MEDICATION NAME] and get a STAT PT/INR. LVN D said LVN B took the call and relayed the message to him (LVN D). In an interview on 3/7/19 at 4:01 p.m. the ADON said Resident #1's PT/INR had been high and the facility received an order to hold the [MEDICATION NAME] then get another PT/INR. She said when LVN C realized LVN A was already passing medications on Resident #1's hall, LVN C ran down the hall to tell her not to, but LVN A had already given the [MEDICATION NAME] to Resident #1. The ADON said Physician A was notified the [MEDICATION NAME] was given before the order to hold it was put into the computer system in order for it to show on the MAR. The ADON said the MDS Coordinator was working the floor on the night Resident #1 went to the hospital. She said when the MDS Coordinator called her, she reported that the blood in Resident #1's brief was not very much but she and the MDS Coordinator didn't want to wait around, so they sent her to hospital on [DATE] and she returned to the facility on [DATE]. In an interview on 3/7/19 at 4:43 p.m. the MDS Coordinator said on the evening of 1/25/19, she was called to Resident #1's room due to bleeding from her rectal area. The MDS Coordinator said she ran to the room where she noted Resident #1 had a thin ribbon of a red substance in her brief. She said it was thin, watery, pink-tinged. The MDS Coordinator said she was aware that Resident #1 had a critical PT/INR value and determined the resident needed to go to the hospital. She said she called Physician A and got an order to send Resident #1 out. The MDS Coordinator said after she sent Resident #1 to the hospital, she found out that the resident had been given [MEDICATION NAME] the night before that should have been held. The MDS Coordinator said there was not a lot of blood, but enough to concern her because of the critical lab value, so she called Physician A and reminded her of the critical lab value and Physician A said to send Resident #1 to the ER for evaluation. The MDS Coordinator said she knew Resident #1 did not get a blood transfusion, but she got vitamin K in the hospital and when she returned to the facility, Resident #1 was good. In an interview on 3/8/19 at 3:33 p.m. the DON said on 1/24/19 the facility received a critical lab (PT/INR) result on Resident #1 and Physician A was informed, who in turn, ordered the facility to hold the [MEDICATION NAME]. He said the order to hold the [MEDICATION NAME] was not put into the computer before LVN A administered it early. The DON said had LVN A not administered the [MEDICATION NAME] too early, she would have known that it was to be held. The DON said he felt that LVN A thought that since she was a medication nurse she didn't need to take report. He said he told LVN A she needed to take report every day to know if something had been changed or discontinued. He said since the incident, LVN A had been participating in report. The DON confirmed that LVN B took the order from Physician A to hold the [MEDICATION NAME]. He said LVN B should have put the order into the computer and never passed it off to LVN C. The DON said the nurse who took the order should have transcribed the order into the computer. The DON said LVNs B, C, and D were given verbal warnings for not following through on physician's telephone orders which caused a medication error. He said he gave LVN A a written warning for giving a medication too early, giving a medication that had been held and for not participating in report. The DON said he initiated a Quality Assurance and Performance Improvement (QAPI) plan for transcribing physicians' orders and administering medications at the correct time. He said he in-serviced all of the nurses on the plan including receiving and transcribing physicians' orders, medication errors, administration of oral medications, and he presented an all-staff in-service on abuse and neglect. The DON said his expectation was that nurses were to put physician's orders [REDACTED]. He said the nurses should put a copy of the order in his box and the ADON's box for them to review and confirm the order had been entered into the computer system correctly. The DON said after the incident with Resident #1, he checked all of the residents' orders for accuracy. The ADON said following the incident, she participated in the in-services to the nurses. She said the nurses were instructed on as soon as they received orders they were to put them into the computer system. She said a QAPI plan was initiated on the medication error and receiving orders from the doctors. She said an in-service on abuse and neglect was also presented. The ADON said the four nurses involved in the incident were counseled and that she was not aware that any nurses had given medications too early in the past. The facility completed the following actions to correct the non-compliance on 1/28/19: 1. Initiated a facility investigation dated 1/25/19 2. Completed a Medication Error Report dated 1/25/19. 3. Conducted in-services on Medication Errors and Drug Reactions policy; Oral Medications policy; Abuse, Neglect and Exploitation policy; Discontinued Medications policy (policies undated), and Texas Health and Human Services Provider Letter No. 17-19 Abuse, Neglect and Exploitation that Must Be Reported. 4. Initiated Plans of Action on Transcription errors with the potential to cause a medication error and medication errors due to medication being administered at incorrect time both dated 1/28/19. 5. Issued a written warning to LVN A, and verbal warnings to LVNs B, C, and D. Review of the Plan of Action for transcription errors with the potential to cause a medication error revealed the following: .6. Process for accepting verbally communicated orders: .c. Place the order in the medical chart as soon as possible . In an interview on 3/9/19 at 1:05 p.m., the DON said there was not a policy for tra

Based on observations, interviews, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #1) reviewed for significant medication errors. LVN B failed to transcribe Physician A's order to hold Resident #1's [MEDICATION NAME]; LVNs B, C, and D failed to communicate to LVN A that Resident #1's [MEDICATION NAME] was to be held and LVN A administered the [MEDICATION NAME] to Resident #1 earlier than it was scheduled to be given. The next day, Resident #1 was hospitalized with rectal bleeding. This was determined to be past-noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure placed the residents at risk for complications due to errors in medication administration. Findings included: Review of Resident #1's Admission Record printed 1/29/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 14-day Minimum (MDS) data set [DATE] revealed she had a Brief Interview for Mental Status score of 10 which indicated her cognitive function was moderately impaired and she required extensive assistance with her activities of daily living. Review of Resident #1's Care Plan dated 2/21/19 revealed: potential for alteration in bleeding tendencies and increased bruising r/t use of anticoagulants/antiplatelet therapy for [DIAGNOSES REDACTED].Administer medication as ordered, monitor for side effects and report findings to MD (medical doctor). In an observation and interview on 3/7/19 at 1:30 p.m., Resident #1 was dressed and groomed, sitting in her wheelchair in her room watching television. She was receiving oxygen via nasal cannula. Resident #1 said she went to the hospital because they found blood in her rectum. She said her blood was too thin because they had given her too much [MEDICATION NAME]. Resident #1 said the [MEDICATION NAME] was stopped for a couple of days and she was back on it now. Observation of exposed areas of Resident #1's face, neck, hands, arms and lower legs revealed no signs of bruising or bleeding. Review of a Lower Extremity Venous Report performed at Hospital B's cardiology services dated 1/11/19 revealed Resident #1 had a non-occlusive chronic [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot) in the left popliteal vein; a non-occlusive hyperechoic thrombus suggestive of chronic [MEDICAL CONDITION] in the right femoral vein; a non-occlusive chronic [MEDICAL CONDITION] in the right popliteal vein; a [MEDICAL CONDITION] in the right peroneal vein; and a [MEDICAL CONDITION] in the right posterior tibial vein. Review of Resident #1's Nurse Progress Notes, physician's orders [REDACTED]. Following the result of the lab draw on 1/14/19, Physician A discontinued the [MEDICATION NAME] 5 mg and increased the dosage to 7.5 mg at bedtime for two days for [MEDICAL CONDITION]. On 1/17/19, Physician A renewed the order for [MEDICATION NAME] 7.5 mg at bedtime related to acute embolism and [MEDICAL CONDITION] of unspecified veins of unspecified lower extremity until 1/24/19. Review of a lab result for Resident #1 drawn at 1:15 a.m. on 1/24/19 revealed the PT was 56 which was high according to the range of 12.0-14.7; and the INR was 6.2 which was high high according to the range of 0.9-1.1. Documentation on the lab result indicated the critical result was called to and read back by LVN C on 1/24/19 at 14:16 (2:16 p.m.). According to the Mayo Clinic, a PT is a [MEDICATION NAME] time test to measure how quickly blood clots. [MEDICATION NAME] is a protein produced by the liver and is one of many factors that help blood to clot appropriately. If a blood-thinning medication such as [MEDICATION NAME] ([MEDICATION NAME]) is being taken the [MEDICATION NAME] time test results will be expressed as a ratio called the international normalized ratio (INR). In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking [MEDICATION NAME] ([MEDICATION NAME]) for disorders such as [MEDICAL CONDITION] or a blood clot in the leg or lung .When the INR is higher than the recommended range, it means that the blood clots more slowly than desired, and a lower INR means the blood clots more quickly than desired .[MEDICATION NAME] side effects that require immediate medical attention: Severe bleeding, including heavier than normal menstrual bleeding Red or brown urine Black or bloody stool Severe headache or stomach pain Joint pain, discomfort or swelling, especially after an injury Vomiting of blood or material that looks like coffee grounds Coughing up blood Bruising that develops without an injury you remember Dizziness or weakness Vision changes Accessed on 3/11/19 at https://www.mayoclinic.org/tests-procedures/[MEDICATION NAME]-time/about/pac- 661?p=1 Review of the following Nurse Progress Note for Resident #1 revealed: 1/17/19 at 17:32 (5:32 p.m.) Per Physician A, Resident is to stop [MEDICATION NAME] and continue on [MEDICATION NAME] 7.5 mg and repeat PT/INR in 1 week (01/24/2019) .Signed by LVN E Review of Resident #1's active, completed and discontinued physician's orders [REDACTED]. In interview on 3/9/19 at 2:15 p.m., when asked what she did after she wrote the Nurse Progress note to discontinue the [MEDICATION NAME] and draw the PT/INR on 1/24/19, LVN E said I'm pretty sure I discontinued the [MEDICATION NAME] and put the lab slip in the lab book. When asked if she usually entered the physician's orders [REDACTED]. Review of the following Nurse Progress Notes for Resident #1 revealed: 1/24/19 at 14:26 (2:26 p.m.): Received call from lab with critical PT result of 56 and INR result of 6.2. Called to Physician A's office with results and had to leave a message. Signed by LVN C 1/24/19 at 16:22 (4:22 p.m.): Physician A's nurse called stating .hold [MEDICATION NAME] 3 days due to elevated PT/INR and recheck PT/INR on 1/27/19 STAT order . Signed by LVN B 1/24/19 at 16:29 (4:29 p.m.): Call (Physician A) at (phone number) for lab result obtained STAT. Signed by LVN B Review of Resident #1's paper and electronic current, completed and discontinued physician's orders [REDACTED]. Review of the following Nurse Progress note for Resident #1 revealed: 1/24/19 at 19:35 (7:35 p.m.): Physician A called back due to night nurse (LVN A) gave [MEDICATION NAME] when it was on hold. This nurse told Physician A that there was a communication error. Physician A stated to discontinue the [MEDICATION NAME] now and resident is to be bed rest until further orders and to call Physician A stat when lab is obtain (sp). This nurse relay the messages to night nurse (LVN D) .Signed by LVN B Review of Resident #1's MAR dated 1/1/19-1/31/19 indicated LVN A did not document she administered the [MEDICATION NAME] on 1/24/19, after Physician A ordered it to be held. Review of a STAT lab result drawn on 1/24/19 at 22:39 (10:39 p.m.) revealed the PT was 58.9 and the INR was 6.6. Documentation on the lab result was as follows: Tried calling results not able to after three attempts. Will fax and leave for AM to call. 1/24/19 23:29 (11:29 p.m.). Critical result. Results called to and read back by (LVN E's name) RN on 1/25/19 at 08:24 (8:24 a.m.). Review of the Nurse Progress Notes revealed they did not contain a note by LVN E that indicated she called or communicated Resident #1's critical lab result to Physician A. In an interview on 3/8/19 LVN E said she did not remember taking a phone call from the lab about Resident #1's STAT lab result. This surveyor provided LVN E with a copy of the result to review. LVN E said, I know that if I had a critical lab I would have called Physician A immediately. She said, if I called the doctor, I would document in the nurse's notes-I know I would have called her on a critical value. LVN E reviewed the Nurse Progress notes but did not find documentation that she had called Physician A. LVN E said, I know that I messed up by failing to document that I called her (Physician A). Review of the following Nurse Progress Notes revealed: 1/25/19 at 08:45 (8:45 a.m.): Rec'd call from (Physician A's nurse's name) in regards to lab results. Informed her that results were not in from STAT lab draw last night. Called Lab and spoke with (lab staff), she stated all PT/INR are sent to Hospital A. Explained to her order was STAT and we needed the results for Physician A. She then stated she would call Hospital A and send lab to us ASAP (as soon as possible). Signed by the ADON. 1/25/19 11:30 a.m.: Called Physician to report PT/INR of 58.9/6.6 reported that the [MEDICATION NAME] has been discontinued per orders. Received new order for PT/INR in the AM and call Physician A with result. Signed by the DON 1/25/19 15:43 (3:43 p.m.): Notified resident's niece to ensure notification of [MEDICATION NAME] administered last night in error. Also reported no physical harm to resident .Signed by ADON 1/25/19 19:55 (7:55 p.m.): called into (Resident #1's) room by aide for bleeding in the rectal area. Called PCP (primary care physician-Physician A) new order send to ER (emergency room ) for evaluation. Niece called and updated. 911 called and arrived at 2000 (8:00 p.m.) .Signed by the MDS Coordinator 1/28/19 12:12 p.m.: Resident returned back to the facility from Hospital A via facility van. Resident is alert and oriented .Resident's vital signs all are within normal limits .Signed by LVN E Review of a history and physical from Hospital A dated 1/25/19 dictated by Physician B revealed: Chief complaint: bright red blood per rectum. History of present illness: .female with [DIAGNOSES REDACTED] as well as recently diagnosed right lower extremity [MEDICAL CONDITION], currently on [MEDICATION NAME] for anticoagulation, who presents to our emergency room with complaints of bright red blood per rectum. She reports that earlier today while being changed after having a bowel movement, the nursing staff at the facility had noticed that she had bright red blood in her stools. It is unclear the quantity of blood, but the patient reports that she has been more so constipated over the last few days, but this is the only time she has been told that she had blood in her stools. She has denied any hematemesis, denied any abdominal pain. Additionally, denies any recent NSAID use .Initially, she was on Eliquis; however, she was found to have a [MEDICAL CONDITION] while on Eliquis and was switched over to [MEDICATION NAME] earlier this year. Records from the facility indicate that she recently had her [MEDICATION NAME] dose increased from 5 mg to 7.5 mg.Assessment: 1. Probable lower GI bleed 2. Supratherapeutic INR 3. [DIAGNOSES REDACTED] 4. History of recent right lower extremity [MEDICAL CONDITION] .Plan: we will admit the patient to a medical-surgical floor. At this time, she has no active signs of bleeding and is hemodynamically stable. Additionally, H and H (hemoglobin and hematocrit) appear to be stable .For now, we will hold her [MEDICATION NAME] and hold off on any reversal agents; although, I do believe she got 10 mg dose of vitamin K .she has been bedridden for the last couple of weeks per instructions after being diagnosed with [REDACTED]. Review of Resident #1's discharge summary from Hospital A dated 1/28/19 revealed: The patient was admitted to the hospital and observed. Because she was on [MEDICAL CONDITION] and had a previous [MEDICAL CONDITION], we elected not to give her anything to reverse her anticoagulation. She was not hemodynamically unstable. She was given IV fluids and did well. Her [MEDICATION NAME] gradually corrected and her bleeding stopped. We are unsure of the etiology, but because of her overall state and fact that she had a normal colonoscopy within the past year, we elected not to perform a repeat colonoscopy .She is discharged back to the facility .She is to take [MEDICATION NAME] 5 mg 1 tablet once a day .We stopped her multiple vitamin, stopped her [MEDICATION NAME], decreased her [MEDICATION NAME], and for now held her losartan as her blood pressure was low normal .Final Diagnoses: [REDACTED]. Acute blood loss [MEDICAL CONDITION] 3. Over-anticoagulated with [MEDICATION NAME] 4. [DIAGNOSES REDACTED]-currently in sinus rhythm . Review of Resident #1's lab result on 1/31/19 following her discharge from the hospital on [DATE] revealed her PT was 16.4 and her INR was 1.3. Review of the facility's Provider Investigation Report dated 1/25/19 revealed LVN A administered medication prior to scheduled administration time . Based on our investigation we concluded that one nurse failed to enter order in timely manner and another nurse failed to follow medication administration schedule. Resident back to facility in 72 hours .Alleged perpetrators: LVN B and LVN A. In a telephone interview on 3/7/19 at 1:07 p.m., LVN A said she worked from 6:00 p.m. to 10:00 p.m. on 1/24/19 passing medications. She said she did not get report that day from the previous shift nurse that the 8:00 p.m. dose of [MEDICATION NAME] was to be held because Resident #1's PT/INR was too high. LVN A said she gave the dose early and then LVN C came down the hall to tell her that the [MEDICATION NAME] was supposed to be held. LVN A said she notified the DON (Director of Nursing) and the physician was notified. She said the physician ordered a STAT (Latin word meaning immediate) PT/INR and it was higher than the first result. LVN A said the next two to three days, no bleeding or bruising was noted, but on Friday (1/25/19) Resident #1 had blood in her bottom area and was sent to the emergency room . LVN A said she did not remember the result of the ER visit, but she said Resident #1 had been fine since. LVN A said a medication error report was completed and the DON counseled her on not giving medications too early. She said the process for handling/managing held or discontinued medication was that the nurses were supposed to tell each other and document it on the (computerized) medication administration record (MAR). LVN A said she did not know which nurse took the order to hold the [MEDICATION NAME] and it was not documented on the MAR. She said the nurses gave each other report, but she did not get a report on Resident #1; she said she remembered LVN A told her about a new admission on hall 1. She said the nurses did not refuse to give report, but it was a busy day, and nurses did not make resident rounds during report. Review of a witness statement signed by LVN A on 1/28/19 revealed: I came on shift around 5:30 p (p.m.), was told by charge report nurse hall 100 had 2 new patients. No other information was given. I gave [MEDICATION NAME] to patient. Then charge nurse came down the hall and asked if I had given Pt. (patient) her [MEDICATION NAME] I said yes. She stated it was to be held. I told her I was not told and at that tim (time) the medication was still showing on the EMAR (electronic MAR). In a telephone interview on 3/7/10 at 5:12 p.m., LVN A said the reason she gave the [MEDICATION NAME] early was because the staff was really busy and she was trying to get medications administered and help the aides/CNAs (Certified Nurse Assistants/Aide). LVN A said, it was my fault, I shouldn't have given it that early. She said she gave the medication around 6:45 p.m. She said she should have waited 15 minutes, but resident #1 wanted to go to bed. Review of a witness statement signed by LVN B on 1/28/19 revealed: this nurse recieved (sp) phone call from (Physician A's nurse) of res's (Resident #1's) n/o (new order) around 1600 (4:00 p.m.). (Physician A's nurse) stated that she would like to talk to the nurse taking care of (Resident #1). This nurse stated that the nurse is passing out meds at the moment et. (and) ask her for what messages she would like me to give to (LVN C). She stated .HOLD [MEDICATION NAME] for 3 days d/t PT/INR is elevated. On Saturday (1/26/19) to draw PT/INR STAT et. to call MD (Physician A) direct cell phone when lab result is obtained. This nurse gave a note pad to (LVN C) of the orders that was taken by this nurse et. directly verbalize the orders to her et. (LVN C) accepted et. understand the orders. On shift report as what (LVN C) told this Nurse that (LVN A) gave [MEDICATION NAME] to (Resident #1). And ask this nurse of what to do. (LVN C) has stated that she gave (LVN D) night shift nurse the reports of (Resident #1) situations. On night shift, (LVN A) give meds to 100/200 halls. (LVN C) came back to this nurse et. stated that she went down 100 hall et. ask (LVN A) if she has given Warferin (sp) to (Resident #1) et. said that she did. (LVN C) ask this nurse what should be done? This nurse told (LVN C) to call (Physician C) d/t the error. (LVN D) called (Physician A) cell phone with no answer et. left a messages (sp). Around 1900 (7:00 p.m.) (Physician A) called back et. this nurse spoke to (Physician A). This nurse explained to (Physician A) that the messages did not completely relaid (sp) to all the nurse that was taking care of (Resident #1). (Physician A) was upset et. gave this nurse a n/o: STAT PT/INR, D/C'd (discontinued) Warferin (sp) now, (Resident #1 is to be bed rest until further orders, et. to call (Physician A) when result is obtain (sp) STAT. This nurse gave the orders to (LVN D) et. LVN C) is aware of the n/o. (LVN D) wrote the n/o, called lab d/t STAT orders. Around 2030 (8:30 p.m.) lab (lab staff's first name) draw PT/INR. In an interview on 3/7/19 at 2:53 p.m. LVN B said he had worked at the facility for approximately a year and worked the 200 and 400 halls. He said on 1/24/19 he received a call from Physician A and he put it in a progress note. LVN B was not able to tell this surveyor the specific order. Surveyor provided LVN B with his witness statement to refer to. LVN B said he took a call from Physician A's nurse about 4:00 p.m., but he was not taking care of the hall that Resident #1 was on. Physician A's nurse wanted to talk to LVN C but LVN C was busy at the moment so she gave LVN B the message. LVN B said he told LVN C to hold the [MEDICATION NAME] for three days due to an increase in Resident #1' PT/INR and on Saturday to call Physician on her cell phone after another PT/INR had been drawn. He said LVN C had it all on her note pad and she carried it to LVN D the night charge nurse on Resident #1's hall and told him about the order to hold the [MEDICATION NAME]. LVN B said LVN A was not in report at the shift change and was passing medications earlier than usual. LVN C asked LVN A if she had given the [MEDICATION NAME] to Resident #1 and she said yes. LVN B said he told LVN D who called Physician A's cell phone but she didn't answer. When Physician A called back LVN B said he answered the phone and told Physician A what had happened. LVN B said Physician A was pretty upset and gave an order for [REDACTED].#1 on bed rest until further notice. LVN B said the procedure to give report from one shift to the next was to usually just give report to the one scheduled to work on that hall at the nurse's station. He said the nurses would tell each other what was going on with the residents and if needed they would go to the specific resident. LVN B said he did not know why LVN A did not get report. LVN B said at that time, the process for transcribing telephone orders into the computerized system had been that each charge nurse transcribed for their own residents, just because they didn't know the status of other residents, so he gave LVN C a sticky note with the order for Resident #1. LVN B said Resident #1 took the [MEDICATION NAME] at night. Review of a witness statement signed by LVN C (date not visible on copy of statement) revealed: On 1/24/19 I received a phone call from the lab with critical PT/INR results on (Resident #1) at 2:26 (p.m.). Results immediately called to (Physician A's) office and had to leave a message. I went to lunch at 2:45 (p.m.). When I returned from lunch I went down to do feeding on a resident. Shortly after I came out of this resident (sp) room (LVN B) came down the hall and handed me a sticky note with a message written on it and he said, this is for you. It said (Physician B) wouldn't see (Resident #1) while on SNF (skilled nursing facility) and then below this was about holding [MEDICATION NAME] and having lab drawn. I went on to pass 5 pm meds for hall 100 and 300 and check blood sugars. The [MEDICATION NAME] was on schedule to be given at 8 pm. I then gave report to (LVN D) and in report I told him the [MEDICATION NAME] was to be held-that the order wasn't in (computer) yet and I would put it in as soon as report was finished. As I was starting to put order in I noticed (LVN A) at the end of hall 100 and went down to her and asked if (LVN D) had told her (Resident #1's) [MEDICATION NAME] was to be held. She (LVN A) said she had already given the med to (Resident #1) and no one had told her not to. At this time it was 6:15 p.m. and I went back to nurses station and told (LVN B) then (LVN D) med was given. (LVN D) immediately called (Physician A) on cell phone and left a message. (Physician A) called at 7 pm and (LVN B) spoke with her. (LVN B) then relayed to (LVN D) what (Physician A) said/ordered. In an interview on 3/7/19 at 3:13 p.m., LVN C said she had gone to lunch late and when she came back LVN B brought her a sticky note that had some stuff written on it. She said she was administering medications at that time and doing a tube feeding that was due at 3:30 p.m., so it was around 4:00 when LVN B handed her the sticky note. LVN C said the information at the top of the sticky note was about moving Resident #1 to another hall. She said she showed the ADON (Assistant Director of Nursing) the information about the move and they discussed it. LVN C said later she noted the information about the medication change at the bottom of the sticky note. LVN C said she gave report to LVN D (the night charge nurse for halls 100 and 400) and told him the [MEDICATION NAME] was on hold, that Resident #1 was not to get any. LVN C said she told LVN D she had not put the order into the computer yet, but she was getting ready to do it. She said LVN D arrived at 5:45 p.m. and between 5:45 p.m. and 6:00 p.m. was when she gave LVN D report. LVN C said she went to enter the order into the computer and LVN D went to hall 400 to do meds and LVN A was doing meds on hall 100. LVN C said she saw LVN A at the end of hall 100 (Resident #1's hall) around 6:00 p.m. passing medications. LVN C said she went to LVN A and asked her if she gave Resident #1 the [MEDICATION NAME] and LVN A said yes and that LVN D did not tell her (LVN A) not to give it. LVN C said she went to LVN D to ask if he told LVN A not to give the medication and LVN D said no. LVN D immediately called Physician A. LVN C said the medication was scheduled to be given at 8:00 p.m. LVN C said the lab came out an drew blood work again. LVN C said LVN B wrote a progress note when he received the telephone order but did not enter the order into the computer. Review of a witness statement signed by LVN D on 1/29/19 revealed: During change of shift report I was informed by day shift nurse that resident (Resident #1's name) [MEDICATION NAME] was going to be put on hold due to a critical lab value. I was informed that the order was just given and that the nurse was still working on the residnets (sp) orders in the system at that time. Once report was finished, I headed down the 400 hall to make my initial rounds and see the residnets (s). Within only a few minutes at approximately 1825 (6:25 p.m.) the day shift nurse came down the hall to inform me that she noticed the med aid (sp) (LVN A) down 100 hall and that she got up to go make sure she was not going to give the [MEDICATION NAME] to (Resident #1) but that it had already been given. At this time (Physician A) was called and message was left about the residnet (sp). In a telephone interview on 3/7/19 at 4:17 p.m. LVN D said he was the charge nurse for hall 100 on which Resident #1 had resided and on hall 400. He said he administered medications on 400 while LVN A administered medications on hall 100, then he took over hall 100 when LVN A left at 10:00 p.m. LVN D said he was coming on shift when LVN C was working on putting the medication ([MEDICATION NAME]) order into the computer. He said he went down to the 400 hall to check on his residents after report. LVN D said LVN A was not in report and he did not know why. LVN D said LVN A usually was up at nurse's station during report. LVN D said after he went down hall 400 around 6:15 or 6:20 p.m., LVN C came down the hall and told him that LVN A had already given the [MEDICATION NAME] to Resident #1 after the facility had an order to hold, and LVN C reported that LVN A gave the [MEDICATION NAME] early. LVN D said he called Physician A and left a message. He said Physician A called back and gave the order to discontinue the [MEDICATION NAME] and get a STAT PT/INR. LVN D said LVN B took the call and relayed the message to him (LVN D). In an interview on 3/7/19 at 4:01 p.m. the ADON said Resident #1's PT/INR had been high and the facility received an order to hold the [MEDICATION NAME] then get another PT/INR. She said when LVN C realized LVN A was already passing medications on Resident #1's hall, LVN C ran down the hall to tell her not to, but LVN A had already given the [MEDICATION NAME] to Resident #1. The ADON said Physician A was notified the [MEDICATION NAME] was given before the order to hold it was put into the computer system in order for it to show on the MAR. The ADON said the MDS Coordinator was working the floor on the night Resident #1 went to the hospital. She said when the MDS Coordinator called her, she reported that the blood in Resident #1's brief was not very much but she and the MDS Coordinator didn't want to wait around, so they sent her to hospital on [DATE] and she returned to the facility on [DATE]. In an interview on 3/7/19 at 4:43 p.m. the MDS Coordinator said on the evening of 1/25/19, she was called to Resident #1's room due to bleeding from her rectal area. The MDS Coordinator said she ran to the room where she noted Resident #1 had a thin ribbon of a red substance in her brief. She said it was thin, watery, pink-tinged. The MDS Coordinator said she was aware that Resident #1 had a critical PT/INR value and determined the resident needed to go to the hospital. She said she called Physician A and got an order to send Resident #1 out. The MDS Coordinator said after she sent Resident #1 to the hospital, she found out that the resident had been given [MEDICATION NAME] the night before that should have been held. The MDS Coordinator said there was not a lot of blood, but enough to concern her because of the critical lab value, so she called Physician A and reminded her of the critical lab value and Physician A said to send Resident #1 to the ER for evaluation. The MDS Coordinator said she knew Resident #1 did not get a blood transfusion, but she got vitamin K in the hospital and when she returned to the facility, Resident #1 was good. In an interview on 3/8/19 at 3:33 p.m. the DON said on 1/24/19 the facility received a critical lab (PT/INR) result on Resident #1 and Physician A was informed, who in turn, ordered the facility to hold the [MEDICATION NAME]. He said the order to hold the [MEDICATION NAME] was not put into the computer before LVN A administered it early. The DON said had LVN A not administered the [MEDICATION NAME] too early, she would have known that it was to be held. The DON said he felt that LVN A thought that since she was a medication nurse she didn't need to take report. He said he told LVN A she needed to take report every day to know if something had been changed or discontinued. He said since the incident, LVN A had been participating in report. The DON confirmed that LVN B took the order from Physician A to hold the [MEDICATION NAME]. He said LVN B should have put the order into the computer and never passed it off to LVN C. The DON said the nurse who took the order should have transcribed the order into the computer. The DON said LVNs B, C, and D were given verbal warnings for not following through on physician's telephone orders which caused a medication error. He said he gave LVN A a written warning for giving a medication too early, giving a medication that had been held and for not participating in report. The DON said he initiated a Quality Assurance and Performance Improvement (QAPI) plan for transcribing physicians' orders and administering medications at the correct time. He said he in-serviced all of the nurses on the plan including receiving and transcribing physicians' orders, medication errors, administration of oral medications, and he presented an all-staff in-service on abuse and neglect. The DON said his expectation was that nurses were to put physician's orders [REDACTED]. He said the nurses should put a copy of the order in his box and the ADON's box for them to review and confirm the order had been entered into the computer system correctly. The DON said after the incident with Resident #1, he checked all of the residents' orders for accuracy. The ADON said following the incident, she participated in the in-services to the nurses. She said the nurses were instructed on as soon as they received orders they were to put them into the computer system. She said a QAPI plan was initiated on the medication error and receiving orders from the doctors. She said an in-service on abuse and neglect was also presented. The ADON said the four nurses involved in the incident were counseled and that she was not aware that any nurses had given medications too early in the past. The facility completed the following actions to correct the non-compliance on 1/28/19: 1. Initiated a facility investigation dated 1/25/19 2. Completed a Medication Error Report dated 1/25/19. 3. Conducted in-services on Medication Errors and Drug Reactions policy; Oral Medications policy; Abuse, Neglect and Exploitation policy; Discontinued Medications policy (policies undated), and Texas Health and Human Services Provider Letter No. 17-19 Abuse, Neglect and Exploitation that Must Be Reported. 4. Initiated Plans of Action on Transcription errors with the potential to cause a medication error and medication errors due to medication being administered at incorrect time both dated 1/28/19. 5. Issued a written warning to LVN A, and verbal warnings to LVNs B, C, and D. Review of the Plan of Action for transcription errors with the potential to cause a medication error revealed the following: .6. Process for accepting verbally communicated orders: .c. Place the order in the medical chart as soon as possible . In an interview on 3/9/19 at 1:05 p.m., the DON said there was not a policy for transcribing physician orders [REDACTED]. He said the statement place the order in the medical chart as soon as possible meant enter the order into the facility's computerized charting system. During interviews on 3/7/19 and 3/8/19 six nurses confirmed they had received the in-services and all were able to describe the correct procedure for receiving and transcribing physicians' orders and the importance of administering medications within the window of time for which they were to be administered.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 10 (Residents #1, #2, #3, #5, #9, #10, #11, #12, #15, and #17) of 20 residents reviewed for pharmacy services. A. The facility failed to ensure Resident #17 received her prescribed antipsychotic medication Seroquel for fifteen days after LVN D discontinued the order by mistake. The facility failed to ensure that Resident #17 had signed physician orders [REDACTED]. B. The facility failed to ensure Resident #10 received her Lasix 40mg that was ordered on [DATE] until 05/22/17. LVN B failed to administer, provide education and document the correct dose of Norvasc administered to Resident #10 on 05/23/17.The facility failed to ensure Resident #10 had signed consolidated Physician order [REDACTED]. C. The facility failed to ensure Resident #12's Lovenox injections (blood thinner) were administered as ordered on four consecutive days-5/18/17, 5/19/17, 5/20/17, and 5/21/17. D. The facility failed to ensure Resident #2's medications ordered during his physician's visit on 04/25/17 and a hospital visit on 05/15/17 were reconciled with the medications Resident #2 received in the facility. Resident #2's Order Summary Reports were either unsigned and/or did not identify all the medications received by Resident #2 during the time frame specified by the Order Summary Report. E. The facility failed to ensure Resident #11 received her Flagyl as ordered. Resident #11 received 8 doses of Flagyl after it was ordered for the medication to be discontinued. Resident #11 did not have signed Physician's admission orders [REDACTED]. F. The facility failed to ensure Resident #1's Order Summary Report for April 2017 identified all the medications received by Resident #1 during the time frame specified by the Order Summary Report. Resident #1 did not receive his evening medications within the specified time frame the evenings of 05/10/17, 05/11/17, and 05/13/17. G. The facility failed to ensure Resident #3 had signed Admission physician's orders [REDACTED]. As a result Resident #3's Buspirone was not administered on the five days she was in the facility from 4/28/17 through 5/11/17 (4/29/17, 4/30/17, 5/5/17, 5/10/17, 5/11/17). Resident #3's evening medications were administered over 2-4 hours late on 5/10/17 and over 1-3 hours late on 5/11/17. H. The facility failed to ensure Resident #5's 5/10/17 evening medications were administered within the required time frame. Resident #5's evening medications were administered 2-5 hours late on 05/11/17. I. The facility failed to ensure Resident #9's evening medications were administered within the required time frame on 05/10/17. J. The facility failed to ensure Resident #15 had signed Physician's admission orders [REDACTED]. On 5/17/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 5/26/17, the facility remained out of compliance at a severity level of Actual Harm that is not Immediate Jeopardy and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed all 50 residents who resided in the facility at risk for complications and/or death due to the potential for medications being erroneously discontinued, omitted from administration, administration of wrong medication; wrong frequency, dosage or timing of medications; and/or duplication of medications administered. Findings Included: A. Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section I identified that she had [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives psychotropic medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine Seroquel is a medication used to treat the symptoms of schizophrenia . episodes of mania . or depression in patients with bipolar disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. (https://medlineplus.gov/druginfo/meds/a 9.html) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA E stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital A. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record (MAR) for April 2017 and May 2017 revealed the following order with a start date of 04/03/2017, (which was the date that the facility started using PointClickCare for their electronic Medication Administration Record): Seroquel Tablet 25mg, Give one tablet by mouth at bedtime related to Major Depressive Disorder, Recurrent, In Remission. The MAR revealed that Resident #17 had received this medication daily 4/4/17 through 04/09/17. On 04/10/17, the April 2017 MAR revealed the order had changed from administering the Seroquel at 8:00PM to administering it in the evening. Resident #17 continued to receive Seroquel Tablet 25mg daily from 04/10/17-04/16/17. Further review of the April and May 2017 MARs revealed from 04/17/17 through 05/02/17 an X in the boxes where nurses' initial to indicate the medication was administered. The x indicated the medication was not due to be administered on those dates. Record review of both Resident #17's electronic and paper clinical record revealed the order for Seroquel was discontinued by LVN D on 04/17/17 with an explanation of order reentered correctly. In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of March 2017. She said that she recalled changing Resident #17's Seroquel on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Seroquel and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. LVN D denied speaking to Resident #17's physician about changing the order, and stated she was just changing the time the medication was administered. She said that she had not had any training with PCC (Point Click Care-electronic medical records system); however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said that she had alerted both DON A and DON B about the error on May 2nd, 2017 and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was not asked to fill out any medication error report. Record review of both Resident #17's electronic and paper clinical record revealed no documentation of Physician O ordering the Seroquel to be discontinued. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, revealed on 05/02/2017 Resident #17's order for Seroquel 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' This order and explanation was entered into PCC by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Seroquel being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of suicidal ideations, antipsychotic medication side effect monitoring or behavior monitoring. In addition, record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/17 thru 05/10/17 revealed no accurate consolidated physician orders [REDACTED]. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Seroquel. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Seroquel was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Seroquel she seemed to get a lot better and felt that with her being placed back on the Seroquel would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of April 2017, specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for April 2017, that her Seroquel was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON A. She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON A. DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Seroquel. DON A said I have no idea why (MDS Coordinator) would make that comment. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. In an interview on 05/23/17 at 3:30 PM the Corporate RN said that over the past few days when they had conducted chart audits there were many resident's that did not have signed consolidated physician orders [REDACTED]. B. Resident #10 Record review of Resident #10's admission record dated 04/19/17 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with her most recent readmission being 05/05/17 with the following Diagnoses: [REDACTED]. Resident #10's admission record indicated that Physician G was her primary care physician. Record review of Resident #10's initial minimum data set ((MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 15, indicating no cognitive impairment. Section I revealed an active [DIAGNOSES REDACTED].#10 received a diuretic. Record review of Residents #10's both electronic and paper care plan dated 03/16/17 revealed Problem: (Resident #10) has dx (diagnosis) of congestive heart failure. Review of Resident #10's paper consolidated Physician order [REDACTED]. Review of Resident #10's most recent Clinical Summary, documentation of the physician visit conducted by Physician G on 05/11/17, revealed Resident #10 was ordered 19 medications, including the following: amlodipine Besylate (Norvasc) 10 mg (for high blood pressure), Lasix 40 mg, (for edema related to congestive heart failure). The Clinical Summary was electronically signed by Physician G on 05/11/17. Review of Resident #10's both paper and electronic Medication Administration Record for May 2017, revealed Resident #10's order for Norvasc was identified as Norvasc 5mg once a day (Note: order was for 10mg). Further review of Resident #10's May 2017 MAR revealed her order for Lasix was not identified and not administered to Resident #10 until 05/22/17, which resulted in Resident #10 not receiving at least 10 doses of her medication. In an interview on 05/23/17 at 3:30 PM the Corporate RN said that she had conducted a full chart audit of Resident #10's mediations and compared the May 2017 MAR to her most recent physician visit Resident #10 had on 05/11/17 with Physician G and that there had been a discrepancy with her Lasix 40mg not being given. She said that all the other medication showed to be correct. When the surveyor pointed out the discrepancy with the Norvasc, she said, Yes, (Resident #10) should have received Norvasc 10mg instead of Norvasc 5mg and that she must have overlooked that when the chart audit was conducted. In an interview on 05/24/17 at 10:40 AM Resident #10 said that a new nurse had just came into her room to administer her morning medication and that she questioned an extra blue pill. She said that she did not take it due to the fact that she was not sure what it was. She said the nurse did not give her any explanation as to what it was and just left the room. In an interview on 05/24/17 at 10:43 AM LVN B said that she had prepared Resident #10's morning medications just a few minutes ago and that she had noticed the change that her Norvasc dose had increased from 5mg to 10mg. She said that she had to pull an extra blue pill from the emergency medication kit to make the correct dose. She said that she prepared the medication for Resident #10, however she did not go into the room to administer the medication that she had given the medication to a nurse she was training. She said that the nurse in training returned from Resident #10's room with the extra blue pill and told her that Resident #10 had refused to take the medication. She said that she disposed of the medication and stated that a resident has the right to refuse their medication. When asked if any education was provided as to why she was receiving an extra blue pill, LVN B said that she had not explained to Resident #10 why there was an extra blue pill in her medication cup. She said that she should have gone into Resident #10's room to explain what the extra blue pill was for. LVN B admitted to documenting on the MAR that Resident #10 had received the full dose of Norvasc 10mg. She said that she should not have documented that she took the full dose and that she should have documented the refusal of the 5mg. She said that she could go back in and change it. In a second interview on 05/25/17 at 3:07 PM, LVN B said that she should not have given the medication to the nurse in training and that she should have been the nurse to administer the medications to Resident #10. In an interview on 05/24/17 at 11:43 AM DON B and the Corporate RN, DON B said that LVN B should have never allowed the nurse in training to administer the medications to Resident #10. DON B said that education should have been provided to Resident #10 when Resident #10 questioned the extra pill in her cup. DON B and the Corporate RN said that the nurse that pulls the medication should be the one to administer the medication. DON B said that LVN B should not have documented that Resident #10 had received the full dose of Norvasc 10mg. C. Resident #12 Resident #12 Record review of Resident #12's Admission Record, dated 05/22/17, revealed he was a [AGE] year old male admitted to the facility on [DATE] under the care of his attending physician, Physician Y. His [DIAGNOSES REDACTED]. Record review of Resident #12's clinical records both paper and electronic revealed a Medical Data Set (MDS) had not been initiated due to his recent admission. Record review of Resident #12's electronic Admission Care Plan, dated 05/18/17 and signed by the MDS Coordinator, revealed Anticoagulant use was identified as an area of concerns with the goal of no complications. The interventions identified to address this concerns included: Monitor labs as ordered, monitor signs/symptoms of bleeding, protect for injury, and PT/INR as ordered. Record review of Resident #12's Order Summary Report, dated 05/19/17 and unsigned, for the period of 05/18/17-05/31/17 revealed the following orders: Lovenox Solution 100mg/ml (milligram/milliliters) (Enoxaparin Sodium). Inject 100 mg subcutaneously at bedtime for prevention Inject abdominal Sub-q every day at bedtime Order Date: 05/18/17. According to the U.S. National Library of Medicine Lovenox (Enoxaparin) is a medication used to prevent blood clots in the leg in patients who are on bedrest . It is also used in combination with warfarin to treat blood clots in the leg. Enoxaparin is in a class of medications called low molecular weight heparins. It works by stopping the formation of substances that cause clots. https://medlineplus.gov/druginfo/meds/a 0.html Record review of Resident #12's electronic Medication Administration Record (MAR) for May 2017 revealed Resident #12 did not receive his Lovenox (Lovenox Solution 100mg/ml Inject 100 mg subcutaneously at bedtime), start date 05/18/17, on the following dates: 05/18/17, 05/19/17, 05/20/17, 05/21/17. The boxes on the MAR where the nurse would sign to specify the Lovenox had been administered were blank on the identified dates, indicating the medication had not been administered. Record review of Resident #12's electronic clinical records of Progress Notes printed 05/24/2017 from 05/18/2017 thru 05/24/2017 did not reveal any documentation of Lovenox being administered or held. In an interview on 05/24/2017 at 11:15 AM LVN D stated Resident 12's medications came with him when he was admitted on the 05/18/17. LVN D indicated Resident #12's Lovenox was available for administration on 05/18/17. Observation on 05/24/2017 at 11:15 AM revealed Resident 12's Lovenox was available on the medication cart, and was dated 05/15/17. In an interview on 05/25/2017 at 2:44 PM Physician Y stated he was aware Resident 12 did not receive his Lovenox as ordered. Physician Y stated he can be contacted five days a week, including via fax. Physician Y indicated he would be satisfied with Resident #12's INR being no lower than 1.8. Record review of the facility's policy entitled Medication Errors and Drug Reactions undated revealed .The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. 1. All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician, and the pharmacist. 2. A detailed account of the incident must be recorded in the resident's medical record. Such documentation must include, but is not limited to: a. The time and date of the incident; b. The name, strength, and dosage of medication administered; c. The resident's reaction to the medication; d. The condition of the resident; e. Any treatment administered; and f. The date and time the physician was notified and his/her instructions.4. The staff/charge nurse will be responsible for completing an incident report and submitting a copy to the Director of Nursing Services and a copy to the Administrator. 5. All incident reports relating to medication errors and drug reactions will be reviewed by the Pharmaceutical Services Committee at their next regularly scheduled meeting. D. Resident #2 Record review of Resident #2's paper Admission Record, dated 05/15/17, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Admission Record also revealed Resident #2's Primary Physician was Physician A. Record review of Resident #2's paper and electronic clinical record revealed the following: Physician order [REDACTED]. Order Summary Report: 03/01/17-03/31/17 Unsigned by Physician A Order Summary Report (undated) Unsigned by Physician A Order Summary Report: 05/01/17-05/31/17 Unsigned by Physician A Record review of Resident #2's paper and electronic clinical record revealed an Order Summary Report: 04/01/17-04/30/17, signed by Physician A on 05/05/17 and RN B on 05/03/17, with only the following medications identified: Doxazosin Mesylate tablet 8 MG (milligram) related to Hypertension LevETIRAcetam Tablet 500 MG related to Convulsions Vitamin D3 Tablet 1000 Unit related to Vitamin Deficiency Record review of Resident #2's paper and electronic Medication Administration Record (MAR) for 04/01/17-04/30/17 revealed Resident #2 revealed the following medications during April 2017 that were not identified on the Order Summary Report for 04/01/17-04/30/17: Citalopram Hydrobromide Tablet 40 MG related to Major Depressive Disorder- received 28 days out of 30 Cyanocobalamin Tablet 500 MCG related to Vitamin B Deficiency- received 28 days out of 30 LevETIRAcetam Tablet 250 MG related to Convulsions- received 28 days out of 30 Opti-Vitamins Tablet related to Vitamin Deficiency- received 28 days out of 30 LamoTRIgine Tablet 200 MG related to Convulsions- received 28 days out of 30 in the morning and 27 days out of 30 in the evening Omeprazole Capsule Delayed Release 20 MG related to Reflux- received 28 days out of 30 in the morning and 27 days out of 30 in the evening Mecilizine HCI Tablet 25 MG related to Motion Sickness-received 2 days out of 30 Record review of Resident #2's paper and electronic clinical record revealed a Progress Note, dated 04/25/17, from the local Veteran's Administration (VA) facility. The Progress Note identified the following medications as Active Outpatient Medications that were not present (after 04/25/17) on Resident #2's MAR prior to 05/17/17 or his Order Summary Report prior to 05/24/17: Carboxymethylcellulose NA. 5% (eye drops) related to Dry Eyes Simvastatin Tablet 40 MG related to [DIAGNOSES REDACTED] (high cholesterol) Further review of the Progress Note, dated 04/25/17, from the local Veteran's Administration facility revealed Resident #2 was to take his blood sugar every other day due to his [DIAGNOSES REDACTED]. Record review of Resident #2's paper and electronic clinical record revealed no documentation of Resident #2's blood sugar being tested every other day from the date of admission until 05/20/17 when it was added to his MAR. Record review of Resident #2's paper and electronic clinical record revealed hospital records, dated 05/15/17, from a local hospital visited by Resident #2. The hospital records revealed the following medications were ordered following discharge, but were not on Resident #2's MAR or Order Summary Report prior to 05/17/17: Aspirin 81 MG Propranolol HCI Tablet 20 MG Simvastatin Tablet 40 MG Record review of Resident #2's paper and electronic clinical record revealed no documentation of Resident #2's primary physician, Physician A, being contacted prior to 05/17/17 to clarify medications and/or orders from the VA visit on 04/25/17 or the hospital visit on 05/15/17. Record review of Resident #2's paper and electronic clinical record revealed an Order Summary Report, dated 05/24/17, that indicated all the medications had been reviewed and approved by Physician A on 05/24/17. The following medications and orders identified at the VA visit on 04/25/17 and the hospital visit on 05/15/17, but not identified on the MAR prior to 05/16/17, were added to the 05/24/17 Order Summary Report and approved by Physician A. These medications were also added to the MAR, including blood sugar checks every other day: Aspirin Tablet Delayed Related 81 MG BusPIRone HCI Tablet 5 MG related to Anxiety Propranolol HCI Tablet 10 MG related to Hypertension (high blood pressure) Refresh Tears Solution. 5% related to Dry Eyes Simvastatin Tablet 40 MG related to [DIAGNOSES REDACTED] (high cholesterol) In an interview on 05/18/17 at 1:00 PM Physician A confirmed he was one of the facility's medical directors and the physician for Resident #2. Physician

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for two (Resident #17 and Resident #2) of eighteen residents reviewed for neglect. A) The facility failed to establish and implement care that addressed Resident #17's psychological and psychiatric needs upon admission. Resident #17 was admitted to the facility on [DATE] with a recent discharge from a psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #17 did not receive her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. On 05/10/17 at 12:50 PM Resident #17 had a call light wrapped around her neck attempting to strangle herself. B) Resident #2 was admitted to the facility on [DATE] along with his wife who was receiving hospice care for end-[MEDICAL CONDITION]. On 04/24/17 Resident #2 requested he be prescribed an antianxiety medication, and then requested the medication almost daily due to reported feelings of anxiety. Resident #2 did not receive any other interventions to address his increased anxiety. On 05/20/17 Resident #2 requested from staff rat poison or a gun to kill himself. Resident #2 was then referred for psychological services. This failure resulted in an Immediate Jeopardy (IJ) identified on 05/15/17. While the IJ was lowered on 05/26/17, the facility remained out of compliance at Actual Harm at a pattern due to the facility's need to monitor their plan for effectiveness. This failure could have affected the facility's other 20 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section E did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA E stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital A. Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review of both Resident # 17's electronic and paper clinical record on 05/11/17 at 3:45 PM revealed no documentation from LVN D regarding Resident #17's suicide attempt on 05/10/17. In an interview on 05/11/17 at 4:00 PM, LVN D said that she Forgot to document the incident with (Resident #17) on 05/10/17 when she was attempting to strangle herself with her call light. She said she should have documented the incident and filled out an incident and accident report and charted it in the progress notes. In an interview on 05/12/17 at 9:00 AM with the admissions coordinator from Psychiatric Hospital A, he said that Resident #17 was admitted to their facility on 05/10/17 at 5:28 PM with [MEDICAL CONDITION]. He said Resident #17 was familiar to him, he said that Resident #17 had had a prior admission on 03/19/17 for [MEDICAL CONDITION] and was discharged on [DATE] to a local nursing facility. In an interview on 05/12/17 at 9:26 AM with the social worker from the local nursing facility Resident #17 had been discharged to on 03/27/17 from Psychiatric Hospital A, she said that Resident #17 was readmitted to their facility on 03/27/17 after being discharged from Psychiatric Hospital A for having had [MEDICAL CONDITION]. She said that Resident #17's daughter had called and requested records be sent to a new facility that had just opened. In an interview on 05/12/17 at 12:30 PM with Resident #17's daughter, she said that the facility, specifically the Administrator was aware of her mother's previous psychiatric hospital stay in March 2017 and that she informed the Administrator that Resident #17 had been suicidal and Tried to kill herself. Resident #17's daughter also stated that she had spoken with the Admissions Coordinator upon Resident #17's admission to the facility on [DATE] about her mother's previous suicide attempt. She said that her mother had recently shown an increase in sadness and would call her numerous times from the facility crying and asking her to come get her. She said that her mother had been upset due to the fact that she (the daughter) had taken her cell phone from her due to previous calls made to 911 when she was at another long term care facility. She said that she visited her mother often, usually during the evening hours and her mother had been very sad and cried all the time. She said that her mother used the facility phone and that the nurses would have had to have known her mother had shown increased sadness and crying episodes because they were the ones that assisted her in dialing the phone number to call her. She said that she had not received any phone calls in regards to her mother's change in condition other than on 05/10/17 when the Social Worker contacted her about the incident on 05/10/17. In an interview on 05/12/17 at 12:40 PM the Medical Records Clerk was asked for all records that pertained to Resident #17. The Medical Records Clerk at that time pulled from a filing cabinet Resident #17's Admission Paperwork, which encompassed an Admit Approval letter, MDS Worksheet, Documentation from the local long term care facility that Resident #17 had transferred from, along with medical records regarding her previous admission to Psychiatric Hospital A on 03/19/17 thru 03/27/17. Record review of Resident #17's paper admission records on 05/12/17 at 12:15 PM, obtained by the Medical Records Clerk, revealed faxed copies sent from Resident #17's previous nursing home on 03/30/17 that indicated Resident #17 had a known recent history of suicidal ideation. Review of Resident #17's medical records from Psychiatric Hospital A from 03/19/17-03/27/17 revealed the following: admitting [DIAGNOSES REDACTED]. Resident #17's Psychiatric Evaluation revealed that according to the Care Attendant from the local nursing facility, (Resident #17) had a specific plan to cut her wrists. Further review of Resident #17's faxed admission records from the previous long term care facility Resident #17 was transferred from revealed a care plan that revealed Resident #17 had a problem identified on 09/6/16 as being at risk for alteration in mood/behaviors related to history of anxiety. The care plan identified within this problem that Resident #17 told a nurse that she felt like killing herself, had a plan and that a referral was made to Psychiatric Hospital A on 03/19/17. There were several approaches identified within this problem that revealed Resident #17 had previous psychiatric issues which included Resident #17 was monitored for signs and symptoms of anxiety that included: expressing worry, fidgety, difficulty sleeping, not eating well. She had also been referred to psych services on 02/02/17 and that resident #17 was placed on 1:1 supervision until sent to Psychiatric Hospital A on 03/19/17 for [MEDICAL CONDITION]. Attached to this information with a paperclip was the Pending Admission Sheet dated 3/29/17, signed by the Admissions Coordinator. There was a circle around the work Approval, an X under the Clinical Approval box with the Administrator's name next to the DON's Signature line and an X that indicated her financial approval, which was signed by the Business Office Manager. The Administrator/CEO Approval box was blank. In addition, there was another sheet within this stack of clinical records for Resident #17 entitled MDS Worksheet that was used to collect information for Resident #17's initial MDS at the facility. It referenced Resident #17's recent stay at the Psychiatric Hospital A with dated marked 03/19/17-03/27/17. In an interview on 05/12/17 at 2:27 PM the Admissions Coordinator said that she had been contacted by Resident #17's daughter to admit Resident #17 to the facility. She said that she knew Resident #17 from a previous facility she worked at and did not recall any reason to not admit her. She said that the admissions process requires three green lights and that involves a clinical approval, financial approval and Administrator/CEO Approval. She said that once she has three green lights she can admit that resident. When asked if she was aware of Resident #17's recent stay at a local Psychiatric Hospital, the Admissions Coordinator said I think so; I think I remember seeing something about it. She said that any clinical information was given to the DON and that she was not responsible for approving residents from a clinical standpoint. She said that at the time of the admission, she thought she had spoken to DON A regarding the clinical records; however she did not recall if DON A was employed at the facility yet, but remembered she did call the Administrator on the telephone and gained approval from her that way. She could not recall if she had disclosed at the time she gained approval if she conveyed to the Administrator about her recent suicidal ideation. She said that the Administrator did not sign the Approval sheet, that she had written the Administrator's name and marked the approval box. There was not a signature by the DON on the form. She said that all of the admission paperwork with Resident #17's previous clinical records would have been given to the nurse at the time of the admission and should have been placed in her chart. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record for April 2017 and May 2017 revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the March 30, 2017-April 2nd, 2017 MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for April 2017 revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for April 2017 and May 2017 revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 1:55 PM LVN G said that she worked at the facility as needed (PRN) and that she had cared for Resident #17. She said that she would often come out for meals and would demand to call her daughter. She said that she was never told anything about increased monitoring for Resident #17 or that she had any type of previous psychosocial history. In an interview on 05/12/17 at 2:01 PM LVN C said that she had worked at the facility since January 2017. She said that she was familiar with Resident #17. She said that she had not been told anything regarding Resident #17's psychiatric history and that she was not aware of any special monitoring that was in place for Resident #17. She said she had recently been off from work for the past few weeks and had not had any interaction with Resident #17; therefore she could not contribute any information regarding a change in her behavior. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. DON A said at the time of Resident #17's admission, she was not employed at the facility. The Administrator and DON A said that the clinical information that was normally reviewed for a potential admission was the history and physical, lab work, nurses notes, and PASSR information. The Administrator and DON A at this time said that they were not aware the Resident #17 had a previous psychiatric history with a recent stay in a local Psychiatric Hospital where she had [MEDICAL CONDITION]. The Administrator then interrupted the interview and said that she perhaps did recall Resident #17 being a local psychiatric hospital because she said I thought, well is she coming from (local nursing facility) or (local psychiatric hospital)? The Administrator then remembered the daughter of Resident #17 came to the facility for a tour. The Administrator said that she remembered the daughter talking about her mother being at Psychiatric Hospital A for [MEDICAL CONDITION]. DON A said that she was hired on 04/05/17 and was not aware of Resident #17's previous psychiatric issues. She said that interventions for increased monitoring should have been in place if she had a recent history of suicidal ideation and that there were not any implemented from her admission on 03/30/17 to 05/10/17, the day she was discharged to Psychiatric Hospital A. She said that residents with a known psychiatric history should be assessed individually and a plan devised to monitor. She said that if a resident had a known history of [MEDICAL CONDITION] that absolutely staff would be informed and educated with the resident's history and interventions that are implemented. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of April 2017, specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said she did not recall Resident #17's history of being at Psychiatric Hospital A in March prior to admission. She stated that she had written on the MDS Worksheet (that was a tool she used when she gathered information for an MDS assessment), about Resident #17's previous stay dates at (Psychiatric Hospital A), however she was not aware of the reason for her stay there and given that it exceeded her look back period she did not inquire about it. She said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for April 2017, that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON A. She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON A. DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. The Administrator and DON A both acknowledged that the facility had Resident #17's clinical records from the previous long term care facility she was at and the previous psychiatric hospital that clearly identified she was at risk for [MEDICAL CONDITION] prior to her admission and that her records had not been reviewed appropriately to implement the psychiatric services and monitoring Resident #17 should have received. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of March 2017. She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on May 2nd, 2017 and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA E said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA E did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. In an interview on 05/24/17 at 1:58 PM, DON B said that the Administrator had not kept a log of facility investigations and to his knowledge there were only two facility investigations that had been self reported to the state office. Record review of the past 30 days of the facility's incident/accident logs and self-report investigations did not reveal that Resident #17's incident on 05/10/17 had been investigated or reported by the Administrator or DON A. In an interview on 05/25/17 at 3:05 PM with the Vice President of Operations, he said that the Administrator had not mentioned to him about any ongoing investigations that the facility had. He said that the incident regarding Resident #17 having the call light wrapped around her neck and having [MEDICAL CONDITION] should have been investigated and called in by the facility. Resident # 2 Record review of Resident #2's paper Admission Record, dated 05/15/17, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Admission Record also revealed Resident #2's Primary Physician was Physician A. Record review of Resident #2's Comprehensive Minimum Data Set (MDS), both paper and electronic versions, dated 03/22/17, revealed he had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated Resident #2 was able to perform most of his Activities of Daily Limited independently or with limited supervision. The MDS also indicated Resident #2 received an antidepressant on all 7 days prior to the date of the MDS. Record review of Resident #2's current Care Plan (recreated when the facility changed to a new electronic medical records system), undated, both paper and electronic versions, revealed the following focus areas, goals to address the identified focus area, and the interventions required to achieve the identified goal: Focus: (Resident #2) receives [MEDICAL CONDITION] medication to manage target behaviors. Date Initiated: 03/15/2017 Goal: (Resident #2) will receive maximum results with minimal side effects through next review. Date Initiated: 03/15/2017 Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Date Initiated: 03/15/2017 Refer to Social Services or consultant psychiatric provider as needed. Date Initiated: 03/15/2017 Focus: (Resident #2) is a risk for depression r/t (related to) dx (diagnosis) Date Initiated: 03/15/2017 Goal: (Resident #2) will not have increased s/s (signs/symptoms) of depression through next revie(TRUNCATED)

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who displayed mental and psychological difficulties were provided appropriate care and treatments for assessed problems for 2 of 18 residents (Resident #17 and Resident #2) reviewed for psychosocial care and services. A) The facility failed to establish and implement care that addressed Resident #17's psychological and psychiatric needs upon admission. Resident #17 was admitted to the facility on [DATE] with a recent discharge from a psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #17 did not receive her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. Resident #17 was observed on 05/10/17 at 12:50 PM to have a call light wrapped around her neck attempting to strangle herself. B) Resident #2 was admitted to the facility on [DATE] along with his wife who was receiving hospice care for end-[MEDICAL CONDITION]. On 04/24/17 Resident #2 requested he be prescribed an antianxiety medication, and then requested the medication almost daily due to reported feelings of anxiety. Resident #2 did not receive any other interventions to address his increased anxiety. On 05/20/17 Resident #2 requested from staff rat poison or a gun to kill himself. Resident #2 was then referred for psychological services. This failure resulted in an Immediate Jeopardy (IJ) identified on 05/15/17. While the IJ was lowered on 05/26/17, the facility remained out of compliance at Actual Harm at a pattern due to the facility's need to monitor their plan for effectiveness. This failure could have affected the facility's other 20 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section E did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA E stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital A. Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review of both Resident # 17's electronic and paper clinical record on 05/11/17 at 3:45 PM revealed no documentation from LVN D regarding Resident #17's suicide attempt on 05/10/17. In an interview on 05/11/17 at 4:00 PM, LVN D said that she Forgot to document the incident with (Resident #17) on 05/10/17 when she was attempting to strangle herself with her call light. She said she should have documented the incident and filled out an incident and accident report and charted it in the progress notes. In an interview on 05/12/17 at 9:00 AM with the admissions coordinator from Psychiatric Hospital A, he said that Resident #17 was admitted to their facility on 05/10/17 at 5:28 PM with [MEDICAL CONDITION]. He said Resident #17 was familiar to him, he said that Resident #17 had had a prior admission on 03/19/17 for [MEDICAL CONDITION] and was discharged on [DATE] to a local nursing facility. In an interview on 05/12/17 at 9:26 AM with the social worker from the local nursing facility Resident #17 had been discharged to on 03/27/17 from Psychiatric Hospital A, she said that Resident #17 was readmitted to their facility on 03/27/17 after being discharged from Psychiatric Hospital A for having had [MEDICAL CONDITION]. She said that Resident #17's daughter had called and requested records be sent to a new facility that had just opened. In an interview on 05/12/17 at 12:30 PM with Resident #17's daughter, she said that the facility, specifically the Administrator was aware of her mother's previous psychiatric hospital stay in March 2017 and that she informed the Administrator that Resident #17 had been suicidal and Tried to kill herself. Resident #17's daughter also stated that she had spoken with the Admissions Coordinator upon Resident #17's admission to the facility on [DATE] about her mother's previous suicide attempt. She said that her mother had recently shown an increase in sadness and would call her numerous times from the facility crying and asking her to come get her. She said that her mother had been upset due to the fact that she (the daughter) had taken her cell phone from her due to previous calls made to 911 when she was at another long term care facility. She said that she visited her mother often, usually during the evening hours and her mother had been very sad and cried all the time. She said that her mother used the facility phone and that the nurses would have had to have known her mother had shown increased sadness and crying episodes because they were the ones that assisted her in dialing the phone number to call her. She said that she had not received any phone calls in regards to her mother's change in condition other than on 05/10/17 when the Social Worker contacted her about the incident on 05/10/17. In an interview on 05/12/17 at 12:40 PM the Medical Records Clerk was asked for all records that pertained to Resident #17. The Medical Records Clerk at that time pulled from a filing cabinet Resident #17's Admission Paperwork, which encompassed an Admit Approval letter, MDS Worksheet, Documentation from the local long term care facility that Resident #17 had transferred from, along with medical records regarding her previous admission to Psychiatric Hospital A on 03/19/17 thru 03/27/17. Record review of Resident #17's paper admission records on 05/12/17 at 12:15 PM, obtained by the Medical Records Clerk, revealed faxed copies sent from Resident #17's previous facility on 03/30/17 that indicated Resident #17 had a known recent history of suicidal ideation. Review of Resident #17's medical records from Psychiatric Hospital A from 03/19/17-03/27/17 revealed the following: admitting [DIAGNOSES REDACTED]. Resident #17's Psychiatric Evaluation revealed that according to the Care Attendant from the local nursing facility, (Resident #17) had a specific plan to cut her wrists. Further review of Resident #17's faxed admission records from the previous long term care facility Resident #17 was transferred from revealed a care plan that revealed Resident #17 had a problem identified on 09/6/16 as being at risk for alteration in mood/behaviors related to history of anxiety. The care plan identified within this problem that Resident #17 told a nurse that she felt like killing herself, had a plan and that a referral was made to Psychiatric Hospital A on 03/19/17. There were several approaches identified within this problem that revealed Resident #17 had previous psychiatric issues which included Resident #17 was monitored for signs and symptoms of anxiety that included: expressing worry, fidgety, difficulty sleeping, not eating well. She had also been referred to psych services on 02/02/17 and that resident #17 was placed on 1:1 supervision until sent to Psychiatric Hospital A on 03/19/17 for [MEDICAL CONDITION]. Attached to this information with a paperclip was the Pending Admission Sheet dated 3/29/17, signed by the Admissions Coordinator. There was a circle around the work Approval, an X under the Clinical Approval box with the Administrator's name next to the DON's Signature line and an X that indicated her financial approval, which was signed by the Business Office Manager. The Administrator/CEO Approval box was blank. In addition, there was another sheet within this stack of clinical records for Resident #17 entitled MDS Worksheet that was used to collect information for Resident #17's initial MDS at the facility. It referenced Resident #17's recent stay at the Psychiatric Hospital A with dated marked 03/19/17-03/27/17. In an interview on 05/12/17 at 2:27 PM the Admissions Coordinator said that she had been contacted by Resident #17's daughter to admit Resident #17 to the facility. She said that she knew Resident #17 from a previous facility she worked at and did not recall any reason to not admit her. She said that the admissions process requires three green lights and that involves a clinical approval, financial approval and Administrator/CEO Approval. She said that once she has three green lights she can admit that resident. When asked if she was aware of Resident #17's recent stay at a local Psychiatric Hospital, the Admissions Coordinator said I think so; I think I remember seeing something about it. She said that any clinical information was given to the DON and that she was not responsible for approving residents from a clinical standpoint. She said that at the time of the admission, she thought she had spoken to DON A regarding the clinical records; however she did not recall if DON A was employed at the facility yet, but remembered she did call the Administrator on the telephone and gained approval from her that way. She could not recall if she had disclosed at the time she gained approval if she conveyed to the Administrator about her recent suicidal ideation. She said that the Administrator did not sign the Approval sheet, that she had written the Administrator's name and marked the approval box. There was not a signature by the DON on the form. She said that all of the admission paperwork with Resident #17's previous clinical records would have been given to the nurse at the time of the admission and should have been placed in her chart. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record for April 2017 and May 2017 revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the March 30, 2017-April 2nd, 2017 MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for April 2017 revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for April 2017 and May 2017 revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 1:55 PM LVN G said that she worked at the facility as needed (PRN) and that she had cared for Resident #17. She said that she would often come out for meals and would demand to call her daughter. She said that she was never told anything about increased monitoring for Resident #17 or that she had any type of previous psychosocial history. In an interview on 05/12/17 at 2:01 PM LVN C said that she had worked at the facility since January 2017. She said that she was familiar with Resident #17. She said that she had not been told anything regarding Resident #17's psychiatric history and that she was not aware of any special monitoring that was in place for Resident #17. She said she had recently been off from work for the past few weeks and had not had any interaction with Resident #17; therefore she could not contribute any information regarding a change in her behavior. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. DON A said at the time of Resident #17's admission, she was not employed at the facility. The Administrator and DON A said that the clinical information that was normally reviewed for a potential admission was the history and physical, lab work, nurses notes, and PASSR information. The Administrator and DON A at this time said that they were not aware the Resident #17 had a previous psychiatric history with a recent stay in a local Psychiatric Hospital where she had [MEDICAL CONDITION]. The Administrator then interrupted the interview and said that she perhaps did recall Resident #17 being a local psychiatric hospital because she said I thought, well is she coming from (local nursing facility) or (local psychiatric hospital)? The Administrator then remembered the daughter of Resident #17 came to the facility for a tour. The Administrator said that she remembered the daughter talking about her mother being at Psychiatric Hospital A for [MEDICAL CONDITION]. DON A said that she was hired on 04/05/17 and was not aware of Resident #17's previous psychiatric issues. She said that interventions for increased monitoring should have been in place if she had a recent history of suicidal ideation and that there were not any implemented from her admission on 03/30/17 to 05/10/17, the day she was discharged to Psychiatric Hospital A. She said that residents with a known psychiatric history should be assessed individually and a plan devised to monitor. She said that if a resident had a known history of [MEDICAL CONDITION] that absolutely staff would be informed and educated with the resident's history and interventions that are implemented. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of April 2017, specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said she did not recall Resident #17's history of being at Psychiatric Hospital A in March prior to admission. She stated that she had written on the MDS Worksheet (that was a tool she used when she gathered information for an MDS assessment), about Resident #17's previous stay dates at (Psychiatric Hospital A), however she was not aware of the reason for her stay there and given that it exceeded her look back period she did not inquire about it. She said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for April 2017, that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON A. She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON A. DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. The Administrator and DON A both acknowledged that the facility had Resident #17's clinical records from the previous long term care facility she was at and the previous psychiatric hospital that clearly identified she was at risk for [MEDICAL CONDITION] prior to her admission and that her records had not been reviewed appropriately to implement the psychiatric services and monitoring Resident #17 should have received. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of March 2017. She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on May 2nd, 2017 and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA E said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA E did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. Resident # 2 Record review of Resident #2's paper Admission Record, dated 05/15/17, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Admission Record also revealed Resident #2's Primary Physician was Physician A. Record review of Resident #2's Comprehensive Minimum Data Set (MDS), both paper and electronic versions, dated 03/22/17, revealed he had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated Resident #2 was able to perform most of his Activities of Daily Limited independently or with limited supervision. The MDS also indicated Resident #2 received an antidepressant on all 7 days prior to the date of the MDS. Record review of Resident #2's current Care Plan (recreated when the facility changed to a new electronic medical records system), undated, both paper and electronic versions, revealed the following focus areas, goals to address the identified focus area, and the interventions required to achieve the identified goal: Focus: (Resident #2) receives [MEDICAL CONDITION] medication to manage target behaviors. Date Initiated: 03/15/2017 Goal: (Resident #2) will receive maximum results with minimal side effects through next review. Date Initiated: 03/15/2017 Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Date Initiated: 03/15/2017 Refer to Social Services or consultant psychiatric provider as needed. Date Initiated: 03/15/2017 Focus: (Resident #2) is a risk for depression r/t (related to) dx (diagnosis) Date Initiated: 03/15/2017 Goal: (Resident #2) will not have increased s/s (signs/symptoms) of depression through next review. Date Initiated: 03/15/2017 Interventions: Encourage family support . Meds as ordered . Notify MD as needed of any changes in behaviors . Social services director to provide support as necessary Date Initiated: 03/15/2017 Record review of Resident #2's initial Care Plan (created in the previous electronic medical records system) revealed the following problem areas, goal to address the identified problem, and the interventions required to achieve the identified goal: Problem: (Resident #2)'s wife is in facility and on hospice services for terminal illness. Problem Start State: 03/17/2017 Goal: (Resident #2) will demonstrate appropriate grieving skills/strategies relate to his wife's terminal illness.(TRUNCATED)

Based on record review and interviews the facility failed to ensure two ( (Resident's #17 and #12) out of 18 residentswho's medications regiments were reviewed was free of significant medication errors. A) The facility failed to ensure Resident #17received her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. B) The facility failed to administer the dose of [MEDICATION NAME] (blood thinning agent administered to prevent blood clots) to Resident #12 for four consecutive days (05/18/17, 05/19/17, 05/20/17 and 05/21/17). On 5/17/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 5/26/17, the facility remained out of compliance at a severity level of Actual Harm that is not Immediate Jeopardy and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This deficient practice could place one resident (Resident #17) that received the medication Quetiapine [MEDICATION NAME] and 1 resident (Resident #12) who received [MEDICATION NAME] at risk of not receiving the therapeutic benefits from the medications placing them at risk for hospitalization , harm or even death. Findings Include: [NAME] Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section [NAME] did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Section N revealed that she had received an antipsychotic, antidepressant and antianxiety medication for the seven day look back period. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA [NAME] stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital [NAME] Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the (MONTH) 30, (YEAR)-April 2nd, (YEAR) MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for (MONTH) (YEAR) revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of (MONTH) (YEAR), specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for (MONTH) (YEAR), that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON [NAME] She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON [NAME] DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of (MONTH) (YEAR). She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on (MONTH) 2nd, (YEAR) and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA [NAME] said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA [NAME] did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. Resident #12 Record review of Resident #12's Admission Record, dated 05/22/17, revealed he was a [AGE] year old male admitted to the facility on [DATE] under the care of his attending physician, Physician Y. His [DIAGNOSES REDACTED]. Record review of Resident #12's clinical records both paper and electronic revealed a Medical Data Set (MDS) had not been initiated due to his recent admission. Record review of Resident #12's electronic Admission Care Plan, dated 05/18/17 and signed by the MDS Coordinator, revealed Anticoagulant use was identified as an area of concerns with the goal of no complications. The interventions identified to address this concerns included: Monitor labs as ordered, monitor signs/symptoms of bleeding, protect for injury, and PT/INR as ordered. Record review of Resident #12's Order Summary Report, dated 05/19/17 and unsigned, for the period of 05/18/17-05/31/17 revealed the following orders: [MEDICATION NAME] Solution 100mg/ml (milligram/milliliters) ([MEDICATION NAME] Sodium). Inject 100 mg subcutaneously at bedtime for prevention Inject abdominal Sub-q every day at bedtime Order Date: 05/18/17. According to the U.S. National Library of Medicine [MEDICATION NAME] ([MEDICATION NAME]) is a medication used to prevent blood clots in the leg in patients who are on bedrest . It is also used in combination with [MEDICATION NAME] to treat blood clots in the leg. [MEDICATION NAME] is in a class of medications called low molecular weight [MEDICATION NAME]. It works by stopping the formation of substances that cause clots. https://medlineplus.gov/druginfo/meds/a 0.html Record review of Resident #12's electronic Medication Administration Record (MAR) for (MONTH) (YEAR) revealed Resident #12 did not receive his [MEDICATION NAME] ([MEDICATION NAME] Solution 100mg/ml Inject 100 mg subcutaneously at bedtime), start date 05/18/17, on the following dates: 05/18/17, 05/19/17, 05/20/17, 05/21/17. The boxes on the MAR where the nurse would sign to specify the [MEDICATION NAME] had been administered were blank on the identified dates, indicating the medication had not been administered. Record review of Resident #12's electronic clinical records of Progress Notes printed 05/24/2017 from 05/18/2017 thru 05/24/2017 did not reveal any documentation of [MEDICATION NAME] being administered or held. In an interview on 05/24/2017 at 11:15 AM LVN D stated Resident 12's medications came with him when he was admitted on the 05/18/17. LVN D indicated Resident #12's [MEDICATION NAME] was available for administration on 05/18/17. Observation on 05/24/2017 at 11:15 AM revealed Resident 12's [MEDICATION NAME] was available on the medication cart, and was dated 05/15/17. In an interview on 05/25/2017 at 2:44 PM Physician Y stated he was aware Resident 12 did not receive his [MEDICATION NAME] as ordered. Physician Y stated he can be contacted five days a week, including via fax. Physician Y indicated he would be satisfied with Resident #12's INR being no lower than 1.8. Record review of the facility's policy entitled Medication Errors and Drug Reactions undated revealed .The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. 1. All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician, and the pharmacist. 2. A detailed account of the incident must be recorded in the resident's medical record. Such documentation must include, but is not limited to: a. The time and date of the incident; b. The name, strength, and dosage of medication administered; c. The resident's reaction to the medication; d. The condition of the resident; e. Any treatment administered; and f. The date and time the physician was notified and his/her instructions.4. The staff/charge nurse will be responsible for completing an incident report and submitting a copy to the Director of Nursing Services and a copy to the Administrator. 5. All incident reports relating to medication errors and drug reactions will be reviewed by the Pharmaceutical Services Committee at their next regularly scheduled meeting. The Administrator and Regional Director of Operations were notified of the Immediate Jeopardy on 5/17/17 at 11:25 AM The Facility's 11th Plan of Removal for Immediate Jeopardy was accepted on 5/26/17 and reflected the following: Plan of action to remove immediate Jeopardy (MONTH) 15, (YEAR) (facility) . Alleged deficiency -IJ Failure to ensure medications are transcribed appropriately and available for administering to residents. Failure to ensure systems for pharmacy services are in place to include processes that ensure accurate acquisition, recording, dispensing and administration of all drugs to meet the needs of each resident. Facility immediate plan of removal: 1. All medication carts were audited by DON, ADON, and MDS Coordinators (all RNs), to ensure orders are transcribed correctly and medications are available and ready for dispensing. Any issues were addressed and corrected immediately. Responsible discipline: DON/designee, ADON, Administrator/designee, pharmacist consultant . Date of completion: (MONTH) 15, (YEAR) and ongoing 2. Nursing staff in-serviced and retrained regarding the need to notify the Primary Care Physician, DON, ADON and administrator if a resident has been without medications or medications not administered per attending physicians' orders, and to follow-through with Medication Error policy and procedure to include notifications to physician and family. Responsible discipline: DON/designee, ADON, Administrator/designee, Weekend RN supervisor, Licensed Nurses . Date of completion: (MONTH) 15, (YEAR) and ongoing 3. ( Pharmacist consultant), came to facility on Monday, (MONTH) 22, (YEAR)- to conduct med-pass audit, medications and medication cart review, re-training and re-education of nursing staff regarding policy and procedure on medication administration, Quality Assurance review, and other interventions as required. Responsible discipline: Pharmacist consultant, ADON, RN, DON/designee, Administrator/designee . Date of completion: (MONTH) 22, (YEAR) and ongoing 4. Medication Administration Audit form in PointClickCare software (see attached blank audit) will be conducted every morning by DON and/or ADON and Weekend RN to ensure medications have been administered per orders - to monitor for late administration. If late medication administration is evident, Medication Error form (See Attached) following Policy and Procedure will be completed and notifications made to family and attending physician. Administrator must be notified. Medication Administration Audit will be reviewed in Clinical Stand-up and verified on Stand-Up form. Responsible discipline: director of nursing/designee, assistant director of nursing, administrator/designee, weekend RN supervisor . Date of completion: (MONTH) 17, (YEAR) and ongoing 5. At any time that nurses feel they will be out of compliance with medication administration parameters, they will notify the ADON and DON immediately so that assistance will be provided, to maintain compliance. Nurses have been in-serviced regarding the above and this is verified with return demonstration of understanding. Responsible discipline: director of nursing/designee, assistant director of nursing, administrator/designee, weekend RN supervisor . Date of completion: (MONTH) 17, (YEAR) and ongoing 6. Physician telephone orders (hard copy) and those entered into PointClickCare will be reviewed and verified daily in Stand-up Meeting and on weekends by Weekend RN to ensure medications are transcribed correctly, medications have been ordered and available for administration. All new orders and medication changes will be documented in the Nurses Notes in PCC on the date and shift the orders were received, Nurses in-serviced and training verified with return demonstration of understanding. Responsible discipline: director of nursing/designee, ADON, administrator/designee, weekend RN . Date of completion (MONTH) 18, (YEAR) and ongoing 7. Admission and readmission checklist will be utilized for residents to ensure orders are complete and valid. Any orders needing clarification (dosage, time, discontinuation, etc.) will be included on the checklist form. See attached. Attending physician will be notified of the need for clarification by the DON/RN, and his/her recommendations will be implemented. The notification to the attending physician and clarification orders will be documented in the nurses' notes. Notation will be included on the 24-Hour Report for follow-up and completion. 24-Hour Report will be reviewed in daily Clinical Stand-up and verified on the Stand-Up form. Utilization of forms reviewed again on 5/24/17. Responsible discipline: Administrator/designee, DON/designee/ADON, medical records tech . Date of completion (MONTH) 18, (YEAR), (MONTH) 24, (YEAR) and ongoing . 9. Medication administration times have been changed throughout facility to ensure medications are administered timely. Medication Orders will be received and recorded per facility Medication Orders Policy and Procedure. See attached. Nurses have been in-serviced regarding the change in medication administration times and Policy and Procedure and verified with return demonstration of understanding. Computerized MAR is automatically updated when medication administration times change. When printed, the monthly Physician Consolidated Orders will reflect the medication administration time changes. The medication administration pack that is delivered by the pharmacy will be updated with a change of direction label to reflect the change. As MARs are updated and medications are refilled, the medication administration pack will reflect the new changes. The medication administration times were changed in PCC and medication packets re-labeled with change of direction labels by the ADON and MDS RN. Responsible disciplines: DON/designee, RN . Date of completion: (MONTH) 17, (YEAR), (MONTH) 18, (YEAR), (MONTH) 19, (YEAR), and ongoing 10. The 24-hour report will be utilized as a communication tool to ensure medication problems with acquisition, recording, dispensing and/or administration can be followed up timely - to ensure continuity of care. Licensed nurses have been in-serviced by ADON regarding the 24-hour report utilization. This is verified with return demonstration of understanding. Responsible discipline: DON/designee, Administrator/designee, ADON, RN . Date of completion: (MONTH) 17, (YEAR) and ongoing 11. Telephone orders (hard copy or printed from PointClickCare (PCC) software will be reviewed daily by DON, ADON and/or weekend RN, and then will be given to Medical Records Technician. She will organize the orders by physician, placed in manila envelopes and they will be delivered to physicians weekly by van driver, Medical Records Tech, and/or Marketing Director for signatures. Weekly new orders will be delivered and the physician-signed orders from previous week will be picked up. Prior to delivery to the physicians, the telephone orders will be copied and copies placed in the resident clinical record (hard copy) - as a tickler system to ensure orders are returned in a timely manner. Once signed orders are returned, the Medical Records Technician and/or designee will place the orders in the resident clinical record (hard chart) and remove the copies. Medical Records Tech has been in-serviced and retrained regarding the above and this is verified with return demonstration of understanding. Staff in serviced again regarding system for ensuring physician signature and clarification. Responsible discipline: DON/designee, ADON, RN, medical records Tech . Date of completion: (MONTH) 17, (YEAR), (MONTH) 24, (YEAR) and ongoing 12. Weekly, the Medical Records Tech and/or DON/ADON will print all orders for the prior week (Tuesday through Monday) for all residents, to ensure no orders from the PCC system have been missed/omitted. They will then be processed and sent to physicians via steps outlined above. Responsible discipline: medical records Tech, DOM/designee, ADON . Date of completion: (MONTH) 17, (YEAR) and ongoing 13. Physician Consolidated Orders will be printed on or around the 25th of every month by the Medical Records Tech and/or designee, and given to the DON, ADON and/or RN for review and signatures - to ensure accuracy and completeness, The Physician Consolidated Orders will then be copied on colored paper and dated as to when they were delivered, and colored copies placed in residents' clinical record (hard chart). The original Physician Consolidated Orders will be separated by physician, placed in manila envelopes, and delivered to physicians for timely signatures - by the facility van driver, Medical Records Tech, and/or Marketing Director. They will be delivered on or before the first of the month. The orders will be picked up the following week and signed originals placed in the clinical record (hard chart), and copies removed. Responsible disciplines: medical records Tech, DON/designee, ADON, administrator/designee . Date of completion: (MONTH) 17, (YEAR) and ongoing 14. Hard copy chart audit will be done by Medical Records Tech and/or designee weekly to determine if all orders have been returned. If orders have not returned, another copy will be sent to physician utilizing process described above. If the orders continue to not be signed and are later than 2 weeks, the Medical Director will be asked to intervene and help get orders signed. Medical Records

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who displayed mental and psychological difficulties were provided appropriate care and treatments for assessed problems for 2 of 18 residents (Resident #17 and Resident #2) reviewed for psychosocial care and services. A) The facility failed to establish and implement care that addressed Resident #17's psychological and psychiatric needs upon admission. Resident #17 was admitted to the facility on [DATE] with a recent discharge from a psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #17 did not receive her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. Resident #17 was observed on 05/10/17 at 12:50 PM to have a call light wrapped around her neck attempting to strangle herself. B) Resident #2 was admitted to the facility on [DATE] along with his wife who was receiving hospice care for end-[MEDICAL CONDITION]. On 04/24/17 Resident #2 requested he be prescribed an antianxiety medication, and then requested the medication almost daily due to reported feelings of anxiety. Resident #2 did not receive any other interventions to address his increased anxiety. On 05/20/17 Resident #2 requested from staff rat poison or a gun to kill himself. Resident #2 was then referred for psychological services. This failure resulted in an Immediate Jeopardy (IJ) identified on 05/15/17. While the IJ was lowered on 05/26/17, the facility remained out of compliance at Actual Harm at a pattern due to the facility's need to monitor their plan for effectiveness. This failure could have affected the facility's other 20 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section [NAME] did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA [NAME] stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital [NAME] Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review of both Resident # 17's electronic and paper clinical record on 05/11/17 at 3:45 PM revealed no documentation from LVN D regarding Resident #17's suicide attempt on 05/10/17. In an interview on 05/11/17 at 4:00 PM, LVN D said that she Forgot to document the incident with (Resident #17) on 05/10/17 when she was attempting to strangle herself with her call light. She said she should have documented the incident and filled out an incident and accident report and charted it in the progress notes. In an interview on 05/12/17 at 9:00 AM with the admissions coordinator from Psychiatric Hospital A, he said that Resident #17 was admitted to their facility on 05/10/17 at 5:28 PM with [MEDICAL CONDITION]. He said Resident #17 was familiar to him, he said that Resident #17 had had a prior admission on 03/19/17 for [MEDICAL CONDITION] and was discharged on [DATE] to a local nursing facility. In an interview on 05/12/17 at 9:26 AM with the social worker from the local nursing facility Resident #17 had been discharged to on 03/27/17 from Psychiatric Hospital A, she said that Resident #17 was readmitted to their facility on 03/27/17 after being discharged from Psychiatric Hospital A for having had [MEDICAL CONDITION]. She said that Resident #17's daughter had called and requested records be sent to a new facility that had just opened. In an interview on 05/12/17 at 12:30 PM with Resident #17's daughter, she said that the facility, specifically the Administrator was aware of her mother's previous psychiatric hospital stay in (MONTH) (YEAR) and that she informed the Administrator that Resident #17 had been suicidal and Tried to kill herself. Resident #17's daughter also stated that she had spoken with the Admissions Coordinator upon Resident #17's admission to the facility on [DATE] about her mother's previous suicide attempt. She said that her mother had recently shown an increase in sadness and would call her numerous times from the facility crying and asking her to come get her. She said that her mother had been upset due to the fact that she (the daughter) had taken her cell phone from her due to previous calls made to 911 when she was at another long term care facility. She said that she visited her mother often, usually during the evening hours and her mother had been very sad and cried all the time. She said that her mother used the facility phone and that the nurses would have had to have known her mother had shown increased sadness and crying episodes because they were the ones that assisted her in dialing the phone number to call her. She said that she had not received any phone calls in regards to her mother's change in condition other than on 05/10/17 when the Social Worker contacted her about the incident on 05/10/17. In an interview on 05/12/17 at 12:40 PM the Medical Records Clerk was asked for all records that pertained to Resident #17. The Medical Records Clerk at that time pulled from a filing cabinet Resident #17's Admission Paperwork, which encompassed an Admit Approval letter, MDS Worksheet, Documentation from the local long term care facility that Resident #17 had transferred from, along with medical records regarding her previous admission to Psychiatric Hospital A on 03/19/17 thru 03/27/17. Record review of Resident #17's paper admission records on 05/12/17 at 12:15 PM, obtained by the Medical Records Clerk, revealed faxed copies sent from Resident #17's previous facility on 03/30/17 that indicated Resident #17 had a known recent history of suicidal ideation. Review of Resident #17's medical records from Psychiatric Hospital A from 03/19/17-03/27/17 revealed the following: admitting [DIAGNOSES REDACTED]. Resident #17's Psychiatric Evaluation revealed that according to the Care Attendant from the local nursing facility, (Resident #17) had a specific plan to cut her wrists. Further review of Resident #17's faxed admission records from the previous long term care facility Resident #17 was transferred from revealed a care plan that revealed Resident #17 had a problem identified on 09/6/16 as being at risk for alteration in mood/behaviors related to history of anxiety. The care plan identified within this problem that Resident #17 told a nurse that she felt like killing herself, had a plan and that a referral was made to Psychiatric Hospital A on 03/19/17. There were several approaches identified within this problem that revealed Resident #17 had previous psychiatric issues which included Resident #17 was monitored for signs and symptoms of anxiety that included: expressing worry, fidgety, difficulty sleeping, not eating well. She had also been referred to psych services on 02/02/17 and that resident #17 was placed on 1:1 supervision until sent to Psychiatric Hospital A on 03/19/17 for [MEDICAL CONDITION]. Attached to this information with a paperclip was the Pending Admission Sheet dated 3/29/17, signed by the Admissions Coordinator. There was a circle around the work Approval, an X under the Clinical Approval box with the Administrator's name next to the DON's Signature line and an X that indicated her financial approval, which was signed by the Business Office Manager. The Administrator/CEO Approval box was blank. In addition, there was another sheet within this stack of clinical records for Resident #17 entitled MDS Worksheet that was used to collect information for Resident #17's initial MDS at the facility. It referenced Resident #17's recent stay at the Psychiatric Hospital A with dated marked 03/19/17-03/27/17. In an interview on 05/12/17 at 2:27 PM the Admissions Coordinator said that she had been contacted by Resident #17's daughter to admit Resident #17 to the facility. She said that she knew Resident #17 from a previous facility she worked at and did not recall any reason to not admit her. She said that the admissions process requires three green lights and that involves a clinical approval, financial approval and Administrator/CEO Approval. She said that once she has three green lights she can admit that resident. When asked if she was aware of Resident #17's recent stay at a local Psychiatric Hospital, the Admissions Coordinator said I think so; I think I remember seeing something about it. She said that any clinical information was given to the DON and that she was not responsible for approving residents from a clinical standpoint. She said that at the time of the admission, she thought she had spoken to DON A regarding the clinical records; however she did not recall if DON A was employed at the facility yet, but remembered she did call the Administrator on the telephone and gained approval from her that way. She could not recall if she had disclosed at the time she gained approval if she conveyed to the Administrator about her recent suicidal ideation. She said that the Administrator did not sign the Approval sheet, that she had written the Administrator's name and marked the approval box. There was not a signature by the DON on the form. She said that all of the admission paperwork with Resident #17's previous clinical records would have been given to the nurse at the time of the admission and should have been placed in her chart. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the (MONTH) 30, (YEAR)-April 2nd, (YEAR) MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for (MONTH) (YEAR) revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 1:55 PM LVN G said that she worked at the facility as needed (PRN) and that she had cared for Resident #17. She said that she would often come out for meals and would demand to call her daughter. She said that she was never told anything about increased monitoring for Resident #17 or that she had any type of previous psychosocial history. In an interview on 05/12/17 at 2:01 PM LVN C said that she had worked at the facility since (MONTH) (YEAR). She said that she was familiar with Resident #17. She said that she had not been told anything regarding Resident #17's psychiatric history and that she was not aware of any special monitoring that was in place for Resident #17. She said she had recently been off from work for the past few weeks and had not had any interaction with Resident #17; therefore she could not contribute any information regarding a change in her behavior. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. DON A said at the time of Resident #17's admission, she was not employed at the facility. The Administrator and DON A said that the clinical information that was normally reviewed for a potential admission was the history and physical, lab work, nurses notes, and PASSR information. The Administrator and DON A at this time said that they were not aware the Resident #17 had a previous psychiatric history with a recent stay in a local Psychiatric Hospital where she had [MEDICAL CONDITION]. The Administrator then interrupted the interview and said that she perhaps did recall Resident #17 being a local psychiatric hospital because she said I thought, well is she coming from (local nursing facility) or (local psychiatric hospital)? The Administrator then remembered the daughter of Resident #17 came to the facility for a tour. The Administrator said that she remembered the daughter talking about her mother being at Psychiatric Hospital A for [MEDICAL CONDITION]. DON A said that she was hired on 04/05/17 and was not aware of Resident #17's previous psychiatric issues. She said that interventions for increased monitoring should have been in place if she had a recent history of suicidal ideation and that there were not any implemented from her admission on 03/30/17 to 05/10/17, the day she was discharged to Psychiatric Hospital [NAME] She said that residents with a known psychiatric history should be assessed individually and a plan devised to monitor. She said that if a resident had a known history of [MEDICAL CONDITION] that absolutely staff would be informed and educated with the resident's history and interventions that are implemented. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of (MONTH) (YEAR), specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said she did not recall Resident #17's history of being at Psychiatric Hospital A in (MONTH) prior to admission. She stated that she had written on the MDS Worksheet (that was a tool she used when she gathered information for an MDS assessment), about Resident #17's previous stay dates at (Psychiatric Hospital A), however she was not aware of the reason for her stay there and given that it exceeded her look back period she did not inquire about it. She said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for (MONTH) (YEAR), that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON [NAME] She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON [NAME] DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. The Administrator and DON A both acknowledged that the facility had Resident #17's clinical records from the previous long term care facility she was at and the previous psychiatric hospital that clearly identified she was at risk for [MEDICAL CONDITION] prior to her admission and that her records had not been reviewed appropriately to implement the psychiatric services and monitoring Resident #17 should have received. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of (MONTH) (YEAR). She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on (MONTH) 2nd, (YEAR) and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA [NAME] said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA [NAME] did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. Resident # 2 Record review of Resident #2's paper Admission Record, dated 05/15/17, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Admission Record also revealed Resident #2's Primary Physician was Physician [NAME] Record review of Resident #2's Comprehensive Minimum Data Set (MDS), both paper and electronic versions, dated 03/22/17, revealed he had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated Resident #2 was able to perform most of his Activities of Daily Limited independently or with limited supervision. The MDS also indicated Resident #2 received an antidepressant on all 7 days prior to the date of the MDS. Record review of Resident #2's current Care Plan (recreated when the facility changed to a new electronic medical records system), undated, both paper and electronic versions, revealed the following focus areas, goals to address the identified focus area, and the interventions required to achieve the identified goal: Focus: (Resident #2) receives [MEDICAL CONDITION] medication to manage target behaviors. Date Initiated: 03/15/2017 Goal: (Resident #2) will receive maximum results with minimal side effects through next review. Date Initiated: 03/15/2017 Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Date Initiated: 03/15/2017 Refer to Social Services or consultant psychiatric provider as needed. Date Initiated: 03/15/2017 Focus: (Resident #2) is a risk for depression r/t (related to) dx (diagnosis) Date Initiated: 03/15/2017 Goal: (Resident #2) will not have increased s/s (signs/symptoms) of depression through next review. Date Initiated: 03/15/2017 Interventions: Encourage family support . Meds as ordered . Notify MD as needed of any changes in behaviors . Social services director to provide support as necessary Date Initiated: 03/15/2017 Record review of Resident #2's initial Care Plan (created in the previous electronic medical records system) revealed the following problem areas, goal to address the identified problem, and the interventions required to achieve the identified goal: Problem: (Resident #2)'s wife is in facility and on hospice services for terminal illness. Problem Start State: 03/17/2017 Goal: (Resident #2) will demonstrate appropriate grieving skills/strategies relate to his wife's terminal illness. Target Date: 0 (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibited neglect for two (Resident #17 and Resident #2) of eighteen residents reviewed for neglect. A) The facility failed to establish and implement care that addressed Resident #17's psychological and psychiatric needs upon admission. Resident #17 was admitted to the facility on [DATE] with a recent discharge from a psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #17 did not receive her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. On 05/10/17 at 12:50 PM Resident #17 had a call light wrapped around her neck attempting to strangle herself. B) Resident #2 was admitted to the facility on [DATE] along with his wife who was receiving hospice care for end-[MEDICAL CONDITION]. On 04/24/17 Resident #2 requested he be prescribed an antianxiety medication, and then requested the medication almost daily due to reported feelings of anxiety. Resident #2 did not receive any other interventions to address his increased anxiety. On 05/20/17 Resident #2 requested from staff rat poison or a gun to kill himself. Resident #2 was then referred for psychological services. This failure resulted in an Immediate Jeopardy (IJ) identified on 05/15/17. While the IJ was lowered on 05/26/17, the facility remained out of compliance at Actual Harm at a pattern due to the facility's need to monitor their plan for effectiveness. This failure could have affected the facility's other 20 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: Record review of the facility's policy entitled recognizing signs and symptoms of abuse/neglect, dated 2001 and revised (MONTH) 2012, revealed: policy statement - our facility will not condone any form of resident abuse or neglect. Policy interpretation and implementation: . 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms of actual abuse/neglect may be a parent. When in doubt, report it. Be. Signs of/actual physical neglect: . 6. inadequate provision of care . See. Possible signs/symptoms of psychological abuse/neglect: 3 depression; . 9. Suicidal ideation. Record review of the facility's policy entitled abuse investigation, undated, revealed: policy: all reports of resident abuse, neglect, misappropriation of resident property and injuries of an unknown source shall be promptly and thoroughly investigated. Policy interpretation and implementation: 1. When an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown sources reported, the administrator will appoint a staff member to investigate the incident. 2. The administrator will provide the person in charge of the investigation the tools necessary for the investigation and any supporting documents relative to the incident. 3. The investigation shall consist of: an interview with the person reporting the incident, interviews with any witnesses to the incident, an interview with the resident that was allegedly abused, an interview with the residents attending physician if indicated, a review of the residence medical record, an interview with staff members having contact with the resident during the period of the alleged incident, interviews with the residents roommate, family members and visitors. Interviews with other residents to which the accused employee provides care or services, a review of all the circumstances surrounding the incident. 4. Witness report shall be reduced to writing. Witnesses will be required to sign and date such reports. 5 the administrator or director of nurses will complete the 24 hour notification of abuse/neglect form within 24 hours of occurrence or discovery of the incident and fax this form to DHH . 10. The results of the investigation will be recorded on the abuse/neglect final report and faxed/mailed to health standards within five working days of submission of the initial report . Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section [NAME] did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA [NAME] stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital [NAME] Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review of both Resident # 17's electronic and paper clinical record on 05/11/17 at 3:45 PM revealed no documentation from LVN D regarding Resident #17's suicide attempt on 05/10/17. In an interview on 05/11/17 at 4:00 PM, LVN D said that she Forgot to document the incident with (Resident #17) on 05/10/17 when she was attempting to strangle herself with her call light. She said she should have documented the incident and filled out an incident and accident report and charted it in the progress notes. In an interview on 05/12/17 at 9:00 AM with the admissions coordinator from Psychiatric Hospital A, he said that Resident #17 was admitted to their facility on 05/10/17 at 5:28 PM with [MEDICAL CONDITION]. He said Resident #17 was familiar to him, he said that Resident #17 had had a prior admission on 03/19/17 for [MEDICAL CONDITION] and was discharged on [DATE] to a local nursing facility. In an interview on 05/12/17 at 9:26 AM with the social worker from the local nursing facility Resident #17 had been discharged to on 03/27/17 from Psychiatric Hospital A, she said that Resident #17 was readmitted to their facility on 03/27/17 after being discharged from Psychiatric Hospital A for having had [MEDICAL CONDITION]. She said that Resident #17's daughter had called and requested records be sent to a new facility that had just opened. In an interview on 05/12/17 at 12:30 PM with Resident #17's daughter, she said that the facility, specifically the Administrator was aware of her mother's previous psychiatric hospital stay in (MONTH) (YEAR) and that she informed the Administrator that Resident #17 had been suicidal and Tried to kill herself. Resident #17's daughter also stated that she had spoken with the Admissions Coordinator upon Resident #17's admission to the facility on [DATE] about her mother's previous suicide attempt. She said that her mother had recently shown an increase in sadness and would call her numerous times from the facility crying and asking her to come get her. She said that her mother had been upset due to the fact that she (the daughter) had taken her cell phone from her due to previous calls made to 911 when she was at another long term care facility. She said that she visited her mother often, usually during the evening hours and her mother had been very sad and cried all the time. She said that her mother used the facility phone and that the nurses would have had to have known her mother had shown increased sadness and crying episodes because they were the ones that assisted her in dialing the phone number to call her. She said that she had not received any phone calls in regards to her mother's change in condition other than on 05/10/17 when the Social Worker contacted her about the incident on 05/10/17. In an interview on 05/12/17 at 12:40 PM the Medical Records Clerk was asked for all records that pertained to Resident #17. The Medical Records Clerk at that time pulled from a filing cabinet Resident #17's Admission Paperwork, which encompassed an Admit Approval letter, MDS Worksheet, Documentation from the local long term care facility that Resident #17 had transferred from, along with medical records regarding her previous admission to Psychiatric Hospital A on 03/19/17 thru 03/27/17. Record review of Resident #17's paper admission records on 05/12/17 at 12:15 PM, obtained by the Medical Records Clerk, revealed faxed copies sent from Resident #17's previous nursing facility on 03/30/17 that indicated Resident #17 had a known recent history of suicidal ideation. Review of Resident #17's medical records from Psychiatric Hospital A from 03/19/17-03/27/17 revealed the following: admitting [DIAGNOSES REDACTED]. Resident #17's Psychiatric Evaluation revealed that according to the Care Attendant from the local nursing facility, (Resident #17) had a specific plan to cut her wrists. Further review of Resident #17's faxed admission records from the previous long term care facility Resident #17 was transferred from revealed a care plan that revealed Resident #17 had a problem identified on 09/6/16 as being at risk for alteration in mood/behaviors related to history of anxiety. The care plan identified within this problem that Resident #17 told a nurse that she felt like killing herself, had a plan and that a referral was made to Psychiatric Hospital A on 03/19/17. There were several approaches identified within this problem that revealed Resident #17 had previous psychiatric issues which included Resident #17 was monitored for signs and symptoms of anxiety that included: expressing worry, fidgety, difficulty sleeping, not eating well. She had also been referred to psych services on 02/02/17 and that resident #17 was placed on 1:1 supervision until sent to Psychiatric Hospital A on 03/19/17 for [MEDICAL CONDITION]. Attached to this information with a paperclip was the Pending Admission Sheet dated 3/29/17, signed by the Admissions Coordinator. There was a circle around the work Approval, an X under the Clinical Approval box with the Administrator's name next to the DON's Signature line and an X that indicated her financial approval, which was signed by the Business Office Manager. The Administrator/CEO Approval box was blank. In addition, there was another sheet within this stack of clinical records for Resident #17 entitled MDS Worksheet that was used to collect information for Resident #17's initial MDS at the facility. It referenced Resident #17's recent stay at the Psychiatric Hospital A with dated marked 03/19/17-03/27/17. In an interview on 05/12/17 at 2:27 PM the Admissions Coordinator said that she had been contacted by Resident #17's daughter to admit Resident #17 to the facility. She said that she knew Resident #17 from a previous facility she worked at and did not recall any reason to not admit her. She said that the admissions process requires three green lights and that involves a clinical approval, financial approval and Administrator/CEO Approval. She said that once she has three green lights she can admit that resident. When asked if she was aware of Resident #17's recent stay at a local Psychiatric Hospital, the Admissions Coordinator said I think so; I think I remember seeing something about it. She said that any clinical information was given to the DON and that she was not responsible for approving residents from a clinical standpoint. She said that at the time of the admission, she thought she had spoken to DON A regarding the clinical records; however she did not recall if DON A was employed at the facility yet, but remembered she did call the Administrator on the telephone and gained approval from her that way. She could not recall if she had disclosed at the time she gained approval if she conveyed to the Administrator about her recent suicidal ideation. She said that the Administrator did not sign the Approval sheet, that she had written the Administrator's name and marked the approval box. There was not a signature by the DON on the form. She said that all of the admission paperwork with Resident #17's previous clinical records would have been given to the nurse at the time of the admission and should have been placed in her chart. Record review on 05/12/17 at 2:00 PM of both Resident #17's electronic and paper Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the (MONTH) 30, (YEAR)-April 2nd, (YEAR) MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for (MONTH) (YEAR) revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 1:55 PM LVN G said that she worked at the facility as needed (PRN) and that she had cared for Resident #17. She said that she would often come out for meals and would demand to call her daughter. She said that she was never told anything about increased monitoring for Resident #17 or that she had any type of previous psychosocial history. In an interview on 05/12/17 at 2:01 PM LVN C said that she had worked at the facility since (MONTH) (YEAR). She said that she was familiar with Resident #17. She said that she had not been told anything regarding Resident #17's psychiatric history and that she was not aware of any special monitoring that was in place for Resident #17. She said she had recently been off from work for the past few weeks and had not had any interaction with Resident #17; therefore she could not contribute any information regarding a change in her behavior. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. DON A said at the time of Resident #17's admission, she was not employed at the facility. The Administrator and DON A said that the clinical information that was normally reviewed for a potential admission was the history and physical, lab work, nurses notes, and PASSR information. The Administrator and DON A at this time said that they were not aware the Resident #17 had a previous psychiatric history with a recent stay in a local Psychiatric Hospital where she had [MEDICAL CONDITION]. The Administrator then interrupted the interview and said that she perhaps did recall Resident #17 being a local psychiatric hospital because she said I thought, well is she coming from (local nursing facility) or (local psychiatric hospital)? The Administrator then remembered the daughter of Resident #17 came to the facility for a tour. The Administrator said that she remembered the daughter talking about her mother being at Psychiatric Hospital A for [MEDICAL CONDITION]. DON A said that she was hired on 04/05/17 and was not aware of Resident #17's previous psychiatric issues. She said that interventions for increased monitoring should have been in place if she had a recent history of suicidal ideation and that there were not any implemented from her admission on 03/30/17 to 05/10/17, the day she was discharged to Psychiatric Hospital [NAME] She said that residents with a known psychiatric history should be assessed individually and a plan devised to monitor. She said that if a resident had a known history of [MEDICAL CONDITION] that absolutely staff would be informed and educated with the resident's history and interventions that are implemented. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of (MONTH) (YEAR), specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said she did not recall Resident #17's history of being at Psychiatric Hospital A in (MONTH) prior to admission. She stated that she had written on the MDS Worksheet (that was a tool she used when she gathered information for an MDS assessment), about Resident #17's previous stay dates at (Psychiatric Hospital A), however she was not aware of the reason for her stay there and given that it exceeding her look back period she did not inquire about it. She said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for (MONTH) (YEAR), that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON [NAME] She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON [NAME] DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. The Administrator and DON A both acknowledged that the facility had Resident #17's clinical records from the previous long term care facility she was at and the previous psychiatric hospital that clearly identified she was at risk for [MEDICAL CONDITION] prior to her admission and that her records had not been reviewed appropriately to implement the psychiatric services and monitoring Resident #17 should have received. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of (MONTH) (YEAR). She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on (MONTH) 2nd, (YEAR) and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA [NAME] said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA [NAME] did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibited neglect for two (Resident #17 and Resident #2) of eighteen residents reviewed for neglect. A) The facility failed to establish and implement care that addressed Resident #17's psychological and psychiatric needs upon admission. Resident #17 was admitted to the facility on [DATE] with a recent discharge from a psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #17 did not receive her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. On 05/10/17 at 12:50 PM Resident #17 had a call light wrapped around her neck attempting to strangle herself. B) Resident #2 was admitted to the facility on [DATE] along with his wife who was receiving hospice care for end-[MEDICAL CONDITION]. On 04/24/17 Resident #2 requested he be prescribed an antianxiety medication, and then requested the medication almost daily due to reported feelings of anxiety. Resident #2 did not receive any other interventions to address his increased anxiety. On 05/20/17 Resident #2 requested from staff rat poison or a gun to kill himself. Resident #2 was then referred for psychological services. This failure resulted in an Immediate Jeopardy (IJ) identified on 05/15/17. While the IJ was lowered on 05/26/17, the facility remained out of compliance at Actual Harm at a pattern due to the facility's need to monitor their plan for effectiveness. This failure could have affected the facility's other 20 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: Record review of the facility's policy entitled recognizing signs and symptoms of abuse/neglect, dated 2001 and revised April 2012, revealed: policy statement - our facility will not condone any form of resident abuse or neglect. Policy interpretation and implementation: . 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms of actual abuse/neglect may be a parent. When in doubt, report it. Be. Signs of/actual physical neglect: . 6. inadequate provision of care . See. Possible signs/symptoms of psychological abuse/neglect: 3 depression; . 9. Suicidal ideation. Record review of the facility's policy entitled abuse investigation, undated, revealed: policy: all reports of resident abuse, neglect, misappropriation of resident property and injuries of an unknown source shall be promptly and thoroughly investigated. Policy interpretation and implementation: 1. When an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown sources reported, the administrator will appoint a staff member to investigate the incident. 2. The administrator will provide the person in charge of the investigation the tools necessary for the investigation and any supporting documents relative to the incident. 3. The investigation shall consist of: an interview with the person reporting the incident, interviews with any witnesses to the incident, an interview with the resident that was allegedly abused, an interview with the residents attending physician if indicated, a review of the residence medical record, an interview with staff members having contact with the resident during the period of the alleged incident, interviews with the residents roommate, family members and visitors. Interviews with other residents to which the accused employee provides care or services, a review of all the circumstances surrounding the incident. 4. Witness report shall be reduced to writing. Witnesses will be required to sign and date such reports. 5 the administrator or director of nurses will complete the 24 hour notification of abuse/neglect form within 24 hours of occurrence or discovery of the incident and fax this form to DHH . 10. The results of the investigation will be recorded on the abuse/neglect final report and faxed/mailed to health standards within five working days of submission of the initial report . Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section E did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA E stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital A. Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review of both Resident # 17's electronic and paper clinical record on 05/11/17 at 3:45 PM revealed no documentation from LVN D regarding Resident #17's suicide attempt on 05/10/17. In an interview on 05/11/17 at 4:00 PM, LVN D said that she Forgot to document the incident with (Resident #17) on 05/10/17 when she was attempting to strangle herself with her call light. She said she should have documented the incident and filled out an incident and accident report and charted it in the progress notes. In an interview on 05/12/17 at 9:00 AM with the admissions coordinator from Psychiatric Hospital A, he said that Resident #17 was admitted to their facility on 05/10/17 at 5:28 PM with [MEDICAL CONDITION]. He said Resident #17 was familiar to him, he said that Resident #17 had had a prior admission on 03/19/17 for [MEDICAL CONDITION] and was discharged on [DATE] to a local nursing facility. In an interview on 05/12/17 at 9:26 AM with the social worker from the local nursing facility Resident #17 had been discharged to on 03/27/17 from Psychiatric Hospital A, she said that Resident #17 was readmitted to their facility on 03/27/17 after being discharged from Psychiatric Hospital A for having had [MEDICAL CONDITION]. She said that Resident #17's daughter had called and requested records be sent to a new facility that had just opened. In an interview on 05/12/17 at 12:30 PM with Resident #17's daughter, she said that the facility, specifically the Administrator was aware of her mother's previous psychiatric hospital stay in March 2017 and that she informed the Administrator that Resident #17 had been suicidal and Tried to kill herself. Resident #17's daughter also stated that she had spoken with the Admissions Coordinator upon Resident #17's admission to the facility on [DATE] about her mother's previous suicide attempt. She said that her mother had recently shown an increase in sadness and would call her numerous times from the facility crying and asking her to come get her. She said that her mother had been upset due to the fact that she (the daughter) had taken her cell phone from her due to previous calls made to 911 when she was at another long term care facility. She said that she visited her mother often, usually during the evening hours and her mother had been very sad and cried all the time. She said that her mother used the facility phone and that the nurses would have had to have known her mother had shown increased sadness and crying episodes because they were the ones that assisted her in dialing the phone number to call her. She said that she had not received any phone calls in regards to her mother's change in condition other than on 05/10/17 when the Social Worker contacted her about the incident on 05/10/17. In an interview on 05/12/17 at 12:40 PM the Medical Records Clerk was asked for all records that pertained to Resident #17. The Medical Records Clerk at that time pulled from a filing cabinet Resident #17's Admission Paperwork, which encompassed an Admit Approval letter, MDS Worksheet, Documentation from the local long term care facility that Resident #17 had transferred from, along with medical records regarding her previous admission to Psychiatric Hospital A on 03/19/17 thru 03/27/17. Record review of Resident #17's paper admission records on 05/12/17 at 12:15 PM, obtained by the Medical Records Clerk, revealed faxed copies sent from Resident #17's previous nursing facility on 03/30/17 that indicated Resident #17 had a known recent history of suicidal ideation. Review of Resident #17's medical records from Psychiatric Hospital A from 03/19/17-03/27/17 revealed the following: admitting [DIAGNOSES REDACTED]. Resident #17's Psychiatric Evaluation revealed that according to the Care Attendant from the local nursing facility, (Resident #17) had a specific plan to cut her wrists. Further review of Resident #17's faxed admission records from the previous long term care facility Resident #17 was transferred from revealed a care plan that revealed Resident #17 had a problem identified on 09/6/16 as being at risk for alteration in mood/behaviors related to history of anxiety. The care plan identified within this problem that Resident #17 told a nurse that she felt like killing herself, had a plan and that a referral was made to Psychiatric Hospital A on 03/19/17. There were several approaches identified within this problem that revealed Resident #17 had previous psychiatric issues which included Resident #17 was monitored for signs and symptoms of anxiety that included: expressing worry, fidgety, difficulty sleeping, not eating well. She had also been referred to psych services on 02/02/17 and that resident #17 was placed on 1:1 supervision until sent to Psychiatric Hospital A on 03/19/17 for [MEDICAL CONDITION]. Attached to this information with a paperclip was the Pending Admission Sheet dated 3/29/17, signed by the Admissions Coordinator. There was a circle around the work Approval, an X under the Clinical Approval box with the Administrator's name next to the DON's Signature line and an X that indicated her financial approval, which was signed by the Business Office Manager. The Administrator/CEO Approval box was blank. In addition, there was another sheet within this stack of clinical records for Resident #17 entitled MDS Worksheet that was used to collect information for Resident #17's initial MDS at the facility. It referenced Resident #17's recent stay at the Psychiatric Hospital A with dated marked 03/19/17-03/27/17. In an interview on 05/12/17 at 2:27 PM the Admissions Coordinator said that she had been contacted by Resident #17's daughter to admit Resident #17 to the facility. She said that she knew Resident #17 from a previous facility she worked at and did not recall any reason to not admit her. She said that the admissions process requires three green lights and that involves a clinical approval, financial approval and Administrator/CEO Approval. She said that once she has three green lights she can admit that resident. When asked if she was aware of Resident #17's recent stay at a local Psychiatric Hospital, the Admissions Coordinator said I think so; I think I remember seeing something about it. She said that any clinical information was given to the DON and that she was not responsible for approving residents from a clinical standpoint. She said that at the time of the admission, she thought she had spoken to DON A regarding the clinical records; however she did not recall if DON A was employed at the facility yet, but remembered she did call the Administrator on the telephone and gained approval from her that way. She could not recall if she had disclosed at the time she gained approval if she conveyed to the Administrator about her recent suicidal ideation. She said that the Administrator did not sign the Approval sheet, that she had written the Administrator's name and marked the approval box. There was not a signature by the DON on the form. She said that all of the admission paperwork with Resident #17's previous clinical records would have been given to the nurse at the time of the admission and should have been placed in her chart. Record review on 05/12/17 at 2:00 PM of both Resident #17's electronic and paper Medication Administration Record for April 2017 and May 2017 revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the March 30, 2017-April 2nd, 2017 MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for April 2017 revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for April 2017 and May 2017 revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 1:55 PM LVN G said that she worked at the facility as needed (PRN) and that she had cared for Resident #17. She said that she would often come out for meals and would demand to call her daughter. She said that she was never told anything about increased monitoring for Resident #17 or that she had any type of previous psychosocial history. In an interview on 05/12/17 at 2:01 PM LVN C said that she had worked at the facility since January 2017. She said that she was familiar with Resident #17. She said that she had not been told anything regarding Resident #17's psychiatric history and that she was not aware of any special monitoring that was in place for Resident #17. She said she had recently been off from work for the past few weeks and had not had any interaction with Resident #17; therefore she could not contribute any information regarding a change in her behavior. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. DON A said at the time of Resident #17's admission, she was not employed at the facility. The Administrator and DON A said that the clinical information that was normally reviewed for a potential admission was the history and physical, lab work, nurses notes, and PASSR information. The Administrator and DON A at this time said that they were not aware the Resident #17 had a previous psychiatric history with a recent stay in a local Psychiatric Hospital where she had [MEDICAL CONDITION]. The Administrator then interrupted the interview and said that she perhaps did recall Resident #17 being a local psychiatric hospital because she said I thought, well is she coming from (local nursing facility) or (local psychiatric hospital)? The Administrator then remembered the daughter of Resident #17 came to the facility for a tour. The Administrator said that she remembered the daughter talking about her mother being at Psychiatric Hospital A for [MEDICAL CONDITION]. DON A said that she was hired on 04/05/17 and was not aware of Resident #17's previous psychiatric issues. She said that interventions for increased monitoring should have been in place if she had a recent history of suicidal ideation and that there were not any implemented from her admission on 03/30/17 to 05/10/17, the day she was discharged to Psychiatric Hospital A. She said that residents with a known psychiatric history should be assessed individually and a plan devised to monitor. She said that if a resident had a known history of [MEDICAL CONDITION] that absolutely staff would be informed and educated with the resident's history and interventions that are implemented. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of April 2017, specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said she did not recall Resident #17's history of being at Psychiatric Hospital A in March prior to admission. She stated that she had written on the MDS Worksheet (that was a tool she used when she gathered information for an MDS assessment), about Resident #17's previous stay dates at (Psychiatric Hospital A), however she was not aware of the reason for her stay there and given that it exceeding her look back period she did not inquire about it. She said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for April 2017, that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON A. She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON A. DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. The Administrator and DON A both acknowledged that the facility had Resident #17's clinical records from the previous long term care facility she was at and the previous psychiatric hospital that clearly identified she was at risk for [MEDICAL CONDITION] prior to her admission and that her records had not been reviewed appropriately to implement the psychiatric services and monitoring Resident #17 should have received. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of March 2017. She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on May 2nd, 2017 and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA E said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA E did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for two (Resident #17 and Resident #2) of eighteen residents reviewed for neglect. A) The facility failed to establish and implement care that addressed Resident #17's psychological and psychiatric needs upon admission. Resident #17 was admitted to the facility on [DATE] with a recent discharge from a psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #17 did not receive her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. On 05/10/17 at 12:50 PM Resident #17 had a call light wrapped around her neck attempting to strangle herself. B) Resident #2 was admitted to the facility on [DATE] along with his wife who was receiving hospice care for end-[MEDICAL CONDITION]. On 04/24/17 Resident #2 requested he be prescribed an antianxiety medication, and then requested the medication almost daily due to reported feelings of anxiety. Resident #2 did not receive any other interventions to address his increased anxiety. On 05/20/17 Resident #2 requested from staff rat poison or a gun to kill himself. Resident #2 was then referred for psychological services. This failure resulted in an Immediate Jeopardy (IJ) identified on 05/15/17. While the IJ was lowered on 05/26/17, the facility remained out of compliance at Actual Harm at a pattern due to the facility's need to monitor their plan for effectiveness. This failure could have affected the facility's other 20 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section [NAME] did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA [NAME] stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital [NAME] Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review of both Resident # 17's electronic and paper clinical record on 05/11/17 at 3:45 PM revealed no documentation from LVN D regarding Resident #17's suicide attempt on 05/10/17. In an interview on 05/11/17 at 4:00 PM, LVN D said that she Forgot to document the incident with (Resident #17) on 05/10/17 when she was attempting to strangle herself with her call light. She said she should have documented the incident and filled out an incident and accident report and charted it in the progress notes. In an interview on 05/12/17 at 9:00 AM with the admissions coordinator from Psychiatric Hospital A, he said that Resident #17 was admitted to their facility on 05/10/17 at 5:28 PM with [MEDICAL CONDITION]. He said Resident #17 was familiar to him, he said that Resident #17 had had a prior admission on 03/19/17 for [MEDICAL CONDITION] and was discharged on [DATE] to a local nursing facility. In an interview on 05/12/17 at 9:26 AM with the social worker from the local nursing facility Resident #17 had been discharged to on 03/27/17 from Psychiatric Hospital A, she said that Resident #17 was readmitted to their facility on 03/27/17 after being discharged from Psychiatric Hospital A for having had [MEDICAL CONDITION]. She said that Resident #17's daughter had called and requested records be sent to a new facility that had just opened. In an interview on 05/12/17 at 12:30 PM with Resident #17's daughter, she said that the facility, specifically the Administrator was aware of her mother's previous psychiatric hospital stay in (MONTH) (YEAR) and that she informed the Administrator that Resident #17 had been suicidal and Tried to kill herself. Resident #17's daughter also stated that she had spoken with the Admissions Coordinator upon Resident #17's admission to the facility on [DATE] about her mother's previous suicide attempt. She said that her mother had recently shown an increase in sadness and would call her numerous times from the facility crying and asking her to come get her. She said that her mother had been upset due to the fact that she (the daughter) had taken her cell phone from her due to previous calls made to 911 when she was at another long term care facility. She said that she visited her mother often, usually during the evening hours and her mother had been very sad and cried all the time. She said that her mother used the facility phone and that the nurses would have had to have known her mother had shown increased sadness and crying episodes because they were the ones that assisted her in dialing the phone number to call her. She said that she had not received any phone calls in regards to her mother's change in condition other than on 05/10/17 when the Social Worker contacted her about the incident on 05/10/17. In an interview on 05/12/17 at 12:40 PM the Medical Records Clerk was asked for all records that pertained to Resident #17. The Medical Records Clerk at that time pulled from a filing cabinet Resident #17's Admission Paperwork, which encompassed an Admit Approval letter, MDS Worksheet, Documentation from the local long term care facility that Resident #17 had transferred from, along with medical records regarding her previous admission to Psychiatric Hospital A on 03/19/17 thru 03/27/17. Record review of Resident #17's paper admission records on 05/12/17 at 12:15 PM, obtained by the Medical Records Clerk, revealed faxed copies sent from Resident #17's previous nursing home on 03/30/17 that indicated Resident #17 had a known recent history of suicidal ideation. Review of Resident #17's medical records from Psychiatric Hospital A from 03/19/17-03/27/17 revealed the following: admitting [DIAGNOSES REDACTED]. Resident #17's Psychiatric Evaluation revealed that according to the Care Attendant from the local nursing facility, (Resident #17) had a specific plan to cut her wrists. Further review of Resident #17's faxed admission records from the previous long term care facility Resident #17 was transferred from revealed a care plan that revealed Resident #17 had a problem identified on 09/6/16 as being at risk for alteration in mood/behaviors related to history of anxiety. The care plan identified within this problem that Resident #17 told a nurse that she felt like killing herself, had a plan and that a referral was made to Psychiatric Hospital A on 03/19/17. There were several approaches identified within this problem that revealed Resident #17 had previous psychiatric issues which included Resident #17 was monitored for signs and symptoms of anxiety that included: expressing worry, fidgety, difficulty sleeping, not eating well. She had also been referred to psych services on 02/02/17 and that resident #17 was placed on 1:1 supervision until sent to Psychiatric Hospital A on 03/19/17 for [MEDICAL CONDITION]. Attached to this information with a paperclip was the Pending Admission Sheet dated 3/29/17, signed by the Admissions Coordinator. There was a circle around the work Approval, an X under the Clinical Approval box with the Administrator's name next to the DON's Signature line and an X that indicated her financial approval, which was signed by the Business Office Manager. The Administrator/CEO Approval box was blank. In addition, there was another sheet within this stack of clinical records for Resident #17 entitled MDS Worksheet that was used to collect information for Resident #17's initial MDS at the facility. It referenced Resident #17's recent stay at the Psychiatric Hospital A with dated marked 03/19/17-03/27/17. In an interview on 05/12/17 at 2:27 PM the Admissions Coordinator said that she had been contacted by Resident #17's daughter to admit Resident #17 to the facility. She said that she knew Resident #17 from a previous facility she worked at and did not recall any reason to not admit her. She said that the admissions process requires three green lights and that involves a clinical approval, financial approval and Administrator/CEO Approval. She said that once she has three green lights she can admit that resident. When asked if she was aware of Resident #17's recent stay at a local Psychiatric Hospital, the Admissions Coordinator said I think so; I think I remember seeing something about it. She said that any clinical information was given to the DON and that she was not responsible for approving residents from a clinical standpoint. She said that at the time of the admission, she thought she had spoken to DON A regarding the clinical records; however she did not recall if DON A was employed at the facility yet, but remembered she did call the Administrator on the telephone and gained approval from her that way. She could not recall if she had disclosed at the time she gained approval if she conveyed to the Administrator about her recent suicidal ideation. She said that the Administrator did not sign the Approval sheet, that she had written the Administrator's name and marked the approval box. There was not a signature by the DON on the form. She said that all of the admission paperwork with Resident #17's previous clinical records would have been given to the nurse at the time of the admission and should have been placed in her chart. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the (MONTH) 30, (YEAR)-April 2nd, (YEAR) MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for (MONTH) (YEAR) revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 1:55 PM LVN G said that she worked at the facility as needed (PRN) and that she had cared for Resident #17. She said that she would often come out for meals and would demand to call her daughter. She said that she was never told anything about increased monitoring for Resident #17 or that she had any type of previous psychosocial history. In an interview on 05/12/17 at 2:01 PM LVN C said that she had worked at the facility since (MONTH) (YEAR). She said that she was familiar with Resident #17. She said that she had not been told anything regarding Resident #17's psychiatric history and that she was not aware of any special monitoring that was in place for Resident #17. She said she had recently been off from work for the past few weeks and had not had any interaction with Resident #17; therefore she could not contribute any information regarding a change in her behavior. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. DON A said at the time of Resident #17's admission, she was not employed at the facility. The Administrator and DON A said that the clinical information that was normally reviewed for a potential admission was the history and physical, lab work, nurses notes, and PASSR information. The Administrator and DON A at this time said that they were not aware the Resident #17 had a previous psychiatric history with a recent stay in a local Psychiatric Hospital where she had [MEDICAL CONDITION]. The Administrator then interrupted the interview and said that she perhaps did recall Resident #17 being a local psychiatric hospital because she said I thought, well is she coming from (local nursing facility) or (local psychiatric hospital)? The Administrator then remembered the daughter of Resident #17 came to the facility for a tour. The Administrator said that she remembered the daughter talking about her mother being at Psychiatric Hospital A for [MEDICAL CONDITION]. DON A said that she was hired on 04/05/17 and was not aware of Resident #17's previous psychiatric issues. She said that interventions for increased monitoring should have been in place if she had a recent history of suicidal ideation and that there were not any implemented from her admission on 03/30/17 to 05/10/17, the day she was discharged to Psychiatric Hospital [NAME] She said that residents with a known psychiatric history should be assessed individually and a plan devised to monitor. She said that if a resident had a known history of [MEDICAL CONDITION] that absolutely staff would be informed and educated with the resident's history and interventions that are implemented. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of (MONTH) (YEAR), specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said she did not recall Resident #17's history of being at Psychiatric Hospital A in (MONTH) prior to admission. She stated that she had written on the MDS Worksheet (that was a tool she used when she gathered information for an MDS assessment), about Resident #17's previous stay dates at (Psychiatric Hospital A), however she was not aware of the reason for her stay there and given that it exceeded her look back period she did not inquire about it. She said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for (MONTH) (YEAR), that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON [NAME] She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON [NAME] DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. The Administrator and DON A both acknowledged that the facility had Resident #17's clinical records from the previous long term care facility she was at and the previous psychiatric hospital that clearly identified she was at risk for [MEDICAL CONDITION] prior to her admission and that her records had not been reviewed appropriately to implement the psychiatric services and monitoring Resident #17 should have received. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of (MONTH) (YEAR). She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on (MONTH) 2nd, (YEAR) and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA [NAME] said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA [NAME] did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. In an interview on 05/24/17 at 1:58 PM, DON B said that the Administrator had not kept a log of facility investigations and to his knowledge there were only two facility investigations that had been self reported to the state office. Record review of the past 30 days of the facility's incident/accident logs and self-report investigations did not reveal that Resident #17's incident on 05/10/17 had been investigated or reported by the Administrator or DON [NAME] In an interview on 05/25/17 at 3:05 PM with the Vice President of Operations, he said that the Administrator had not mentioned to him about any ongoing investigations that the facility had. He said that the incident regarding Resident #17 having the call light wrapped around her neck and having [MEDICAL CONDITION] should have been investigated and called in by the facility. Resident # 2 Record review of Resident #2's paper Admission Record, dated 05/15/17, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Admission Record also revealed Resident #2's Primary Physician was Physician [NAME] Record review of Resident #2's Comprehensive Minimum Data Set (MDS), both paper and electronic versions, dated 03/22/17, revealed he had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated Resident #2 was able to perform most of his Activities of Daily Limited independently or with limited supervision. The MDS also indicated Resident #2 received an antidepressant on all 7 days prior to the date of the MDS. Record review of Resident #2's current Care Plan (recreated when the facility changed to a new electronic medical records system), undated, both paper and electronic versions, revealed the following focus areas, goals to address the identified focus area, and the interventions required to achieve the identified goal: Focus: (Resident #2) receives [MEDICAL CONDITION] medication to manage target behaviors. Date Initiated: 03/15/2017 Goal: (Resident #2) will receive maximum results with minimal side effects through next review. Date Initiated: 03/15/2017 Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Date Initiated: 03/15/2017 Refer to Social Services or consultant psychiatric provider as needed. Date Initiated: 03/15/2017 Focus: (Resident #2) is a risk for depression r/t (related to) dx (diagnosis) Date Initiated: 03/15/2017 Goal: (Resident #2) will not have increased s/s (signs/symptoms) of depression through next review. Date Initiat (TRUNCATED)

Based on record review and interviews the facility failed to ensure two ( (Resident's #17 and #12) out of 18 residentswho's medications regiments were reviewed was free of significant medication errors. A) The facility failed to ensure Resident #17received her prescribed antipsychotic medication [MEDICATION NAME] for fifteen days after LVN D discontinued the order by mistake. B) The facility failed to administer the dose of [MEDICATION NAME] (blood thinning agent administered to prevent blood clots) to Resident #12 for four consecutive days (05/18/17, 05/19/17, 05/20/17 and 05/21/17). On 5/17/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 5/26/17, the facility remained out of compliance at a severity level of Actual Harm that is not Immediate Jeopardy and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This deficient practice could place one resident (Resident #17) that received the medication Quetiapine [MEDICATION NAME] and 1 resident (Resident #12) who received [MEDICATION NAME] at risk of not receiving the therapeutic benefits from the medications placing them at risk for hospitalization , harm or even death. Findings Include: A. Resident #17 Record review of Resident #17's paper Admission Record Sheet, dated 05/15/17, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #17's primary care physician was Physician O. Record review of Resident #17's both electronic and paper, initial minimum data set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Section D revealed a mood interview was conducted and Resident #17 scored a 00, which indicated Resident #17 had not had any depressive symptoms during a 14 day look back. Section E did not identify any behaviors or rejection of care. Section G revealed Resident #17 required limited assistance by one staff member for all of her activities of daily living. Section I identified that she had a [DIAGNOSES REDACTED]. Section N revealed that she had received an antipsychotic, antidepressant and antianxiety medication for the seven day look back period. Record review of Resident #17's, both electronic and paper, care plan, dated 03/30/17 revealed Focus: (Resident #17) receives [MEDICAL CONDITION] medication to manage target behaviors: Depression and Anxiety. Goal: (Resident #17) will receive maximum results with minimal side effects through next review. (07/17/17). Interventions: Obtain consent and administer medication as ordered. Monitor for adverse side effects. Refer to Social Services or consultant psychiatric provider as needed. Record review of Resident #17's unsigned, paper, Physician order [REDACTED].#17 to have an order for [REDACTED]. A [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine [MEDICATION NAME] (Generic Name: Quetiapine) is a medication used to treat the symptoms of [MEDICAL CONDITION] . episodes [MEDICAL CONDITION]. or depression in patients with [MEDICAL CONDITION] disorder . Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. [MEDICATION NAME] is used to treat depression. [MEDICATION NAME] is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is thought to work by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. (https://medlineplus.gov/druginfo/meds/a 9.html) (https://medlineplus.gov/druginfo/meds/a 1.html#why) (Accessed on 05/30/17) Observation on 05/10/17 at 12:50 PM revealed CNA E stepped out into the hallway on Hall 3 and yelled for LVN D to come to Resident #17's room. At this time, the surveyor entered the room and observed Resident #17 sitting in her recliner next to her bed and she had a call light wrapped around her neck three times verbalizing I am trying to do what I have wanted to do for a long time. LVN D immediately entered the room and assessed Resident #17. The call light was removed by LVN D and Resident #17 was crying and expressing that she wanted to end her life because she felt that she was in prison at the facility, she wanted to go home and felt that her children did not visit often enough. At approximately 12:53 PM, DON A entered the room, along with the Social Worker and DON B and asked Resident #17 why she wanted to hurt herself. Resident #17 said No one wants to see me anymore. DON A then asked Resident #17 if anything else was bothering her and Resident #17 replied Everything. At this time, CNA CC was placed with Resident #17 to provide one on one supervision and the social worker began interviewing Resident #17 and initiated paperwork to refer to a psychiatric hospital. In an interview on 05/10/17 at 1:10 PM with DON A, she said that Resident #17 did not have any history of being suicidal and that she had not exhibited any behaviors or symptoms of depression. She said that on occasion she would be whiney at times when she had not seen her daughter. In an interview with DON A on 05/10/17 at 2:30 PM she said that Resident #17 was being discharged to Psychiatric Hospital A. Observation on 05/10/17 at approximately 3:00 PM revealed Resident #17 to not be in the facility. Record review on 05/12/17 at 2:00PM of both Resident #17's electronic and paper Medication Administration Record for April 2017 and May 2017 revealed a start date of 04/03/2017, (which is the date that the facility started using PointClickCare for their electronic Medication Administration Record and a copy of the March 30, 2017-April 2nd, 2017 MAR from their previous electronic system was requested but was not provided) for Quetiapine [MEDICATION NAME] Tablet 25mg, Give one tablet by mouth at bedtime related to Major [MEDICAL CONDITION], Recurrent, In Remission. The Medication Administration Record revealed that Resident #17 had received this medication 4/4/17 through 04/09/17. On 04/10/17, the Medication Administration Record for April 2017 revealed that the order had changed from administering the medication at 2000(8:00PM) to administering it in the evening. Resident #17 continued to receive Quetiapine [MEDICATION NAME] Tablet 25mg from 04/10/17-04/16/17. From 04/17/17 through 05/02/17, the Medication Administration Record for April 2017 and May 2017 revealed a X in the boxes for the dates 04/17/17 thru 05/02/17 for Resident #17's Quetiapine [MEDICATION NAME] Tablet 25mg. (The X indicated this was not an active order) Record review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 04/17/17 taken by LVN D revealed the Quetiapine [MEDICATION NAME] was discontinued with an explanation of order reentered correctly. Record Review of Resident #17's electronic and paper verbal orders, unsigned by Physician O, dated 05/02/2017 revealed that Resident #17's order for Quetiapine [MEDICATION NAME] 25mg was reinstated with an explanation of order corrected due to PointClickCare (PCC) error' taken by DON B. Record review of both Resident #17's electronic and paper Clinical Record between the dates of 03/30/2017 thru 05/10/2017, specifically the Progress Notes, did not reveal any documentation to explain Resident #17's Quetiapine [MEDICATION NAME] being discontinued on 04/17/17 or reinstated on 05/03/17. Nor did any clinical records both electronically or paper reveal any monitoring was in place for Resident #17's known history of [MEDICAL CONDITION], antipsychotic medication side effect monitoring or behavior monitoring. In an interview on 05/12/17 at 2:21 PM CNA N said that she had worked at the facility for approximately two weeks. She said that Resident #17 cried a lot and when asked what was wrong she would tell her she wanted to call her daughter. She said that while on the phone with her daughter, Resident #17 would beg her to come up to the facility. She said that when she was told about the incident on 05/10/17 with Resident #17 she was surprised. She said that Resident #17 had cried every day usually right before and after lunch. She said that Resident #17 was not on any special monitoring other than every two hours or as needed. She said that she had not told anyone about her crying because when she came to work other staff (could not recall the names) had told her she gets upset and wants to call her daughter every day. There was not any documentation by facility staff that Resident #17 had experienced increased episodes of sadness or crying except for one entry made by the Social Worker on 04/27/17 at 14:08 (2:08 PM), which stated visited with (resident #17). She presented as tearful and said that she is not able to have a cell phone anymore because she was calling 911. She then said that she just wants a phone to be able to speak to her daughter in Houston. Social worker called resident's daughter who stated it was okay for her mother to call her any day after 3:30 PM as she is a schoolteacher and is at work until then. Social worker went back and spoke to (resident #17). Showed her where the residents phone is captain advised her that she could call her daughter anytime after 3:30 PM and she would be out of work. (Resident #17) smiled and thanked worker. Social worker encouraged her to request this worker or other staff help her as needed to dial the phone. She stated that she would. Further review of Resident #17's electronic and clinical record did not reveal that there was a social history assessment done on Resident #17 between 03/30/17 through 05/10/17. In an interview on 05/12/17 at 2:18 PM with both the Administrator and DON A, DON A said that a resident that has an antipsychotic medication abruptly stopped without an order to discontinue would be considered a medication error. The Administrator said that she was not a nurse but she would think that that would be considered a medication error. She said that Resident #17 had recently started crying a few weeks back but knew she had had her cell phone taken away from her and that she thought she was just upset about not having it. The Administrator said that she felt sure that the social worker had done a referral for psychiatric services recently when she was noted to have increased crying episodes. DON A said at this time, she was unaware of the almost two week gap that Resident #17 did not receive her antipsychotic Quetiapine [MEDICATION NAME]. In an interview on 05/12/17 at 2:57 PM with DON B, he said that he had worked at the facility since 04/14/17 and had not been made aware of any of Resident #17's previous psychiatric history. He could not recall seeing anything specific in her electronic or paper chart regarding her psychiatric history. He said that on 05/02/17 he was approached by LVN D and that LVN D told him that the medication aide (unsure of name) had brought it to her (LVN D's) attention that Resident #17's Quetiapine [MEDICATION NAME] was not on the MAR. DON B said that LVN D explained that she had changed the administration times back in April. DON B said that he believed that the new order just did not generate in Point Click Care (electronic medical record software) and so he had called Physician O to get an order to restart it. He said that there was not a medication error report done and said that there was not a progress note in either electronic or paper clinical record that explained the error. In addition, he said that Resident #17 often asked for her daughter and that the facility often redirected her; however she had been crying a lot and expressed the desire to go home. He said that Resident #17 had gone around the facility having asked staff and other residents to call her daughter for her and DON B said that some residents seemed uncomfortable and it had been reported to him that she had yelled out for her daughter and had outbursts of crying and being upset due to being in a nursing facility over the past several weeks. He said that after she started back on the Quetiapine she seemed to get a lot better and felt that with her being placed back on the Quetiapine [MEDICATION NAME] would help her, therefore he did not look into any further assessments for her. In an interview on 05/12/17 at 3:00 PM with the Administrator and the Social Worker, the Social Worker said that several staff members had approached him towards the end of April 2017, specific names, he could not identify. He said that staff had expressed concerns to him regarding Resident #17 having increased sadness and crying episodes. He said that he discussed the issue with the MDS Coordinator about a week or two ago, he could not recall the exact date about antidepressant medications that Resident #17 was currently taking or possibly the need for a psychiatric referral. He said at that time the MDS Coordinator said that Resident #17 was on an antidepressant so the Social Worker thought the bases were covered. During the interview, the social worker did not provide any information or tell the surveyor that he had spoken to Resident #17 or performed any assessments on Resident #17 when he was approached by staff regarding her increased sadness and crying episodes. In an interview on 05/12/17 at 3:06 PM with the Administrator and the MDS Coordinator, the MDS Coordinator said that she was approached by the social worker on 05/01/17 regarding Resident #17 having increased crying episodes and feeling depressed. She said that he asked her if Resident #17 was on an anti-depressant and she told the social worker that she was. She said at that time it was discovered by looking at her MAR for April 2017, that her Quetiapine [MEDICATION NAME] was not being administered and she said that she saw where LVN D had discontinued the medication, however did not see any progress notes as to why. She said that she took the chart and discussed the medication with DON A. She said that DON A took the chart from her and told her she would look into it. In an interview on 05/12/17 at 3:26 PM with the Administrator and DON A. DON A said that I do not remember talking with (MDS Coordinator) on 05/01/17 regarding her Quetiapine. DON A said I have no idea why (MDS Coordinator) would make that comment. Record review on 05/12/17 at 5:45 PM of a piece of paper entitled Concern Form that was given to the surveyor by DON A revealed the following Resident Name: (Resident #17) A: Concern from Staff: (DON B) dated , 05/02/17, B: Relates to: Nursing Meds, C: Description: PCC order changed on 04/17/17, upon assessment it was noted that the order did not refresh after being changed. D. Investigation Persons/Departments Contacted: 1. (DON B) 05/02/17 2. (DON A) date 05/02/17. E. Summary of Findings: (DON B) spoke with technical support and it appears the order did not re-populate after changes to schedule. (LVN D) states it was changed to meet facility time codes. Tech support stated we could have had it drop out. (Physician O) notified and new order received. F. Recommendations/Actions Taken: Check orders and ensure they are re-entered. Continue PCC education. In an interview on 05/12/17 at 5:47 PM, DON A said that she had forgotten she had this (referring to Concern Form) and that she would be taking it to their next Quality Assurance meeting to address the concern. She said that she did not remember until DON B reminded her that it had been filled out until after the interview with the surveyor earlier that afternoon (05/12/17 at 3:26 PM). In an interview on 05/15/17 at 1:53 PM, LVN D said that she had worked at the facility since the middle of March 2017. She said that she recalled changing Resident #17's Quetiapine [MEDICATION NAME] on 04/17/17. She said that she had needed to change the order due to the time that it was administered. She said that she thought she had entered the new order but had recently been told that there was a problem with Resident #17's Quetiapine [MEDICATION NAME] and that she had not received it for almost two weeks after she had changed the order. She was not sure what happened or why the new order did not generate. She said that she did not recall who told her to change the order. She said that she had not had any training with PCC; however she had worked with the computer program at a different facility and was familiar with the program. She said in May, she noticed it was not on the MAR. She said that Resident #17 had not had any big changes in her behavior other than wanting to call her daughter all the time. She said Resident #17 always had appeared sad since being admitted and felt that her daughter had dropped her off to die. She said that she had alerted both DON A and DON B about the error on May 2nd, 2017 and that to her knowledge the medication was just put back on the MAR and Resident #17 received it from 05/03/17 forward. She said that she did not fill out an incident report and was asked to fill out any medication error report. On 05/16/17 at 12:08 PM an attempted phone interview with Physician O was made. In an interview on 05/16/17 at 2:04 PM, CNA E said that she had noticed a couple of weeks ago Resident #17 expressed a lot of interest about going home. She said that Resident #17 always cried a lot. She was unaware that Resident #17 had any psychiatric history. CNA E did not identify a specific nurse that she had informed about the crying episodes, but felt that all of the staff in the facility were aware of her crying episodes because Resident #17 usually displayed an episode every day around the nurse's station and it would be hard for the staff to not notice it. In an interview on 05/16/17 at 3:27 PM, DON A said that a medication error report (a report completed by the facility when a mistake with medication is made) would only be necessary depending on the circumstances. She said at this time she did not have any medication error reports or incident reports regarding Resident #17 or on anyone for that matter. Resident #12 Record review of Resident #12's Admission Record, dated 05/22/17, revealed he was a [AGE] year old male admitted to the facility on [DATE] under the care of his attending physician, Physician Y. His [DIAGNOSES REDACTED]. Record review of Resident #12's clinical records both paper and electronic revealed a Medical Data Set (MDS) had not been initiated due to his recent admission. Record review of Resident #12's electronic Admission Care Plan, dated 05/18/17 and signed by the MDS Coordinator, revealed Anticoagulant use was identified as an area of concerns with the goal of no complications. The interventions identified to address this concerns included: Monitor labs as ordered, monitor signs/symptoms of bleeding, protect for injury, and PT/INR as ordered. Record review of Resident #12's Order Summary Report, dated 05/19/17 and unsigned, for the period of 05/18/17-05/31/17 revealed the following orders: [MEDICATION NAME] Solution 100mg/ml (milligram/milliliters) ([MEDICATION NAME] Sodium). Inject 100 mg subcutaneously at bedtime for prevention Inject abdominal Sub-q every day at bedtime Order Date: 05/18/17. According to the U.S. National Library of Medicine [MEDICATION NAME] ([MEDICATION NAME]) is a medication used to prevent blood clots in the leg in patients who are on bedrest . It is also used in combination with [MEDICATION NAME] to treat blood clots in the leg. [MEDICATION NAME] is in a class of medications called low molecular weight [MEDICATION NAME]. It works by stopping the formation of substances that cause clots. https://medlineplus.gov/druginfo/meds/a 0.html Record review of Resident #12's electronic Medication Administration Record (MAR) for May 2017 revealed Resident #12 did not receive his [MEDICATION NAME] ([MEDICATION NAME] Solution 100mg/ml Inject 100 mg subcutaneously at bedtime), start date 05/18/17, on the following dates: 05/18/17, 05/19/17, 05/20/17, 05/21/17. The boxes on the MAR where the nurse would sign to specify the [MEDICATION NAME] had been administered were blank on the identified dates, indicating the medication had not been administered. Record review of Resident #12's electronic clinical records of Progress Notes printed 05/24/2017 from 05/18/2017 thru 05/24/2017 did not reveal any documentation of [MEDICATION NAME] being administered or held. In an interview on 05/24/2017 at 11:15 AM LVN D stated Resident 12's medications came with him when he was admitted on the 05/18/17. LVN D indicated Resident #12's [MEDICATION NAME] was available for administration on 05/18/17. Observation on 05/24/2017 at 11:15 AM revealed Resident 12's [MEDICATION NAME] was available on the medication cart, and was dated 05/15/17. In an interview on 05/25/2017 at 2:44 PM Physician Y stated he was aware Resident 12 did not receive his [MEDICATION NAME] as ordered. Physician Y stated he can be contacted five days a week, including via fax. Physician Y indicated he would be satisfied with Resident #12's INR being no lower than 1.8. Record review of the facility's policy entitled Medication Errors and Drug Reactions undated revealed .The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. 1. All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician, and the pharmacist. 2. A detailed account of the incident must be recorded in the resident's medical record. Such documentation must include, but is not limited to: a. The time and date of the incident; b. The name, strength, and dosage of medication administered; c. The resident's reaction to the medication; d. The condition of the resident; e. Any treatment administered; and f. The date and time the physician was notified and his/her instructions.4. The staff/charge nurse will be responsible for completing an incident report and submitting a copy to the Director of Nursing Services and a copy to the Administrator. 5. All incident reports relating to medication errors and drug reactions will be reviewed by the Pharmaceutical Services Committee at their next regularly scheduled meeting. The Administrator and Regional Director of Operations were notified of the Immediate Jeopardy on 5/17/17 at 11:25 AM The Facility's 11th Plan of Removal for Immediate Jeopardy was accepted on 5/26/17 and reflected the following: Plan of action to remove immediate Jeopardy May 15, 2017 (facility) . Alleged deficiency -IJ Failure to ensure medications are transcribed appropriately and available for administering to residents. Failure to ensure systems for pharmacy services are in place to include processes that ensure accurate acquisition, recording, dispensing and administration of all drugs to meet the needs of each resident. Facility immediate plan of removal: 1. All medication carts were audited by DON, ADON, and MDS Coordinators (all RNs), to ensure orders are transcribed correctly and medications are available and ready for dispensing. Any issues were addressed and corrected immediately. Responsible discipline: DON/designee, ADON, Administrator/designee, pharmacist consultant . Date of completion: May 15, 2017 and ongoing 2. Nursing staff in-serviced and retrained regarding the need to notify the Primary Care Physician, DON, ADON and administrator if a resident has been without medications or medications not administered per attending physicians' orders, and to follow-through with Medication Error policy and procedure to include notifications to physician and family. Responsible discipline: DON/designee, ADON, Administrator/designee, Weekend RN supervisor, Licensed Nurses . Date of completion: May 15, 2017 and ongoing 3. ( Pharmacist consultant), came to facility on Monday, May 22, 2017- to conduct med-pass audit, medications and medication cart review, re-training and re-education of nursing staff regarding policy and procedure on medication administration, Quality Assurance review, and other interventions as required. Responsible discipline: Pharmacist consultant, ADON, RN, DON/designee, Administrator/designee . Date of completion: May 22, 2017 and ongoing 4. Medication Administration Audit form in PointClickCare software (see attached blank audit) will be conducted every morning by DON and/or ADON and Weekend RN to ensure medications have been administered per orders - to monitor for late administration. If late medication administration is evident, Medication Error form (See Attached) following Policy and Procedure will be completed and notifications made to family and attending physician. Administrator must be notified. Medication Administration Audit will be reviewed in Clinical Stand-up and verified on Stand-Up form. Responsible discipline: director of nursing/designee, assistant director of nursing, administrator/designee, weekend RN supervisor . Date of completion: May 17, 2017 and ongoing 5. At any time that nurses feel they will be out of compliance with medication administration parameters, they will notify the ADON and DON immediately so that assistance will be provided, to maintain compliance. Nurses have been in-serviced regarding the above and this is verified with return demonstration of understanding. Responsible discipline: director of nursing/designee, assistant director of nursing, administrator/designee, weekend RN supervisor . Date of completion: May 17, 2017 and ongoing 6. Physician telephone orders (hard copy) and those entered into PointClickCare will be reviewed and verified daily in Stand-up Meeting and on weekends by Weekend RN to ensure medications are transcribed correctly, medications have been ordered and available for administration. All new orders and medication changes will be documented in the Nurses Notes in PCC on the date and shift the orders were received, Nurses in-serviced and training verified with return demonstration of understanding. Responsible discipline: director of nursing/designee, ADON, administrator/designee, weekend RN . Date of completion May 18, 2017 and ongoing 7. Admission and readmission checklist will be utilized for residents to ensure orders are complete and valid. Any orders needing clarification (dosage, time, discontinuation, etc.) will be included on the checklist form. See attached. Attending physician will be notified of the need for clarification by the DON/RN, and his/her recommendations will be implemented. The notification to the attending physician and clarification orders will be documented in the nurses' notes. Notation will be included on the 24-Hour Report for follow-up and completion. 24-Hour Report will be reviewed in daily Clinical Stand-up and verified on the Stand-Up form. Utilization of forms reviewed again on 5/24/17. Responsible discipline: Administrator/designee, DON/designee/ADON, medical records tech . Date of completion May 18, 2017, May 24, 2017 and ongoing . 9. Medication administration times have been changed throughout facility to ensure medications are administered timely. Medication Orders will be received and recorded per facility Medication Orders Policy and Procedure. See attached. Nurses have been in-serviced regarding the change in medication administration times and Policy and Procedure and verified with return demonstration of understanding. Computerized MAR is automatically updated when medication administration times change. When printed, the monthly Physician Consolidated Orders will reflect the medication administration time changes. The medication administration pack that is delivered by the pharmacy will be updated with a change of direction label to reflect the change. As MARs are updated and medications are refilled, the medication administration pack will reflect the new changes. The medication administration times were changed in PCC and medication packets re-labeled with change of direction labels by the ADON and MDS RN. Responsible disciplines: DON/designee, RN . Date of completion: May 17, 2017, May 18, 2017, May 19, 2017, and ongoing 10. The 24-hour report will be utilized as a communication tool to ensure medication problems with acquisition, recording, dispensing and/or administration can be followed up timely - to ensure continuity of care. Licensed nurses have been in-serviced by ADON regarding the 24-hour report utilization. This is verified with return demonstration of understanding. Responsible discipline: DON/designee, Administrator/designee, ADON, RN . Date of completion: May 17, 2017 and ongoing 11. Telephone orders (hard copy or printed from PointClickCare (PCC) software will be reviewed daily by DON, ADON and/or weekend RN, and then will be given to Medical Records Technician. She will organize the orders by physician, placed in manila envelopes and they will be delivered to physicians weekly by van driver, Medical Records Tech, and/or Marketing Director for signatures. Weekly new orders will be delivered and the physician-signed orders from previous week will be picked up. Prior to delivery to the physicians, the telephone orders will be copied and copies placed in the resident clinical record (hard copy) - as a tickler system to ensure orders are returned in a timely manner. Once signed orders are returned, the Medical Records Technician and/or designee will place the orders in the resident clinical record (hard chart) and remove the copies. Medical Records Tech has been in-serviced and retrained regarding the above and this is verified with return demonstration of understanding. Staff in serviced again regarding system for ensuring physician signature and clarification. Responsible discipline: DON/designee, ADON, RN, medical records Tech . Date of completion: May 17, 2017, May 24, 2017 and ongoing 12. Weekly, the Medical Records Tech and/or DON/ADON will print all orders for the prior week (Tuesday through Monday) for all residents, to ensure no orders from the PCC system have been missed/omitted. They will then be processed and sent to physicians via steps outlined above. Responsible discipline: medical records Tech, DOM/designee, ADON . Date of completion: May 17, 2017 and ongoing 13. Physician Consolidated Orders will be printed on or around the 25th of every month by the Medical Records Tech and/or designee, and given to the DON, ADON and/or RN for review and signatures - to ensure accuracy and completeness, The Physician Consolidated Orders will then be copied on colored paper and dated as to when they were delivered, and colored copies placed in residents' clinical record (hard chart). The original Physician Consolidated Orders will be separated by physician, placed in manila envelopes, and delivered to physicians for timely signatures - by the facility van driver, Medical Records Tech, and/or Marketing Director. They will be delivered on or before the first of the month. The orders will be picked up the following week and signed originals placed in the clinical record (hard chart), and copies removed. Responsible disciplines: medical records Tech, DON/designee, ADON, administrator/designee . Date of completion: May 17, 2017 and ongoing 14. Hard copy chart audit will be done by Medical Records Tech and/or designee weekly to determine if all orders have been returned. If orders have not returned, another copy will be sent to physician utilizing process described above. If the orders continue to not be signed and are later than 2 weeks, the Medical Director will be asked to intervene and help get orders signed. M(TRUNCATED)