Every finding on record at Avir at Irving

Based on observations, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure the stand-by freezer food items were sealed and labeled. 2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and sealed.3. The facility failed to ensure the dry storage food items were sealed.4. The facility failed to ensure that canned good food items were free of dents.5. The facility failed to ensure that serving utensils were used when handling food items.6. The facility failed to ensure staff personal items were not in the food preparation area.These failures could place residents at risk for foodborne illness and foodborne intoxication. Findings included:Observation on 02/24/2026 at 8:40 A.M. of the facility's only kitchen revealed:In the stand-by freezer:large tub of ice cream with the lid not sealed on the containeran unlabeled frozen dinner boxIn the stand-by refrigerator:an unsealed bag of sliced cheese, with no label or datean unsealed bag of deli meata used bag of shredded cheese, with no label or dateIn the dry storage closet:a dented can of chopped tomatoesa dented can of banana puddingan unsealed bag of cerealA backpack under the food preparation table. During an interview on 02/24/2026 at 8:40 A.M. with [NAME] E revealed the backpack was a personal item, and she removed it from under the food preparation counter. She indicated space for staff items was limited but was able to store it outside of food preparation area where staff personal items were kept. [NAME] E said the risk of a dented can was air can get into it and can become contaminated. She said it was important to ensure food was sealed so nothing can get into the food item and to stay fresh. She indicated contamination was a risk to residents because it can cause a foodborne illness. Observation on 02/25/2026 at 11:20 A.M. of the steam tray line revealed [NAME] E used her gloved hands to handle the bread rolls. Interview on 02/25/2026 at 11:30 A.M with the DM revealed [NAME] E should have used tongs to handle the bread rolls because of the risk of cross contamination. The DM said she had seen the frozen dinner in the freezer and threw it away. The DM indicated dented cans and unsealed food items were a risk because of contamination of food items and it was important to keep residents safe. Record review of the facility's Food Storage policy, dated 2023, reflected: Policy:Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Purpose.7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods.b. Food should be dated as it is placed on the shelves if required by state regulation.c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded.d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging. 13. Refrigerated and storage:.f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. 14. Frozen Foods:.c. All foods should be covered, labeled and dated. All foods will be checked to assure thatfoods will be consumed by their use by dates or discarded. Record review of the facility's General Food Preparation and Handling policy, dated 2023, reflected: Policy:Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. Procedure:.h. Bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash their hands prior to putting gloves on and after removing gloves.i. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared foods. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use.

Based on interviews 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 in 1 of 1 facility reviewed for water management. The facility failed to implement a water management program including: 1.) An assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; and2.) to implement measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. This failure could place residents at risk of waterborne illness. Findings included: In an interview on 2/25/2026 at 11:53 a.m., the Maintenance Director stated that the document titled, Water Management Program was the water management plan. The Maintenance Director was not aware of any type of water management binder and could not state any interventions which were currently being utilized in a water management plan. He could not provide any facility risk assessment related to the water management plan. In an interview on 2/25/26 at 11:55 a.m., The DON stated she was the Infection Control Nurse for the facility, and she had no information or involvement in any facility water plan. She stated that she could not provide any information about the facility's water management plan that it is handled by the ADM. In an interview and record review on 2/25/2026 at 4:39 p.m., the ADM provided a binder as evidence of a water management program which included a policy titled, Water Management Program with date implemented written in as 2/25/26. The binder also contained a document titled, Developing a Water management Program to Reduce Legionella Growth and Spread in Buildings dated 6/4/2021 by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention. The binder included a facility water flow diagram. There was no diagram or other indication that the facility had completed a facility risk assessment of where Legionella and other water-pathogens grow and spread. The binder did not include measures to be implemented as part of the water management program. The ADM was unable to provide this assessment, identified measures, or any documentation of activities related to a water management program. The ADM stated that, We don't need a plan. We don't have Legionella. The ADM stated there were no rooms closed or unused at the facility, and no residents had experienced Legionella infection this past year.Record review of a Policy titled, Water Management Program (undated) stated that, A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. The policy stated, A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic water pathogens could grow and spread in the facility's water system and Control measures will be applied to address potential hazards at each control point. The policy stated, Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years.

Based on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for (1 (Wheelchair #1) of 5 wheelchairs observed for safe operating condition.The facility failed to maintain a working brake on the left wheel of Resident #1's wheelchair.This failure could place residents using wheelchairs at risk of falls and injuries.The findings were: Review of Resident #1's Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses in part including cerebral infarction (stroke), difficulty in walking, unsteadiness on feet, other lack of coordination, and cognitive communication deficit (impairment in communication).Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 had functional limitations in range of motion of his lower extremities and normally used a wheelchair. His BIMS was not assessed because he was never/rarely understood. In an interview and observation on 2/24/2026 at 12:00 p.m., Resident #1 used gestures to indicate that the left wheelchair brake of the wheelchair he was sitting in was broken. The right brake was observed working, but the left brake did not stop the movement of the tire. He indicated that he had told staff (unknown name) in the nursing department but that he had not told the therapy department. He indicated the brake had been broken for about one week. Resident #1 denied he had experienced any injury or fall related to the broken wheelchair brake. In an interview on 2/24/2026 at 01:00 p.m., ST A stated she had completed Resident #1's evaluation for therapy on 12/19/25 and that while he could self-wheel a wheelchair he could not ambulate or transfer independently. She stated she was not aware that Resident #1's wheelchair brake was not working until he had told her this morning (2/24/2026). She stated she had informed the DOR. She stated that a broken brake on a wheelchair could place a resident at risk for falls. She stated she was not aware of any injuries or falls related to Resident #1's broken wheelchair brake.In an interview on 2/24/26 at 01:10 p.m., the DOR stated that Resident #1 has tremors and pushes down too hard on his wheelchair brakes and this is the second time in the past one to two weeks that they will have replaced his wheelchair brake. She stated that any direct care staff who noted a broken wheelchair brake could notify their supervisor and put in an electronic work order to the maintenance department. She stated that the risk to a resident of a wheelchair with a broken brake would be a risk for falls. She stated she did not believe that Resident #1 had ever had an injury or fall due to the broken brake. She stated that Resident #1 had a history of falls, and she related this to him being very impulsive and not wanting to wait for assistance. In an interview and observation on 2/24/2026 at 01:20 p.m., Resident #1 was observed sitting in the dining room in his wheelchair while the Maintenance Director completed the repair on his wheelchair brake. He stated that he had just replaced a brake on Resident #1's chair about a week ago. The Maintenance Director stated that any staff who noted a broken wheelchair brake were responsible for reporting it and could put in an electronic work order for maintenance. He stated that he can sometimes repair the chair and at other times the chair will be switched out and the administrator notified. In an interview on 2/25/2026 at 09:31 a.m., the DON stated that on 2/24/26 at approximately 08:00 a.m., Resident #1 had gestured to her that his wheelchair brake was broken, and she had notified the DOR at that time. In an interview and observation on 2/25/26 at 09:39 a.m., the Maintenance Director showed the surveyor the electronic maintenance record on his laptop stating he could not print it. The record reflected that an electronic work for resident's wheelchair brake was created on 02 /24/2026 at 01:40 p.m. by the DOR. The Maintenance Director stated that he first became aware of the broken brake on Resident #1's wheelchair at approximately 01:00 p.m. on 02/24/26 when he was told verbally by the DOR. He stated this was approximately 20 minutes prior to receiving the notification in the electronic maintenance log. He stated he is responsible for monitoring facility equipment including wheelchairs for needed repairs and that he does this monthly. He also stated that the therapy department also monitors equipment for needed repairs when working with residents. He stated that if a resident's wheelchair brake was broken, the resident could be at risk for falls. In an interview on 2/25/26 at 10:00 a.m., the ADM reported that when a staff member noticed an issue or damaged equipment such as wheelchairs, they were to place an electronic maintenance request (work order). He stated that any staff that noticed broken equipment was to place a work order. He stated that maintenance was responsible for monitoring broken equipment and that the maintenance department typically responded the same day.Review of facility policy titled, Accommodation of Needs revised March 2021 stated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The facility did not provide a policy on equipment maintenance or repair when requested.

Based on observation, interview, and record review, the facility failed to ensure interventions and ongoing monitoring were provided for 1 of 1 resident (Resident #2) reviewed for dialysis services.The facility failed to obtain physician orders for fluid restriction.The facility failed to monitor his fluid intake. This failure could result in fluid overload in the body and residents not being able to maintain the highest practicable level of well-being. Findings included:Record review of Resident #2's face sheet, dated 02/26/2026 revealed a [AGE] year-old male. He was admitted on [DATE] with a principal diagnosis of end stage renal disease (final stage of renal disease, kidneys cannot function adequately to sustain life without treatment). Other pertinent diagnoses included dependence on renal dialysis, cognitive communication deficit (cognitive impairment), altered mental status, hypertension (high blood pressure), and need for assistance with personal care. Resident #2's care providers included NP D. Record review of Resident #2's orders reflected: PATIENT GOES TO [Dialysis facility] DIALYSIS MONDAY, WEDNESDAY, FRIDAY. Order date: 10/09/2025. Orders did not include monitoring or restricting fluid intake. Record review of Resident #2's care plan revealed Resident # 2 had impaired renal function; he receives dialysis (treatment machine removes waste product and excess fluids from the body due to kidneys being unable to) three times per week. He was at risk for increased shortness of breath, chest pains, blood pressure, itchy skin, nausea and vomiting, impaired cognition, infection to shunt site (permanent access created surgically to facilitate blood flow for dialysis), and decreased urine output. Interventions included to administer medications per order, monitor labs, to assess his shunt site, ensure Resident #2 was aware of dietary recommendations/restrictions related to disease process, to monitor compliance with fluid restriction per MD order, and monitoring resident conditions pre and post dialysis, report abnormalities to MD. Record review of Resident #2's progress note dated 02/23/2026 reflected:- Effective Date 02/09/2026: Pt. out of facility per transportation in route to [sic] dialyis. Pt.'s dialysis center called and stated pt. has a scheduled treatment for tomorrow at 11:40 am and completion time between 4:30pm and 4:45pm. [sic]- Effective Date 02/23/2026: Dialysis center called and informed this nurse that resident is to return to dialysis tomorrow 2/24/2026 at 12:00 pm because he has a lot of fluids. Adon notified.Progress notes revealed Resident #2 received additional dialysis treatments on Tuesday 02/10/2026 and Tuesday 02/24/2026. Progress notes did not reflect the dialysis communication forms notes for fluid restrictions or notifying the MD or NP of dialysis recommendations. Record review of Resident #2's dialysis communication notes revealed 13 of 36 dialysis notes under Dialysis Center to Complete for Facility. Recommendations indicated Resident #2 needed to restrict fluids. Notes reflected: 12/1/2025 - control fluid intake; very high fluid intake, limit fluid12/12/2025 - fluid intake restriction 32 ounces per day12/17/2025 - fluid restriction12/19/2025 - restrict fluid intake12/23/2025 - fluid restriction12/28/2025 - fluid restriction01/05/2026 - fluid restriction01/9/2026 - fluid restriction01/12/2026 - fluid restriction01/30/2026 - fluid restriction reinforced02/10/2026 - fluid restriction reinforced to the pt02/20/2026 - fluid intake restriction02/24/2026 - fluid restriction reinforced During observation and interview on 02/25/2026 at 6:31 P.M. with Resident #2, he said he felt great after dialysis. He indicated he went to dialysis on Monday, Wednesday, and Fridays. He said this week he had gone on Tuesday because of the extra fluid in his body. Resident #2 did not confirm nor deny that he had been educated to restrict fluids; he said he used to work out and ride his bike and would sweat out fluids. Resident #2 indicated it was hard to go 2 days (Saturday and Sunday) without dialysis due to swelling (fluid retention) in his ankles. Observation of Resident #2 revealed minimal swelling in ankles. During an interview on 02/25/2026 at 6:44 P.M. with RN A, she said Resident #2 returns from dialysis with paperwork and that was how they communicate with dialysis. She said she reviews (the communication form), charts and checks Resident #2's vitals. RN A said she had seen dietary restrictions but Resident #2 was noncompliant and they have to remind him about fluid restrictions. She indicated she did not upload everything into PCC because Resident #2 had a dialysis binder that was utilized. RN A said nurses report what was on the dialysis communication form by giving reports every time nurses take a shift, they tell them about changes in a resident and to remind Resident #2 to watch how many cups of fluids he drinks. She indicated Resident #2's fluid restrictions were put into the 24-hour report in case a nurse forgets he was on a fluid restriction. During an interview on 02/26/2026 at 11:40 A.M. with LVN B, she said Resident #2 sometimes goes to dialysis an extra day a week because he had more fluid in his body than what dialysis could pull off, so he goes back to get more taken off. She said she had not seen fluid restrictions for Resident #2, and no one had discussed him being on fluid restrictions. LVN B said if Resident #2 came back from dialysis with anything on the communication form, it should be on the 24-hour report and documented in the progress notes. LVN B said if Resident #2's fluids were restricted, an order would be put in, direct care staff would monitor, nursing and dietary staff would give the resident a certain amount of fluid, and the MAR would reflect how much the resident was allowed to receive/restrict. LVN B indicated the importance of the dialysis communication form was it was how the dialysis center communicated with the facility and there may be orders the dialysis center wanted the facility to carry out; it was for the resident's care at the facility and at dialysis. The state surveyor requested records of 24-hour reports on 02/26/2026 at 11:58 A.M. The RNC said those were in-house documents that were not given to state surveyors. During an interview on 02/26/2026 at 1:33 P.M. with NP D revealed she provided direct care for Resident #2. She said she was not aware of Resident #2's recommendation from dialysis regarding a fluid restriction. NP D said the nurses did not communicate the fluid restriction recommendations with her. NP D said when dialysis writes notes in the communication form, nurses can put an order in or let her or the MD know about what dialysis recommends if they were not comfortable putting in an order. She said fluids can be monitored by a log of how much fluid was consumed. She indicated fluid and food management was important for Resident #2 because if he did not go to dialysis, there would be swelling (fluid retention), overload on the heart, and all complications that come with it (end stage renal disease). During an interview on 02/26/2026 at 1:52 P.M. with the RD she revealed she was now the RD for Resident #2 and had not seen him yet. She indicated she had not been notified of issues regarding Resident #2's food and fluid intake but (nutrition) education can be provided for him. The RD stated it would be difficult for her to monitor fluid intake and indicated facility staff would monitor fluid intake. During an interview on 02/26/2026 at 2:39 P.M. with the ADON, she said Resident #2 goes to dialysis on Monday, Wednesday, and Fridays, but went to dialysis on Tuesday due to fluid overload. The ADON indicated there was communication form for Resident #2 to take with him to dialysis and the form included assessments of his dialysis shunt and vital signs (i.e. blood pressure). She said the form was put into his dialysis binder (when returning from dialysis). The ADON indicated if there were changes on orders, the nurse would put the orders in, report it to the oncoming nurse, and put it in Resident #2's progress notes. The ADON said she had not seen fluid restrictions on the communication forms, but he was on fluid restrictions and if it was an order, it should be in Resident #2's orders. During an interview on 02/26/2026 at 2:49 P.M. with the DON revealed Resident #2 was not on a fluid restriction and the communication form was for head-to-toe assessment on the resident pre and post dialysis. The DON said she had not seen anything about fluid restrictions on Resident #2's dialysis communication notes and she reviewed the notes. She said there was not an MD order for fluid restrictions and had not received an MD order for fluid restrictions. The DON said the dialysis communication form was for pre and post resident assessments and even if dialysis made a recommendation, it was not an MD order. She then said the MD and NP were aware of the fluid restriction, but NP D was not Resident #2's NP. The DON said if there was no crackling (in lungs), no edema (fluid retention), nothing different with Resident's BP, then nurses do not feel like the Resident had fluid overload. She stated Resident #2 did go to dialysis on Tuesday due to a fluid overload.The DON said the facility communicates with dialysis through the communication forms. She said for any dire situation, they call, but if it was not dire then the dialysis center writes on the form. She said the form was pertinent to Resident #2's well-being. The DON indicated if dialysis made recommendations on the communication form, nurses reach out to the MD and the MD will decide on implementing the recommendations. She said she had not heard of nurses reaching out to the MD. The DON said that if a recommendation was not conveyed it could delay care if Resident #2 did need it (what dialysis recommended). Record review of the facility's Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement, dated 02/26/2026, reflected: This Agreement is made by and between [Nursing Facility] ( Operator) and [Dialysis Company] ( Company), expressly for the purpose of care coordination as provided in 42 C.F.R S 483.70(f), and is effective upon the date of last signature ( Effective Date) .Operator and Company agree as follows:A. Definition of Renal Dialysis Services.a. includes items and services, such as drugs, biological and laboratory services, for the treatment of end stage renal disease which are ordered by, or in coordination with , the physician or non-physician practitioner responsible for managing the Resident's nephrology care; andb. does not include services that are not essential for the delivery of maintenance dialysis, such as respiratory therapy and monitoring, similar specialized services, sitter services, and transportation of Residents to and from Dialysis Facility. B. Obligations of Operator's Long Term Care Facility1. Information Sharing. For the purpose of care coordination, in advance of each Resident's dialysis treatment, Long Term Care Facility shall furnish all information and documentation necessary for Dialysis Facility to provide safe and appropriate care, including any and all information reasonably requested by Dialysis Facility.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assures the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #1) of four residents reviewed for medication administration. The facility failed to ensure Resident #1 had received her medications as scheduled and as ordered by her physician. This failure placed residents at risk for decreased quality of life, unrelieved pain and misappropriation or property. Findings included: Review of Resident #1's admission MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE], with the diagnoses that included cirrhosis of the liver (severe scarring of the liver), metabolic encephalopathy (change in how your brain works due to an underlying condition), chronic hepatitis (long-term inflammation of the liver) and depression (serious mood disorder causing persistent sadness and loss of interest). The MDS assessment reflected Resident #1's BIMs was an 8 indicating moderately impaired cognition. The MDS assessment revealed Resident #1 received antidepressant medication. The MDS assessment revealed Resident #1 received scheduled pain medication. The MDS assessment revealed when Resident #1 was asked Have you had pain or hurting at any time in the last 5 days the answer was no. The MDS assessment revealed resident had experienced PTSD. Review of Resident #1's January 2026 Physician Orders reflected the following: Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG. Give one tablet by mouth three times a day for pain. Ordered by LVN C on 01/10/26. Review of Resident #1's January 2026 Physician Orders reflected the following: Sertraline HCL Oral Tablet 50 MG. Give one tablet by mouth at bedtime for depression. Ordered by LVN C on 01/09/26. Review of Resident #1's Medication Administration Records for January 2026 documented by MA A and MA B revealed the resident had missed her Hydrocodone-Acetaminophen (pain medication) dose on the following dates:01/12/26 at 2PM and 8PM01/13/26 at 8AM, 2PM and 8PM01/14/26 at 8AM, 2PM and 8PM01/15/26 at 8AM, 2PM and 8PM Review of Resident #1's Medication Administration Records for January 2026 documented by MA B revealed the resident had missed her Sertraline (antidepressant medication) on the following dates:01/12/26 at 8PM01/13/26 at 8PM01/14/26 at 8PM01/15/26 at 8PM Review of Resident #1's Medication Administration Records for January 2026 revealed a pain level of zero for 01/10/26-01/16/26. Review of Resident #1's nursing progress notes dated 01/11/26 - 01/16/26 revealed no indicators of pain or discomfort. Review of Resident #1's Pain Interview dated 01/12/26 revealed Resident #1 was experiencing pain as rarely or not at all. Review of Resident #1's care plan dated 01/08/26 revealed the resident had the following problems addressed: 1) liver disease related to hepatitis with intervention give medications as ordered. Monitor/document effectiveness and side effects. 2) uses antidepressant medication with intervention administer antidepressant medications as ordered by physician. Interview and record review on 01/16/26 at 12:30 PM with the DON of Resident #1's January 2026 physician orders and medication administration records. The DON acknowledged that Resident #1 had an order as of 01/10/26 for Hydrocodone-Acetaminophen oral tablet 7.5-325 MG, TID for pain. The DON stated that the medication administration times for a medication with an order of TID were 8AM, 2PM and 8PM. The DON reviewed Resident #1's medication administration records and acknowledged that Resident #1 did not receive her Hydrocodone-Acetaminophen as ordered on the following days and times: 01/12/26 at 2PM and 8PM, 01/13/26 at 8AM, 2PM and 8PM, 01/14/26 at 8AM, 2PM and 8PM and 01/15/26 at 8AM, 2PM and 8PM. The DON acknowledged that Resident #1 had an order as of 01/09/26 for Sertraline HCL 50 MG at bedtime. The DON stated that the medication administration time for medication with an order of HS was at 8PM. The DON reviewed Resident #1's medication administration records and acknowledged that Resident #1 did not receive her Sertraline on the following days: 01/12/26 at 8PM, 01/13/26 at 8PM, 01/14/26 at 8PM and 01/15/26 at 8PM. The DON stated that if a medication was administered it would have been signed as given by the MA or nurse on the medication administration record. The DON stated that the expectation is for medications to be given according to physician orders. The DON stated the risk of not following physician orders could result in a drug diversion. The DON stated she did not have any knowledge of Resident #1 not receiving her medications as ordered, therefore she did not know why they were not given as ordered. Observation on 01/16/26 at 12:45 PM with the DON and MA A of Resident #1's medications on MA A's medication cart revealed the DON reconciled Resident #1's number of Hydrocodone-Acetaminophen tablets on hand which confirmed that Resident #1 had not been given her Hydrocodone-Acetaminophen as ordered. The DON reconciled Resident #1's number of Sertraline HCL tablets on hand which confirmed that Resident #1 had not been given her Sertraline HCL tablets as ordered. Interview on 01/16/26 at 1:50 PM with Resident #1 revealed resident was alert and able to answer questions. Resident #1 stated she had just returned from a luncheon/shopping outing with other residents and the Activity Director. Resident #1 stated she had a good time on the outing and was not in any pain. Resident #1 stated she was getting rest and was without pain. Resident #1 stated she was not aware of missing her medications. Resident #1 had no concerns regarding her care. Interview on 01/16/26 at 2:04 PM with MA B revealed she was responsible for Resident #1's medications on the 2PM-10PM shift Monday-Friday. MA B stated she did not know Resident #1's Hydrocodone-Acetaminophen and Sertraline HCL were not given as ordered. MA B stated that when a medication is given it is documented on the medication administration record, and if it is blank then the medication was not given. MA B stated she had seen Resident #1 all week and she did not report any issues with pain or discomfort. MA B stated medications are given according to physician orders. MA B stated the risk of not giving medications as ordered could result in a resident not feeling good. Interview on 01/16/26 at 2:13 PM with MA A revealed she was responsible for Resident #1's medication on the 6AM-2PM shift Monday-Friday. MA A stated she did not know Resident #1's Hydrocodone-Acetaminophen was not given as ordered. MA A stated if a medication is administered then it is documented on the medication administration record, and if there is a blank on medication administration record then it was not given. MA A stated it is her responsibility to give medications according to physician orders. MA A stated the risk of not providing medications as ordered is not meeting the residents' needs. Interview on 01/16/26 at 2:30 PM with the Activity Director revealed Resident #1 did attend an offsite luncheon/shopping trip today. The Activity Director stated Resident #1 did not complain of pain or discomfort while on the outing. The Activity Director stated that Resident #1 enjoyed herself on the outing. Interview on 01/16/26 at 3:25 PM with the DON revealed she just did not understand how MA A and MA B would have missed administering Resident #1's Hydrocodone-Acetaminophen and Sertraline HCL unless there was glitch in the electronic medical record even though no other missed medications had been discovered. Interview on 01/16/26 at 3:30 PM with the ADM revealed he was not aware of Resident #1 not receiving her medications as ordered. The ADM stated that the expectation was for residents to receive their medications as ordered. The ADM stated that the risk of residents not receiving medications as ordered could result in illness or sickness. Review of facility policy titled Documentation of Medication Administration dated November 2022 revealed A medication administration record is used to document all medications administered. Review of facility policy titled Physician Orders dated November 2014 revealed Purpose: The Purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure resident receives the necessary care and services. 5. Physician orders are essential for the comprehensive care of the residents.

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 in 1 of 1 kitchen. The facility failed to ensure food items in dry storage were dated, labeled, and securely stored. The facility failed to ensure frozen and refrigerated food items were dated, labeled, and securely stored. The facility failed to ensure that a metal container of butter was covered to avoid risk of contamination. A pastry brush was left inside the melted butter container. The facility failed to ensure that prepared foods were held correctly and maintained safe temperatures. The facility failed to ensure that prepared foods were free of cross-contamination risk. The facility failed to ensure that dishwashing protocol was followed. The facility failed to ensure that food temperatures on the steam table were taken and logged according to food service policy. The facility failed to ensure clean dishware was stored in a clean, dry location and not exposed to other contaminations by splash, dust, and other means. The facility failed to ensure bleach was stored away in the janitorial closet. The facility failed to ensure the ice machine was cleaned. The facility failed to dispose of expired foods in the dry storage room. The facility failed to ensure bulk storage containers for dry foods were not kept under the preparation table open and had lids that were clean. The facility failed to ensure personal items were not being stored in the dry storage closet. These failures could place residents at risk for foodborne illnesses and foodborne intoxication. Findings included: Observation on [DATE] at 8:37 AM upon entry to the kitchen with the Dietary Manager revealed the following: A bag of open bread was on the food preparation counter with the date [DATE]. The steam tray table was open and held pans of breakfast food items, including eggs, bacon, and biscuits, that were uncovered. Parts of the steam table had no pans being held in it and showed the conditions of the grates that held the water for steaming. The spillage pans appeared to have had an accumulation of dark, fuzzy debris covering the water and inside of the container. The griddle on the stove top had an uncovered metal container with melted butter and pastry brush inside of it with a wrapper from a stick of butter under it. The kitchen preparation counter had an opened bottle of ketchup on it without a date or label. The ketchup was room-temperature and had a dark red brownish color. And a container of food thickener without a label to clarify the reason for the date written on the lid. The date written on the lid needed some clarification. Under the kitchen preparation counter, there were four large white storage containers with lids. Two containers had lids that were not sealed and not labeled. One container had a sealed lid with a rag on top of the lids and labeled flour. All containers were dirty with brown- and yellow-colored dried stains of unknown substance on the lids, brown and black patches of stains were noted on the sides of containers. Observation on [DATE] at 9:04 AM of walk-in refrigerated food items revealed the following: One container of cottage cheese dated [DATE] and one container of cocktail sauce dated [DATE] had no use by date. A pitcher of red liquid was undated and unlabeled. Cooked sausage patties wrapped in foil were undated and unlabeled. A clear bag with pureed sausage was undated and unlabeled. A clear bag with eggs was undated and unlabeled. Observation on [DATE] at 9:09 AM of frozen food items in the freezer revealed the following: Frozen food items pancakes, fries, and hash browns were undated and unlabeled One bag of frozen vegetable egg rolls was unsealed and, in a box, dated [DATE]. One bag of frozen chicken breasts was unsealed and, in a box, dated [DATE]. One bag of frozen vegetables opened and resealed in saran wrap, not dated. Interview on [DATE] at 9:09 AM with the Dietary Manager revealed labels did not stick to frozen items. He also stated that using a marker did not work due to the ink being wiped away when touched. Observation on [DATE] at 9:12 AM of the dry storage closet revealed the following: Dry food items that had been opened, including cereals and seasoning mix, were not labeled with a date of opened on nor use by. Red potatoes were stored in a plastic bin without a lid. The bin was labeled potatoes [DATE]X and check for freshness daily. The red potatoes showed signs of sprouts growing out of the potatoes. A box of gallon-sized jugs of bleach was stored on a bottom shelf next to a crate of serving utensils exposed to air in the dry storage closet with food items. A black jacket and a green backpack hung on the food shelf next to exposed paper napkins and open Styrofoam cups. Interview on [DATE] at 09:22 AM with [NAME] A he stated the jacket and purse belonged to kitchen Aide C. He stated he did not know why the jacket and bag were stored in the dry food storage. He stated some staff did not like to leave their things out in the kitchen and he said, I do not steal. [NAME] A stated the bleach was placed in the dry food storage because he did not know where it belongs. He stated, If this was my kitchen bleach would not be in the kitchen at all. [NAME] A stated bleach should not be stored next to food for risk of it spilling and contaminating food. [NAME] A stated all kitchen staff were responsible for labelling and dating the food. He said that all the food that came in during delivery had to have a receive date on it. [NAME] A said all kitchen staff were responsible for cleaning out any expired foods including the potatoes that had wilted and sprouted. He stated he did not do it because he was off on the weekend, and he did not work yesterday. Interview on [DATE] at 09:32 AM with Kitchen Aide C, she stated the coat hanger outside the dry food storage area is usually full, so she keeps her personal items in the dry food storage room. She stated that she should have put her items in the breakroom or on the coat hanger outside. She stated the risk of having her jacket and bag in the dry food storage was cross contamination. Kitchen Aide C stated when she did not know where to store something like bleach, she would ask her manager or take it to his office. Interview with Dietary Manager on [DATE] at 09:34 AM, he stated he had placed the bleach in the dry food storage and forgot to move it. He stated the bleach and other cleaning products go into the Maintenance closet or he will take it to the laundry room for storage. He said the kitchen is very small and they have limited storage space. However, it was an oversight that he got busy and forgot to move the bleach from the dry food storage. The Dietary Manager stated the risk for having bleach in dry food storage was that fumes could leak and contaminate the food in the pantry. The Dietary Manager said some of the staff in the kitchen had had their stuff stolen and that was why they kept their items in the dry food storage room. He stated the expectation was that all personal items were stored on the coat hanger or in the breakroom. He stated potatoes were still good to eat. He said last week some that were wilted were thrown away by [NAME] B. He stated everything should be labelled with date of delivery, then a use by date after opening. Observation on [DATE] at 9:24 AM of the dishwashing area (referred to as dish room by dietary manager) revealed the following: The low-temperature dishwashing machine temperature gauge read 103 degrees Fahrenheit when running. The temperature inside the dishwashing machine was not checked during the cycle. The 1st-compartment contained used dishes, without a washing solution to soak dishes. The 2nd-compartment sink had water running, with no drain stopper to hold water in the compartment to rinse dishes. The 3rd compartment for sanitizing dishes, and after rinsing dishes, contained a water and sanitizer solution. The drainpipe under the 3-compartment sink had water running through it and into the floor drain. The drain appeared to have bacteria and dirt built up around it. The pipe did not reach into the floor drain. The water that ran through the pipe splashed when it drained into the floor ' s drain. The floor's drain cover was not in place. The temperatures and chemicals ppm for the 3-compartment sink had not been logged for the month of [DATE]. Cleaned dishware was stored on metal shelves and uncovered in the dishwashing area. Observation and interview on [DATE] at 9:38 AM of [NAME] A cleaning the steam table revealed the following: Breakfast foods had been removed from the steam table. Surveyors had observed [NAME] A using a liquid solution in a clear container to clean the steam table. In regard to if [NAME] A had used the sanitary solution in the standard red sanitary bucket used to clean kitchen equipment and preparation areas, he responded, I'd be the stupidest dietary manager to use sanitary water for this (pointing to the steam table). No, it ' s not the same (referring to the cleaning solution he used not being the same as the solution in the sanitary buckets). [NAME] A further informed surveyor he used a pot and pan cleaning solution. Observation and interview with the dietary manager and housekeeper on [DATE] at 10:32 AM of the ice machine revealed the following: The ice machine had water marks on the outside. The dietary manager unlocked the ice machine. Inside of the ice machine had a dark moldy/mildew like substance on the left side. Slimy substance was observed across the back where ice fell out of the machine. The ice machine appeared dirty and was full of ice. The dietary manager stated that housekeeping was in charge of cleaning the ice machine. At that time, the housekeeper had walked by and housekeeper was not aware that she was responsible for cleaning the ice machine, she stated, Oh, I guess it is my responsibility. She stated that she had never cleaned the ice machine, but she would notify maintenance to empty it since she could not do it herself and she would then clean it. Further Observation on [DATE] at 3:37 PM of the kitchen revealed the following: Turkey deli meat had been placed in a plastic container and sat on the food preparation countertop. Later observation on [DATE] at 4:47 PM would reveal the same items would remain on the food preparation countertop, uncovered. The metal container with melted butter and a pastry brush remained uncovered and on the stove top griddle. Cook B was washing dishes in the 3-compartment sink. The 1st compartment had a washing solution and dishes in it. [NAME] B rinsed dishes under running water through the faucet in the 2nd compartment, the compartment was not full of rinse water. In the 3rd compartment, [NAME] B used the sanitizer dispenser tube to distribute and cover the rinsed dishes in sanitizer. [NAME] B then placed the sanitized dishes on the bottom of the 3rd compartment sink. There was not a sanitizing solution in the 3rd compartment. Interview on [DATE] at 3:50 PM with [NAME] B revealed she placed the dishes in the 1st-compartment to soak and wash off dishes. She then used the 2nd-compartment to rinse the dishes, using the faucet. After rinsing the dishes, she used the 3rd compartment to sanitize the dishes by using the sanitizer dispenser tube and placed them in the 3rd-compartment to dry. Then the dishes were washed again in the low temperature dish washer. Interview on [DATE] at 4:05 PM with the Dietary Manager revealed how to turn the sanitizer dispenser on, and the tube dispensed sanitizer that could be used to cover the dishes. He stated he didn ' t always dilute the sanitizer and would use the tube because the sanitizer was dispensed with water and diluted. The dietary manager stated that after dishes were washed using the 3-compartment sink, they were not washed again in the low-temperature dish machine. Observation on [DATE] at 4:10 PM of the low-temperature dish machine revealed the thermometer gauge attached to the machine continued to show the water temperature as 103 degrees Fahrenheit. The correct sanitizing chemicals matched the required PPM. The dietary manager ran the dish machine ,d+[DATE] times to test the water temperature. The dietary manager then used a digital thermometer to test the temperature in the dishwasher. The digital thermometer read the temperature to be 126 degrees Fahrenheit, further finding dish machine thermometer gauge appeared broken as it did not change or move according to the change in temperature. Tthe dish washer ran 3 times and the gauge remained at 126 F, not matching the thermometer gauge. Observation on [DATE] at 4:12 PM of steam table temperature checks revealed the following: Cook B used a digital thermometer to check temperatures of foods held on the steam table. Mashed potatoes, peas and carrots, and pureed mashed potatoes at temperatures above 135F. Pureed chicken temperature read 133.5 F and Chicken strips temperature read 132.8 F. When [NAME] B used the digital thermometer, she had laid the thermometer against the side of the metal food pans and touched the probe to the bottom of the metal food pans and measured the temperatures of the metal pans. Observation on [DATE] at 4:47 PM of kitchen revealed the following: Turkey deli meat remained on the kitchen preparation countertop. The metal container of butter remained on the stove top griddle, uncovered. Baked biscuits on a sheet pan sat uncovered and on top of the steam table since 3:37 PM. Observation and interview on [DATE] at 4:51 PM with [NAME] B and the Dietary Manager revealed the butter was used on foods like the biscuits that were baked. The container was cleaned once a day every day and new butter was put in it in the morning. [NAME] B temperature checked the turkey deli meat, temperature read 56.4F. [NAME] B rechecked the steam table foods. Pureed chicken temperature read 161.2F. The chicken strip temperature read 126.3F. [NAME] B and the Dietary Manager stated the temperature to be around ,d+[DATE]F. [NAME] B placed the chicken strips in the oven to reheat them to meet the required minimal temperature. [NAME] B stated the lunch meat should be around 40F. The dietary manager stated that [NAME] B was going to make sandwiches but was distracted by having to take temperatures and discarded the deli meat. Observation revealed bristles, from the pastry brush used for butter, on the uncovered biscuits on top of the steam table. [NAME] B stated its spots were normally on the biscuits when frozen. After further discussion, [NAME] B confirmed it was pastry brush bristles. The dietary manager stated that it looked like the bristles from the pastry brush. He then discarded the biscuits. The dietary manager and [NAME] B responded with residents would be at risk for foodborne illness regarding food temperatures not meeting range and biscuits containing butter from the butter left out on the food preparation counter. Interview on [DATE] at 1:41 PM with the Dietitian revealed she was at the facility once a month for ,d+[DATE] hours. During that time, she would conduct a kitchen audit by observing the cleanliness, temperature logs of foods, fridge, freezer, and dishwashing area. She stated that in the past she had noticed concerns, like those found during observations. However, she had found no issues with temperature logs. She shared her expectations on temperature levels for hot and cold foods, temperature check process, foods held on the steam table, labeling, storage of foods and chemicals, dish washing process, ice machine cleaning, and cleanliness of the kitchen. The dietitian stated that she didn ' t typically do in-service training, and the dietary manager was responsible for doing them. She stated she had done in-service for labeling and dating foods, and temperature logging because they had been issues. She stated she provided the dietary staff with results of her audits and for issues to be resolved. She said If in-service was not followed, she would talk with staff about room for improvement and what she could do to help implement changes. The dietary manager was responsible for following up with her. Interview on [DATE] at AM with Kitchen Aide E revealed the role and responsibilities was divided between the dietary manager, the cooks, and the kitchen aides. Kitchen Aide E explained that food items without labels and dates could be a problem because it was unknown how old the item was. He stated that chemicals should be kept in the closet with other chemicals outside the kitchen. He confirmed that he had seen the large containers of ingredients under the kitchen preparation counter. Kitchen Aide E confirmed the protocol for the 3-compartment sink and low-temperature dish machine but was unsure of the reasons for testing the ppm for chemical solutions. Kitchen Aide E stated no one has asked him to clean the ice machine but he had volunteered ,d+[DATE] months ago. Kitchen Aide E explained the correct process of temperature checking foods and why it must be done that way. He explained the importance of meeting required temperatures and solutions for temperatures that were not within a safe range. In an interview with the Dietary Manager on [DATE] at 10:28 AM revealed the expectation of staff was to label food items by use by day and expiration. He stated food in the fridge that was old, like lettuce, to toss it out. The Dietary Manager stated if something wasn ' t labeled, to toss it out, as it was uncertain how long the food item was in the fridge for. He stated dates and labels were important to know freshness of food and to avoid using old foods, as old food used could cause harm to residents. The Dietary Manager stated cleaning chemicals should be in chemical closet. He stated staff were sidetracked on that day and left the chemicals in dry storage closet. He stated the risk was if the cap to the bottle of chemicals wasn ' t on and was open, the vapor and fumes could seep into foods or if cooking, could infuse with foods. Residents could get sick by that too. The Dietary Manager stated bleach was used for floors and for areas where dirt and grime was hard to get off. The Dietary Manager stated the dry storage bin should have been wiped down and cleaned and dust free to look presentable. He stated if there are dry foods (rice, flour, sugar), it was important to keep clean and secure to avoid getting something like dust and liquids on them. He stated the cook was normally responsible for the storage bins. The Dietary Manager stated the butter bristle appearing on the biscuits happens from the brush being cleaned, and he had since gotten a rubber, silicone brush. He stated the expectation of staff was to clean the steam table after every meal or at the end of the day. He stated staff often clean when the steam table was not in use or when making cold meals. He stated the risk of a dirty steam table was the water could get dirty and contaminated which would cause the steam to be hazardous, and the steam table could potentially not work well. The Dietary Manager stated he did not do an in-service with staff regarding the steam table lately but stated his staff know how to clean the steam table. He stated, after serving, the steam table should be kept on for about ,d+[DATE] minutes after serving. He stated food should be covered when not serving since anyone could cough in it and dust could get into food. He stated he would want to keep food hot and warm at temperature. The Dietary Manager stated the risk of food if not tested correctly was food could be uncooked or cold if not reaching proper temperature. There would be a risk of foodborne illness. He stated worst-case scenario could lead someone into going into the hospital and passing away. The Dietary Manager stated he expected staff to first rinse dishes (that were not going into the low-temperature dishwasher) in the 3-compartment sink before dipping them into water to submerge them and put sanitizer in the sink. Afterwards, the pans and other dishware were left to dry. He stated staff were to follow guidelines, fill the sink with water and use sanitizer. He stated staff were supposed to test the sanitizer and ppm to make sure it was not too high. The Dietary manager stated when the sanitizer was dry, it would evaporate and not too much would be on dishes and (residents) would not be eating off sanitizer. The Dietary manager stated too strong sanitizer could potentially be still on the dishes and could cause food to taste weird. He stated pure, undiluted sanitizer should not be poured on dishes as it could cause someone to get sick. He stated he would tell staff guidelines for washing dishes in the low-temperature dishwasher. He stated the instructions were right there. The Dietary Manager stated he had not trained them on using thermometers for water, one digital and 3 standards. He stated the risk of not knowing how to take the temperature of the low-temp dishwasher was dishes would not get thoroughly cleaned, risking bacteria on plates. He stated someone could get sick if they eat off it, maybe something worse, sickness could spread back into kitchen. The Dietary Manager stated he was not aware dietary was to clean inside of the ice machine, only outside. He was not sure of what chemicals to use. He stated the ice machine dated back to [DATE] when the ice was removed, and the machine was cleaned. He told his staff yesterday he was not aware it fell on them to clean it. The Dietary Manager stated when it came to food items in the freezer, it was hard to get labels or markers to stick to them, which was why some labels were missing. The Dietary Manager stated he was responsible for in-servicing staff for cleaning the kitchen, including the sink and drain. He stated he didn ' t do this due to lack of staff. He stated the risk was bacteria, mold, and critters could appear in the sink and lead to illness. The Dietary Manager stated food in the refrigerator, if used, could only be kept three days after first opened before it should be tossed away. Interview with the Administrator on [DATE] at 6:14 PM, revealed his expectation for the kitchen was for it to be clean and sanitary. He stated, if you have good food, good care, and good activities there is nothing to complain about. He stated he had a dietary background, and he did not appreciate a dirty kitchen. He stated they were going to have an overnight kitchen scrub pizza party and that they bought a water pressure washer to clean the kitchen. He stated the chemical should never be kept where the food was. He stated he did not know what the risk of the sanitizer not being diluted was, but he knew the process and it should be diluted and tested . The administrator stated the food service director (referring to Dietary manager) was responsible for making sure those things were done; it's his goal to run a safe, clean kitchen. He did not know why the dietary manager did not follow the Dietitian recommendations when she audited the kitchen. He stated he couldn 't say why the recommendations from the dietitian audits from September were not done. He stated in the future, they would be coming together and meet with the Dietitian and set dates for when things should be done/corrected. He stated the risk of what was described to him (dish washer temperature not working, incorrectly measurement of food temperatures, personal items in kitchen, food undated and unlabeled, bulk containers with stains and dirty, steam tray table food left open and missing lids, slimy rusted steam table water, chemicals in dry food storage, incorrect sanitization and dirty moldy ice machine) to the resident was the resident not getting the proper care and they could get infections from the dirty sinks. He stated cleanliness was next to godliness. Record Review of kitchen audit titled Quality Assurance Monitor 1 completed by the Dietitian on [DATE] recommendations revealed No sanitization bucket in use, prep area with no lid there appear to be mold in the ice machine .pork tips thawing on counter .turkey slices in fridge open, unlabeled .receive dates not on all items .No use by dates on open items, not all open items covered properly, many items missing receive by dates .no temperature logs for this week . Record Review of kitchen audit titled Quality Assurance Monitor 1 completed by the Dietitian on [DATE] recommendations revealed . Dirt or mold inside ice machine .Right side of plate warmer not working vegetables with no label/date Review of the facility ' s Nutrition & Foodservice Policy and Procedures Manual for Long-term Care, dated 2018, revealed, .To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated . Where possible, leave items in the original cartons placed with the date visible . Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination .Do not use or store cleaning materials or other chemicals where they might contaminate foods. Label and store them in their original containers when possible. Store in a locked area away from any food products .Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage Use all leftovers within 72 hours. Discard items that are over 72 hours old . Store frozen foods in moisture-proof wrap or containers that are labeled and dated . Use clean, sanitized surfaces, equipment and utensils .Take temperatures throughout the preparation process to ensure that food is safe .Cook comminuted meat (such as hamburger) products thoroughly to heat all parts of the meat to a minimum temperature of 155 F for at least 15 seconds .Heat stuffing and poultry throughout to a minimum temperature of 165 F for at least 15 seconds .Cook raw animal products such as eggs, fish, lamb, pork or beef, except roast beef, and foods containing these raw ingredients to an internal temperature of 145 F or above for at least 15 seconds . Prepare cold foods no further in advance than necessary .Prepare cold foods in small batches and place in cold storage immediately .Prepare potentially hazardous foods, such as meat and poultry salads, potato and egg salads and cream-filled dishes using only chilled products that have been refrigerated below 41 F. Prepare foods immediately upon removing the products from the refrigerator and immediately refrigerate after preparation .Maintain all cold prepared items at a temperature of 41 F or below until ready to serve. Do not remove from refrigeration until ready to serve . If a potentially hazardous food is not at the proper temperature, further investigation is required to determine how long the food has been outside the safe temperature zone to determine if it is safe to restore the food to the correct temperature. If food has been outside the safe zone for over 2 hours, discard the food immediately. If food has been outside the safe zone for less than 2 hours, reheat per guidelines . Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes . Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil . Clean and rinse immediately prior to use, moist cloths used for wiping food spills on kitchenware and food-contact surfaces of equipment. Clean frequently during use in a sanitizing solution and do not use for any other purpose. When not in use, hold in a sanitizing solution of the proper concentration (100 ppm Chlorine, 200 ppm Quaternary Ammonia, or 25 ppm Iodine) . Store toxic chemicals away from food products and be sure they are properly labeled . The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly and monthly cleaning . Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing . In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120 F . Rinse in the second sink using clear, clean water between 120 F and 140 F to remove all traces of food, debris and detergent . Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: .a. Immerse for at least 30 seconds in clean, hot water at a temperature of 170 F or above. When hot water is used for sanitizing, the facility must have and use: i. An integral heating device or fixture installed in, on, or under the sanitizing compartment of the sink capable of maintaining the water at a temperature of at least 170 degrees Fahrenheit and ii. A digital or numerically scaled indicating thermometer, accurate to plus or minus three degrees Fahrenheit convenient to the sink for frequent checks of water temperature. Immerse for at least 60 seconds in a clean sanitizing solution containing: A minimum of 50 parts per million of available chlorine at a temperature not less than 75 F or ii. A minimum of 12.5 parts per million of available iodine in a solution with a pH not higher than five and a temperature not less than 75 F or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75 F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer ' s label directions. c. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time . If a machine that uses chemicals for sanitizing is in use, follow these guidelines'. A. The temperature of the wash water must be at least 120 F . Store all cleaned and sanitized utensils and equipment and all single-service articles at least 6 inches above the floor in a clean, dry location in a way that protects them from contamination by splash, dust and other means . The facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day . Record review of the U.S. FDA Food Code 2022 reflected: . C. Packaged Food shall be labeled as specified in LAW , including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form .9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, her [TRUNCATED]

Based on interview and record review, the facility failed to use the services of a Registered Nurse for a minimum of eight consecutive hours a day, seven days a week, for 13 of 26 weekend days. The facility failed to have RN coverage on the following dates in 2024: -April 6, 7, 13, 14, 20, and 21. -May 4, 5, 11, 12, 18, 19, and 26. This failure could place residents at risk of not having their nursing and medical needs met, and not receiving proper care. Findings included: Review of the CMS PBJ Staffing Data Report, a report reflecting data self-reported to CMS by the facility, dated 11/26/24, reflected the facility had not reported RN coverage hours for the weekend dates of April 6, 7, 13, 14, 20, 21, and May 4, 5, 11, 12, 18, 19, and 26. Review of an undated excel file, covering the RN time stamp hours for weekend dates of the second fiscal quarter of 2024 reflected no RN coverage on the following dates of 2024. -April 6, 7, 13, 14, 20, and 21. -May 4, 5, 11, 12, 18, 19, and 26. An interview on 12/05/2024 at 5:45 PM with the DON revealed she started working at the facility in August of 2024, and her weekend RN had to be off twice since then, and she had covered those days herself. She did not know why they were missing RN hours prior to her getting there. An interview on 12/05/2024 at 6:13 PM with the Administrator revealed he had only been in the facility for two weeks, so he did not know why they were missing days of RN coverage. An interview on 12/05/2024 at 7:19 PM with the DON revealed the importance of having RN coverage was that someone in the building might require a higher level of knowledge and training than an LVN. Review of the undated facility policy Nurse Staffing Requirements reflected POLICY: Nurse Staffing Requirements in Nursing Facilities; REQUIREMENT: The requirements for long-term care facilities require that nursing facilities provide 24-hour licensed nursing, provide a Registered Nurse (RN) for eight (8) consecutive hours a day, seven (7) days a week, and that there be a RN designated as Director of Nursing on a full-time basis.

Based on interview, and record review, the facility failed to ensure residents were free from abuse for one of eight residents (Resident #32) reviewed for abuse. The facility failed to ensure Resident #32 was free from physical abuse when the Former Staffing Coordinator grabbed Resident #32's hand hard enough to cause bruising, while attempting to get the resident to allow himself to be taken to the shower. This failure placed residents at risk for abuse. Findings included: Review of Resident #32's face sheet reflected an [AGE] year-old male, admitted on [DATE], with diagnoses of Acute embolism and thrombosis of unspecified deep veins of left lower extremity (a blockage caused by a blood clot in the leg), Urinary tract infection, site not specified, lack of coordination, Spondylolisthesis, lumbar region (a condition in which vertebra slip out of place, and cause pain), and Cauda equina syndrome (a rare condition in which nerve roots at the bottom of the spinal cord are compressed, considered a medical emergency.) Review of Resident #32's care plans reflected the following care plans: - Urinary Incontinence and pain, dated 11/27/24 - ADLs re: Non-compliant behavior dated 11/19/24 Review of Resident #32's Admission MDS Assessment, dated 10/04/24, reflected his sight and hearing were adequate, and he was able to express himself, be understood by others, and to understand others. His BIMS score was 12, indicating possible moderate cognitive impairment. He had no indicators of depression, or psychosis, and exhibited no behavioral problems. Resident #32 indicated it was very important to him to take care of his personal belongings or things, and to have a place to keep them safe. He was able to eat with only set-up or clean-up assistance, but was dependent on staff for toileting and bathing. Review of the facility investigation documentation for a self-reported allegation of abuse by a resident, submitted to HHSC by the Former Administrator on 10/31/24, reflected Resident #32's allegation that some female staff members had entered his room, and tried to get him to take a shower on 10/29/24, which he refused. The document reflected that he stated one of the women (thought to be the Former Staffing Coordinator) handled him roughly and bruised his hand. In the investigation materials provided, a statement by CNA I, dated 11/04/24, (appearing to be a text message) reflected that the CNA had been in the room during this incident, and observed the (Former) Staffing Coordinator was asked to come into the room to assist. The facility investigation reflected the resident was observed to have a small bruise on his left hand, where he was allegedly grabbed. An interview with Resident #32 on 12/03/24 at 3:04 PM, with his friend, Visitor K, present, revealed him to be alert, and oriented, with some forgetfulness. He said that some women came into his room, and told him he had to take a shower. He said that he told them he would do it the following day, and they said no and that he always said that, but he would not do it, so they wanted him to do it right then. He said they removed his clothing and stripped his bed, and he did not remember when he ended up in the chair to go to the shower. He said he did not remember their names, but one of them was a huge woman who was tall, and very strong, and he could not remember if he had seen her before that, but did not think he had seen her since. He thought someone told him she was no longer working there. He said during the disagreement the large woman grabbed his left hand so hard he could not pry her hand off, and she left a bruise. He said they hauled him out of his room. He could not remember when he got into the chair, but he said the abuse happened in the room, and down to the shower room. He said that two male staff then showered him, and were very nice, and repeatedly apologized, though it was not their fault. He said that the staff were all very nice, and he liked them, except for the woman who grabbed his hand. He did not feel afraid of anyone. Observed at the time of this interview was an assortment of disposable plastic cups on his bedside table with items like sugar and salt packets, and margarine packets. He explained there were usually more things on the table and when he left the room the staff took advantage of his absence, and cleaned his room, getting rid of his things, which was why he insisted on having his showers when one of his friends was there, to make sure that did not happen. The surveyor confirmed with the resident that the items on his table were the belongings he was referring to. He said he did not report the incident to anyone when it happened, because he did not know that he could, so they did not know about it right away. He said the staff now knew he wanted to take showers only when his friend was there to watch his things. An interview on 12/04/24 at 12:43 PM with CNA I revealed Resident #32 was very aware of what was happening, during the incident. He said the resident often refused showers, and he thought it had been about a week since he allowed them to shower him. CNA I said the DON and LVN G seemed stuck on doing it (showering the resident), and he kept refusing. He said the Former Staffing Coordinator came into the room, and he thought he remembered her holding the resident down so they could try to clean him, while he tried to push them off, and she held his arm down. He said the Former Staffing Coordinator quit soon after the incident. He said Resident #32 did allow him, another male CNA (CNA J) to take him down to the shower room. An interview on 12/04/24 at 1:27 PM with the Former Staffing Coordinator revealed she had been called into Resident #32's room, and when she got there, CNA I, the DON, and LVN G were in the room. She said she did not know what they wanted her to do, because Resident #32 did not want to shower, so there was nothing she could have done. She said the resident was new to the facility, and she did not really know him well. She said she talked to him, and said it was his shower day, but the resident said he wanted no ladies so she was trying to leave the room. She said she did not remember if she touched him, but she denied ever grabbing him. She said the resident said he would take a shower if all the women left, and CNA I showered him, and she left the room. She said she was not suspended as a result of the incident, and she was never made aware that anyone thought she hurt his arm. While she was in the room, she said, she never saw anyone be rough, or grab at him or his bedding, and everyone was being nice. An interview on 12/04/2024 at 3:16 PM with the Former Administrator revealed on 10/31/24 the SW told her there was a potential abuse report by Resident #32, who said large black ladies went into his room, hurt him, mistreated him, grabbed his arm, and made him take a shower. The SW told her that the DON was in the room during the incident. The Former Administrator went to Resident #32's room, and he told her that it was three, large, black women who came into his room, and asked him about taking a shower. He said he refused and one of them grabbed his arm so tight he had to pry her fingers off his wrist. The Former Administrator said she saw he had about an inch and a half bruise, with a small skin tear in the middle of it. The resident did not know names, and could only describe them as three large, black women and he could not tell her which one grabbed his arm, and could not say an exact time it happened, only the day. She interviewed staff to see who was there. She said someone told her a male CNA entered the room at one point, but Resident #32 did not say anything about any males in the room. She self-reported it and did what she could to protect the resident, not knowing who had been in the room. She said she suspended the Former Staffing Coordinator, who fit the description of the one who hurt his arm, but was not able to get a statement from her, because she left before she could speak to her, and quit and would not return her calls. They had one nurse who was African American, but she was slender, and the resident insisted the one who hurt him was larger, and had been in the room, pulling at his blankets, and trying to get him to take a shower. She had the Social Worker do safe resident surveys, and talked to any staff who were there and might have observed anything. She had some trouble getting CNA I's statement, but later in the investigation, when she got it she found the statement kind of disturbing, but she turned it in with the rest and considered that part of the original self-report. When she finally got his statement, she saw that he said it was the DON, LVN G, and the Former Staffing Coordinator (who was already gone at the time she received the statement.) As part of the investigation she got statements from everyone else, and suspended the perpetrator if one was confirmed or someone fit the description. She said she put the Former Staffing Coordinator on suspension, but she never returned back to work, and even though she tried several times to get her to give a statement, she was never able to get one. An interview on 12/04/2024 at 4:08 PM with the VP revealed it was their protocol to suspend anyone with an allegation. She said when the Former Administrator called her with the original allegation she told her to immediately suspend the Former Staffing Coordinator, who was the staff member who fit the description the resident gave them. The Former Administrator said the Former Staffing Coordinator had left early because she was sick, but she would suspend her, but they never got to suspend her because she never came back to the facility and would not return phone calls. She told the Former Administrator to call the police, and to get statements from anyone who was there, and talk to the DON and other residents. An interview on 12/04/2024 at 4:33 PM with the DSM revealed she was notified to go investigate the incident with Resident #32. Resident #32 had alleged that a larger African American woman had grabbed his wrist, and that there were 3-4 ladies trying to get him to take a shower, and the lady who grabbed him left a bruise. He said everyone there had been professional, and friendly, and that the woman who had grabbed his arm was no longer there and he had never seen her again. He said women had looked at his bottom due to an abscess he had, and tried to get him to take a shower, but they were not the one who grabbed him. He said he felt safe, and comfortable, and this had been an isolated incident. She said she talked to him and learned that he preferred to be showered by males, and that he wanted his friend to be there to watch his things while he was out of the room. The DON was inserviced. An interview on 12/05/2024 at 5:10 PM with LVN G revealed she and the DON had not originally gone to Resident #32's room to get him to shower. She said he had an abscess on his bottom they needed to check on. She said when he rolled to his side to let them look they could see that his bed was filthy with urine, BM, food, and they could see flakes of skin, and he and his bed needed to be cleaned up. She said it had been a while, but she remembered that they talked him into taking a shower. She said they told him he hadn't taken one the day before, she thought. He didn't want to, because he had for a friend, or family member, she thought, but she was having trouble remembering. They told him that they could make sure that someone told his visitor that he would be right back from the shower soon. She thought he said he would consider it if males could shower him. She thought that the Former Staffing Coordinator had also been in the room part of the time, and a male CNA, but she did not know when they came into or left the room. Someone assisted him into the shower chair and took him to the shower room, and while he was gone she and the DON, and the other person she thought was the Former Staffing Coordinator, washed the bed with a basin of water, sanitized it, and wiped down the whole room. They did not throw away anything, just cleaned everything. She said she did not see anyone grab him, or be abusive in any way. If she had, she said she would have reported it to the (former) Administrator immediately. She said that residents had a right to refuse care. An interview on 12/05/2024 at 5:45 PM with the DON revealed she went with LVN G and the Former Staffing Coordinator because they needed to look at Resident #32's abscess. She said the abscess was healed, but his bed was filthy and his brief was soaking wet and had BM on him. He said not right now because he had family coming, and they told him they could tell his family he would be right back when they arrived. He said that was OK, and he wanted male CNAs so they called two male CNAs, and they took him to shower. She and LVN G washed and sanitized the bed, and put clean linen on. She was normally part of the investigations of self-reports, but she was never shown that one. She was informed that there had been an allegation a heavy-set black women going into his room, and making him take a shower. She remembered the bruise on the back of his hand, and he told her it was from scratching himself when he took his watch off. She said the lady who fit the resident's description was no longer working there when the corporate person came. Review of a skin assessment done on 11/08/24 at revealed Resident #32 refused the assessment. Review of the facility Abuse Prevention Program policy, dated 04/08/21, reflected: 1) Prevention Component: Abuse Policy Requirement: It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how, when, and to whom to report concerns, incidents, and grievances without the fear of reprisal. The facility will then provide feedback regarding those concerns or complaints. The facility administrative staff will consistently reinforce this information to residents, families and staff. Procedures: There are policies and procedures written in this program on detecting and preventing abuse, neglect and exploitation. The facility will monitor activities to identify indicators for abuse, neglect and exploitation. Organizational practices that influence quality of care and quality of life including staffing levels, certified nursing assistant involvement in planning and evaluating care, and environmental considerations are monitored. Basic problem-solving components include periodic reviewing and revising policies and procedures for State and Federal compliance, analyzing all incidents, reviewing incident reports, reviewing reports on abuse, neglect, and exploitation and assessing for trends and analyzing satisfaction surveys.

Based on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident #32) of eight residents reviewed for abuse and neglect. The Former Administrator and corporate staff failed to immediately suspend two staff members (the DON and LVN G) pending investigation when an allegation of physical and emotional abuse of Resident #32 was made in a statement by CNA I on 11/04/24 during the investigation of a self-reported allegation by Resident #32 of physical abuse by the Former Staffing Coordinator (who was suspended). The DON and LVN G were also not suspended immediately when corporate staff became aware on 11/17/24 the DON and LVN G staff had not been suspended by the Former Administrator (the day before their re-investigation of the self-report and allegation by CNA I on 11/18/24). This failure could place residents at risk of a lack of protection from being abused pending the investigation of an allegation of abuse. Findings included: Review of the facility Abuse Prevention Program policy, dated 04/08/21, reflected: 5) Protection Component: Abuse Policy Requirement: It is the policy of this facility that rights will be protected of alleged victims of abuse, neglect, misappropriation or mistreatment, as well as the rights of staff who are accused of abuse, neglect, misappropriation or mistreatment- as well as those who report it. Procedures: The alleged perpetrator will immediately be removed from the resident and the resident will be protected. Review of Resident #32's face sheet reflected an [AGE] year-old male, admitted on [DATE], with diagnoses of Acute embolism and thrombosis of unspecified deep veins of left lower extremity (a blockage caused by a blood clot in the leg), Urinary tract infection, site not specified, lack of coordination, Spondylolisthesis, lumbar region (a condition in which vertebra slip out of place, and cause pain), and Cauda equina syndrome (a rare condition in which nerve roots at the bottom of the spinal cord are compressed, considered a medical emergency.) Review of Resident #32's care plans reflected the following care plans: - Urinary Incontinence and pain, dated 11/27/24 - ADLs re: Non-compliant behavior dated 11/19/24 Review of Resident #32's Admission MDS Assessment, dated 10/04/24, reflected his sight and hearing were adequate, and he was able to express himself, be understood by others, and to understand others. His BIMS score was 12, indicating possible moderate cognitive impairment. He had no indicators of depression, or psychosis, and exhibited no behavioral problems. Resident #32 indicated it was very important to him to take care of his personal belongings or things, and to have a place to keep them safe. He was able to eat with only set-up or clean-up assistance, but was dependent on staff for toileting and bathing. Review of the facility investigation documentation for a self-reported allegation of abuse by a resident, submitted to HHSC by the Former Administrator on 10/31/24, reflected Resident #32's allegation that some female staff members had entered his room, and tried to get him to take a shower on 10/29/24, which he refused. The document reflected that he stated one of the women (thought to be the Former Staffing Coordinator) handled him roughly and bruised his hand. In the investigation materials provided, a statement by CNA I, dated 11/04/24, (appearing to be a text message) reflected that the CNA had been in the room during this incident, and observed the DON and LVN G refusing to honor the resident's refusal, telling the resident he had scabies and demanding in a harsh way that he had to be bathed in spite of his refusals, and pulling the bedlinens off the resident while he tried to pull them back. The statement also reflected the (Former) Staffing Coordinator was asked to come into the room to assist, and because the resident continued to refuse, he was informed he would have to have a bed bath. CNA I's statement reflected the DON and the Former Staffing Coordinator asked CNA I to get basins of water, with which they proceeded to pour water onto the resident in his bed while he was still wearing a gown, and wiped him between the legs, and on other parts of his body. The statement reflected that CNA J entered the room and made the women leave, after which CNA I and CNA J were able to shower the resident with his consent, as he preferred showers by male staff. The facility investigation reflected the resident was observed to have a small bruise on his left hand, where he was allegedly grabbed. An interview with Resident #32 on 12/03/24 at 3:04 PM, with his friend, Visitor K, present, revealed him to be alert, and oriented, with some forgetfulness. He said that some women came into his room, and told him he had to take a shower. He said that he told them he would do it the following day, and they said no and that he always said that, but he would not do it, so they wanted him to do it right then. He said they removed his clothing and stripped his bed, and he did not remember when he ended up in the chair to go to the shower. He said he did not remember their names, but one of them was a huge woman who was tall, and very strong, and he could not remember if he had seen her before that, but did not think he had seen her since. He thought someone told him she was no longer working there. He said during the disagreement the large woman grabbed his left hand so hard he could not pry her hand off, and she left a bruise. He said they hauled him out of his room. He could not remember when he got into the chair, but he said the abuse happened in the room, and down to the shower room. He said that two male staff then showered him, and were very nice, and repeatedly apologized, though it was not their fault. Twice during the conversation with the surveyor he denied the women attempting to give him a bed bath, saying that never happened, and he would remember that because he was given bed baths in the hospital, and he did not like them, and did not want them. He said that the staff were all very nice, and he liked them, except for the woman who grabbed his hand. He did not feel afraid of anyone. Observed at the time of this interview was an assortment of disposable plastic cups on his bedside table with items like sugar and salt packets, and margarine packets. He explained there were usually more things on the table and when he left the room the staff took advantage of his absence, and cleaned his room, getting rid of his things, which was why he insisted on having his showers when one of his friends was there, to make sure that did not happen. The surveyor confirmed with the resident that the items on his table were the belongings he was referring to. He said he did not report the incident to anyone when it happened, because he did not know that he could, so they did not know about it right away. He said the staff now knew he wanted to take showers only when his friend was there to watch his things. An interview on 12/04/24 at 12:43 PM with CNA I revealed Resident #32 was very aware of what was happening, during the incident. He said the resident often refused showers, and he thought it had been about a week since he allowed them to shower him. CNA I said the DON and LVN G seemed stuck on doing it (showering the resident), and he kept refusing. He said the Former Staffing Coordinator came into the room, and he thought he remembered her holding the resident down so they could try to clean him, while he tried to push them off, and she held his arm down. He said the Former Staffing Coordinator quit soon after the incident. CNA I said he felt uncomfortable about it, because the resident had a right to refuse care, and he did. He said the DON kept saying Resident #32 had scabies, as a reason that they needed to bathe him, and the resident did not have scabies. He said she was just saying that to try to get him to have a bath, but he continued to refuse, and was completely capable of making his own decisions. CNA I said the resident only wanted to take a shower when one of his trusted friends was there to watch his stuff, because the housekeeper took his things off the table, and he was upset about that. He said Resident #32 did allow him, another male CNA (CNA J) to take him down to the shower room. CNA I said the reason he did not immediately report was because the Administrator was gone that day, and the DON was part of it, so he did not know who to tell, but he did tell the Administrator when he could. He was aware at the time of this interview that the Administrator was to be immediately informed of anything thought to be abuse or neglect. He said the resident preferred to be bathed by men, so he was not going to go for a bunch of women coming in to give him a shower. An interview on 12/04/24 at 1:27 PM with the Former Staffing Coordinator revealed she had been called into Resident #32's room, and when she got there, CNA I, the DON, and LVN G were in the room. She said she did not know what they wanted her to do, because Resident #32 did not want to shower, so there was nothing she could have done. She said the resident was new to the facility, and she did not really know him well. She said she talked to him, and said it was his shower day, but the resident said he wanted no ladies so she was trying to leave the room. She said she did not remember if she touched him, but she denied ever grabbing him. She said the resident said he would take a shower if all the women left, and CNA I showered him, and she left the room. She said she was not suspended as a result of the incident, and she was never made aware that anyone thought she hurt his arm. While she was in the room, she said, she never saw anyone be rough, or grab at him or his bedding, and everyone was being nice. An interview on 12/04/2024 at 3:16 PM with the Former Administrator revealed on 10/31/24 the SW told her there was a potential abuse report by Resident #32, who said large black ladies went into his room, hurt him, mistreated him, grabbed his arm, and made him take a shower. The SW told her that the DON was in the room during the incident. The Former Administrator went to Resident #32's room, and he told her that it was three, large, black women who came into his room, and asked him about taking a shower. He said he refused and one of them grabbed his arm so tight he had to pry her fingers off his wrist. The Former Administrator said she saw he had about an inch and a half bruise, with a small skin tear in the middle of it. The resident did not know names, and could only describe them as three large, black women and he could not tell her which one grabbed his arm, and could not say an exact time it happened, only the day. She interviewed staff to see who was there. She said someone told her a male CNA entered the room at one point, but Resident #32 did not say anything about any males in the room. She self-reported it and did what she could to protect the resident, not knowing who had been in the room. She said she suspended the Former Staffing Coordinator, who fit the description of the one who hurt his arm, but was not able to get a statement from her, because she left before she could speak to her, and quit and would not return her calls. They had one nurse who was African American, but she was slender, and the resident insisted the one who hurt him was larger, and had been in the room, pulling at his blankets, and trying to get him to take a shower. She had the Social Worker do safe resident surveys, and talked to any staff who were there and might have observed anything. She had some trouble getting CNA I's statement, but later in the investigation, when she got it she found the statement kind of disturbing, but she turned it in with the rest and considered that part of the original self-report. She said the resident did not say anything about anyone pouring water on him. She said that CNA I had come to her confidentially, and said he felt threatened, and did not want to speak to anyone about it, but she told him she needed the statement. When she finally got his statement, she saw that he said it was the DON, LVN G, and the Former Staffing Coordinator (who was already gone at the time she received the statement.) She said CNA I said the DON and LVN G were jerking the resident's blankets, roughhousing him, and he said he witnessed them pouring water on the resident while he was in the bed, and coaxing him to turn over so they could look at his bottom, saying he had scabies, something like that. She said she sent the self-report to the regional staff, and was told that CNA I had been written up several times, and that what he said he witnessed did not happen. She said she went back to Resident #32, and asked him about the water, and he said he did not remember all of it, but he was fine. She said what CNA I said was not consistent with any of the other statements, and the DON and LVN G were not suspended. She said that she was not allowed to suspend them, and she was told by the VP that the resident did not say any of that (the DON and LVN G abusing him) happened. She clarified that they did not specifically say she could not suspend the DON and LVN G, but she was told that the DON was a very good DON and that CNA I's statement was more about being upset and falsely saying things in his statement. She said she had not been at the facility very long, and this had happened in the first week or two, and she was going on what the resident told her. As part of the investigation she got statements from everyone else, and suspended the perpetrator if one was confirmed or someone fit the description. She said she put the Former Staffing Coordinator on suspension, but she never returned back to work, and even though she tried several times to get her to give a statement, she was never able to get one. She said LVN G was suspended the day before she left (11/14/24). An interview on 12/04/2024 at 3:41 PM with the SW revealed she had spoken with Resident #32 about the allegation of abuse. She said he told her that some people were rough with him, and he was not able to identify them or give a clear enough description of them for her to identify them. She said when she asked what they did, he told her that they demanded he take a shower. She asked him if he took a shower and he said that a very nice male staff had given him one. The Former Administrator told her to go back and get a written statement, and to return to her office. She was not aware of the statement involving the DON and LVN G, but she said if a staff member was trying to remove blankets that someone did not want removed, or trying to make a resident do something against their will, she would consider that an abuse. She said if a staff member made a statement that named staff member involved in it, those staff members would be investigated immediately. She said it did not matter if it was true, or if they were the Medical Director, Administrator, or DON, they would have to follow their policy the same they would with anyone. An interview on 12/04/2024 at 4:08 PM with the VP revealed that she did not say, and in no way implied, that the Former Administrator could not suspend someone when there was an alleged abuse by them. She said it was their protocol to suspend anyone with an allegation, and it did not matter who it was. She said when the Former Administrator called her with the original allegation she told her to immediately suspend the Former Staffing Coordinator, who was the staff member who fit the description the resident gave them. The Former Administrator said the Former Staffing Coordinator had left early because she was sick, but she would suspend her, but they never got to suspend her because she never came back to the facilty and would not return phone calls. She told the Former Administrator to call the police, and to get statements from anyone who was there, and talk to the DON and other residents. She said they use an electronic meeting and messaging app for communication, and they had a system in place to use it for any high risk event. She said the event gets entered into the facility's events in the app, and the corporate administrative staff would give direction and advice about how to handle the investigation. They would tell the Administrator actions they needed to take, like head-to-to assessments, initial self-report statements and in-service, and they could review the reports and investigation. She said the only thing the Former Administrator reported to her was that there was a disgruntled CNA who was going to write a bad statement against the DON because they were upset with her, and she needed to know what to do from there. The VP said she told the Former Administrator that she needed to see the self-report and investigation to review it, but she never sent her what she sent to the state. She said when the Former Administrator started there was so much chaos and fighting among the department heads, and she described how the Former Administrator appeared to be deliberately trying to turn people against each other, and she had to terminate her employment because of it. She said when the Former Administrator left, she took a lot of original paperwork with her, including the self-report. The VP said after she was gone, they had to get an IT person to retrieve what they could, and they were able to get the investigation documents that way. She said on 11/18/24, the day after they saw the statement by CNA I, she had their DSM, who helps them with clinical issues, and is also a Social Worker, go to the facility and investigate more. She said they called the police to go to the facility, as well. She said they wanted confirmation that it was not the DON who had grabbed his wrist, and the resident told the DSM that it was not her, and that she checked on him all the time, and was nice. They had the resident assessed for scabies, to make sure that was not true, and he did not have scabies. She said that the DSM got everyone's statements again, and they did not think what they found warranted abuse. She said CNA I did speak with the DSM, but she did not have the notes, and he had been written up before. She said when the DON was hired, she started holding staff accountable, and CNA I was probably upset, so his statement did not match anyone else's. She said the resident's statement, and all the other staff statements matched, but CNA I's statement did not. She said the resident's biggest complaint was that they grabbed his wrist. He said he did not have water poured on him, and he did not want females to bathe him. She said they did an inservice on approach with the DON, and told her we know you want everyone to be clean, but when they say no, it's no. She said the DSM had investigated a little further and learned why Resident #32 did not want to go to the shower room. She said if the Former Administrator thought it was abuse, she should have called it in, and followed the policy. An interview on 12/04/2024 at 4:33 PM with the DSM revealed she was notified to go investigate the incident with Resident #32. They had not seen the statement by CNA I until after it had already been reported to the state, and the Former Administrator was gone. Once they saw it, they went back immediately (the following day, 11/18/24), and Resident #32 denied it happened. Resident #32 had alleged that a larger African American woman had grabbed his wrist, and that there were 3-4 ladies trying to get him to take a shower, and the lady who grabbed him left a bruise. She spoke with the resident numerous times, and he said he did not get a bed bath or have water poured on him, and the only problem was that the lady grabbed his arm. She took the DON and LVN G (separately) into his room, and they chit-chatted with him, and she went back each time and made sure that neither of them had harmed or threatened him in any way. He said everyone there had been professional, and friendly, and that the woman who had grabbed his arm was no longer there and he had never seen her again. He said women had looked at his bottom due to an abscess he had, and tried to get him to take a shower, but they were not the one who grabbed him. He said he felt safe, and comfortable, and this had been an isolated incident. She said she talked to him and learned that he preferred to be showered by males, and that he wanted his friend to be there to watch his things while he was out of the room. The DON was inserviced. An interview on 12/05/2024 at 5:10 PM with LVN G revealed she and the DON had not originally gone to Resident #32's room to get him to shower. She said he had an abscess on his bottom they needed to check on. She said when he rolled to his side to let them look they could see that his bed was filthy with urine, BM, food, and they could see flakes of skin, and he and his bed needed to be cleaned up. She said it had been a while, but she remembered that they talked him into taking a shower. She said they told him he hadn't taken one the day before, she thought. He didn't want to, because he had for a friend, or family member, she thought, but she was having trouble remembering. They told him that they could make sure that someone told his visitor that he would be right back from the shower soon. She thought he said he would consider it if males could shower him. She thought that the Former Staffing Coordinator had also been in the room part of the time, and a male CNA, but she did not know when they came into or left the room. Someone assisted him into the shower chair and took him to the shower room, and while he was gone she and the DON, and the other person she thought was the Former Staffing Coordinator, washed the bed with a basin of water, sanitized it, and wiped down the whole room. They did not throw away anything, just cleaned everything. She said she was not aware anyone had made an allegation of abuse about her, and she was never suspended. She did receive an inservice about customer service and the right of residents to say no after that. She said she did not see anyone grab him, or be abusive in any way. If she had, she said she would have reported it to the (former) Administrator immediately. She said that residents had a right to refuse care. An interview on 12/05/2024 at 5:45 PM with the DON revealed she went with LVN G and the Former Staffing Coordinator because they needed to look at Resident #32's abscess. She said the abscess was healed, but his bed was filthy and his brief was soaking wet and had BM on him. He said not right now because he had family coming, and they told him they could tell his family he would be right back when they arrived. He said that was OK, and he wanted male CNAs so they called two male CNAs, and they took him to shower. She and LVN G washed and sanitized the bed, and put clean linen on. She was normally part of the investigations of self-reports, but she was never shown that one. She was informed that there had been an allegation a heavy-set black women going into his room, and making him take a shower. She remembered the bruise on the back of his hand, and he told her it was from scratching himself when he took his watch off. A corporate person came after the Former Administrator left, and said that she and LVN G were mentioned in the self-report. They were in-serviced on approach. She said the lady who fit the resident's description was no longer working there when the corporate person came. The corporate lady said the statement said they poured water on the resident, and that LVN G was rough with him. The corporate came out and did investigation, and said it was something that was blown way out of proportion. An interview on 12/05/2024 at 6:13 PM with the Administrator revealed he had only been at the facility for two weeks, but had been an Administrator for a long time, and the allegation the surveyor described (coercing a resident to shower when they said no, pulling bedding off of them, and pouring water on them in bed) would definitely be considered an allegation of abuse. He said the staff involved should have been suspended, and it did not matter who they were. He said he had once been suspended pending investigation, because he matched a vague description given, and it was not personal. He said if someone made a new allegation during an investigation of another allegation, that would still be investigated. He said if something happened a long time ago, and someone made a new allegation about it, they would still follow the policy, and investigate and suspend. Review of a skin assessment done on 11/08/24 at revealed Resident #32 refused the assessment.

Based on observations, interviews, 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 each resident for one of Two residents (Resident#18) reviewed for medication adminstration via gastrostomy tube (G-tube). RN H did not check placement of Resident #18's G-tube prior to medication administration and feeding. This failure could place residents who had gastrostomy tubes at risk for complications, aspiration, and pneumonia. Findings included: Review of Resident #18's face sheet dated 12/03/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (this is a brain condition that progressively destroys memory and other important mental functions), muscle weakness, lack of coordination, adult failure to thrive and gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individuals who have difficulty swallowing). Review of Resident #18's annual MDS assessment dated [DATE] reflected Resident #18 had a BIMS score of 0 out of 15, indicating severe cognitive impairment and was unable to make self-understood by others and she was dependent on staff for all ADLs and required a feeding tube to obtain 51 % or more nutrition. MDS reflected Resident #18 was dependent on staff for all upper and lower bed mobility including turning and repositioning in bed. Review of Resident #18's physician orders dated December 2024, revealed, Resident #18 had a g-tube and to check g-tube placement prior to feeding and/or medication administration, and by aspiration of gastric contents every shift; check for residual every shift. The resident was to receive formula Isosource 1.5 at 45 ml per hour and water flush of 175 ml every 4 hours via g-tube for 22 hours. Formula: Isosource 1.5 at 45 ml/hour X 20 hours. Off at 8AM and ON at 12 Noon. Twice Day 08:00 AM, 12:00 PM. Enteral Feeding: Water flush Special Instructions: Flush g-tube with 30ml of water before and after medication administration every shift. Every Shift: days, evenings, nights. Baclofen tablet; 10 mg; amt: 1 tab; gastric tube special instructions: Give 1 tab via g/tube 3x daily three times a day 09:00 am, 01:00 pm, 06:00 pm. Review of Resident #18's care plan dated 08/28/24 revealed resident had an enteral feeding tube related to adult failure to thrive. The goal was not to have any problems from g-tube use through the next review date. The interventions were always to elevate head of bed 30-45 degrees, to check residual by aspirating stomach content and to check tube placement by auscultating (listening to) air passage. During an observation and interview on 12/03/24 at 12:08 pm., Resident #18 was in bed with feeding disconnected. RN H administered 30 ml of water, via Resident #18's g-tube. She then administered medication Baclofen, and then another 30 ml of water after medication administration. RN then attached the formula feeding tube to Resident #18's g-tube and restarted the feeding pump. RN H did not check Resident #18's g-tube placement before administering water, medication, and/or feedings. RN H stated she turned off Resident #18's feeding at 08:00 AM for ADL care. RN H stated ADL care included bed bath, incontinent care, oral care, and linen change. RN H stated she listened to Resident #18's g-tube placement and checked the residue this morning before turning it off at 08:00 AM. She stated she forgot to re-check the g-tube placement before medication administration again and before restarting feedings. She stated the reason she forgot was because she was nervous being watched. RN H stated it was important to check placement each time the g-tube was accessed to make sure that the g-tube was still in place due to the risk of tube displacement during ADL care and down time which could cause contents to go into the lungs if the g-tube is not in the correct place. During an interview on 12/05/24 at 5:45 p.m., DON stated the orders for Resident #18 indicated to check placement and residual prior to feeding and medication administration. The DON said RN H should have checked for placement for Resident #18. She stated that not checking placement before medication administering and feeding placed the resident at risk for tube migration (movement). She stated the expectation was to check g-tube placement because it might be dislodged while providing care. She stated the risk of not checking placement was you can administer into the peritoneal cavity (membrane that lines the abdomen and pelvis) and cause infection, or they may put medication in the wrong place and cause the resident to get an infection in the stomach. The DON indicated she expected the nurses to follow the physician orders, and it was the nurse's responsibility to follow orders as prescribed. The DON stated RN H had completed g-tube competency prior to taking care of residents with g-tubes and she had done a 1:1 Inservice after this incident. In an interview with the Administrator on 12/05/24 at 6:14pm., he stated even though he was not clinical, he expected the nursing staff to follow proper policy and procedure, to have job knowledge, and to know the proper channel to go to like the DON or ADON in case they did not know how to do something. He stated the risk to the resident for not following proper procedures can be pretty harmful. Review of facility clinical competency reflected RN H completed check off for g-tube medication administration competency on 10/31/24. Review of facility policy titled Administering Medication through an Enteral Tube, dated 08/26/22 reflected . The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube Verify that there is a physician's medication order for this procedure . Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed) . Confirm placement of feeding tube. 19. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 20. Check gastric residual volume (GRV) to assess for tolerance of enteral feeding. 21. When correct tube placement and acceptable GRV have been verified, flush tubing with 15-30 mL warm water (or prescribed amount) .

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of four residents (Resident #7) reviewed for storage of medication. The facility failed to ensure Resident #7's blood pressure patch medication Clonidine was secured by CMA F and not let unattended on top of the medication cart. This deficient practice could place residents at risk of accidental ingestion of unprescribed medications and adverse reactions. The findings included: Review of Resident #7's face sheet on 12/04/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified dementia (this is a brain disease that alters brain function and causes a cognitive decline), high blood pressure, and stroke. Review of Resident #7's active physician order for December 2024 revealed Clonidine patch weekly; 0.1 mg/24 hr; amt: 1 patch; transdermal Special Instructions: Apply patch to chest wall once weekly. Remove old patch prior to applying new patch. Rotate sites Once a Day on Wed 08:00 AM. Review of Resident #7's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 indicating Resident #7 had moderate cognitive impairment. Review of Resident #7's care plan dated 10/23/23 revealed resident had malignant hypertension (this is a condition that can cause blood pressure to suddenly and severe increase and can lead to heart attack, stroke, and other life-threatening problems). The goal was for Resident #7's blood pressure would range between - greater than 90/less than140 systolic (top number of blood pressure reading) and less than 90_diastolic (bottom number of blood pressure reading). The intervention was to administer medication as ordered, to evaluate/record/report effectiveness or adverse effects, to administer oxygen for shortness of breath or oxygen less than 90% room air, to assess for chest pain and intervene as indicated. During medication observation on 12/04/24 from 07:56 AM to 08:15 AM., CMA F was observed leaving medication Clonidine patch 0.1 mg on top of the medication cart. A staff member was observed passing by the medication cart. CMA F could not see the medication cart due to the privacy curtain in Resident #7's room. The medication cart was unattended and out of view. In an interview with CMA F on 12/04/24 at 08:15am., she stated the Clonidine patch was used to treat high blood pressure and she should have locked the medication in the medication cart since the medication cart was out of view or she could have taken the medication in the room with her. She stated that she left the medication on top of the medication cart by accident. CMA F stated anyone could have taken the medication that was left unattended. She said the resident could eat it and have adverse effects to the medication like low blood pressure. She stated it was her responsibility to lock and secure medication when not in use and when unattended. CMA F stated, it was an honest mistake that she forgot to lock up or take the medication with her. In an interview with the DON on 12/04/24 at 08:18 am., she stated the expectation was for the person to take the medication inside the room or to lock it in the cart. The risk was that a resident or anyone could take it. She stated that she would in service the staff. She stated that she had done a medication check off twice since CMA F had been employed by the facility. Review of the facility's policy titled Medication Storage, dated 08/26/22, reflected: The facility shall store drugs and biologicals in a safe, secure, and orderly manner . Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications, . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others

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 1 of 2 (Resident #18) residents reviewed for enhanced barrier precaution infection control. The facility failed to ensure RN H wore a gown for PPE while providing care to Resident #18 who was on enhanced barrier precaution. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: Review of Resident #18's face sheet dated 12/03/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (this is a brain condition that progressively destroys memory and other important mental functions), muscle weakness, lack of coordination, adult failure to thrive and gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individuals who have difficulty swallowing). Review of Resident #18's annual MDS assessment dated [DATE] reflected Resident # required a feeding tube to obtain 51 % or more nutrition. Review of Resident #18's physician orders dated December 2024, revealed, Resident #18 reflected Enhanced Barrier Precautions for Wound and G-Tube: Gown and gloves for High contact. Every shift Days, evening, Nights. Review of Resident #18's Care Plan initiated 10/22/24, revealed Resident #18 was on Enhanced Barrier precautions related to feeding tube and wound to lower extremity. The goal was for enhanced barrier precaution would reduce the risk of transmission (spread) of known and unknown MDRO. The interventions were to alert the provider for signs and symptoms of an active or worsening infection, to wear EBP which included use of gowns and gloves during high contact resident care, EBP to remain in place for the duration of the resident's stay OR until resolution of the wound or removal of the indwelling medical device, and EBP will be utilized during High-Contact resident care activities including bathing, dressing, and transfer, linen changes, incontinent care, wound care and/or indwelling device care. During an observation and interview on 12/03/24 at 12:08 pm., for Resident #18, revealed door signage read . STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as; central lines, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. RN H did not wear a gown for PPE while providing g-tube care for Resident #18 who was on enhanced barrier precaution isolation. RN H stated, I do not wear a gown for G-tube care, I wear a gown when providing wound care for the resident. RN H did not respond when asked if g-tube was considered an indwelling medical device and PPE should be worn. RN H did not state the risk for not following enhanced barrier precautions. During an interview on 12/05/24 at 5:45 p.m., the DON stated she was also the infection control preventionist. She stated all nursing staff were expected to follow EBP when providing care for residents with indwelling medical devices and that included g-tube care. She stated RN H may have misunderstood the EBP questions when surveyor asked her due to communication barrier. DON stated nursing staff are responsible for making sure that they follow the policy of preventing the spread of infection. The DON stated that not following infection control precautions can cause spread of infection. She stated she had done a 1:1 Inservice after the incident. In an interview with the Administrator on 12/05/24 at 6:14pm., he stated even though he was not clinical, he expected the nursing staff to follow proper policy and procedure, to have job knowledge, and to know the proper channel to go to like the DON or ADON in case they did not know how to do something. He stated the risk to the resident for not following proper procedures can be pretty harmful. Review of the facility's Implementation of Standard and Transmission-Based Precautions policy, dated 03/24, revealed, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use .

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #1, Resident #2) of 10 residents reviewed for call lights. Staff failed to ensure Resident #1 and Resident #2, call buttons were within reach. This failure could place resident at risk for decreased quality of life, self-worth, and dignity. Findings included: Review of Resident #1's face sheet dated 01/10/2024 reflected a [AGE] year-old female admitted to the facility on 10/30/2023 with diagnosis of Other Specified Sepsis (A life-threatening reaction to an infection that damages tissues and organs); Cerebral Infarction, Unspecified (Disrupted blood flow to the brain due to problems with blood vessels that supply it); Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus (Seizures that can't be completely controlled by medicine). Review of Resident #1's Comprehensive Care Plan revised 10/31/20233 reflected Resident #1 is a risk for falls related to CVA (Cerebral Vascular Accident) and cognitive deficits with poor safety awareness. No interventions in place for call light placement within reach. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] reflected the resident was moderately cognitively impaired. Resident #1 required supervised assistance with ADLs. BIMS Score (Brief Interview for Mental Status) was 08/15. Observation on 01/10/2024 at 12:30 pm revealed Resident #1 was in her recliner and her call light was across from her out of reach laying on her bed to the left of her. Resident #1 could not reach the call light if she needed to push the button. On 01/10/2024 at 12:30 pm interview with Resident #1 revealed that she would have to call out for help if she could not reach the call light to push for help. Review of Resident #2's face sheet dated 01/10/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinsonism, unspecified (A motor syndrome that manifests as rigidity, tremors and bradykinesia); Chronic obstructive pulmonary disease, unspecified (A condition involving constriction of the airways and difficulty or discomfort in breathing); Difficulty in walking, not elsewhere specified (Gait disorders are an abnormal walking pattern with many possible causes like an injury, sore, and inner ear (balance) issue or nerve damage). Review of Resident #2's Comprehensive Care Plan revised 11/02/2023 reflected Resident #2 has history of falling related to impaired mobility and unsteady gait. She has poor safety awareness and is very impulsive. Care Plan did not address call lights. Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] reflected the resident moderately cognitively impaired. Resident #2 required supervised to extensive assistance with ADLs. BIMS Score (Brief Interview for Mental Status) was 09/15. Observation on 01/10/2024 at 12:45 PM revealed Resident #2 was in her bed and her call light was under her bed. Interview with Resident #2 revealed that she was doing fine and did not need anything. Resident was not aware her call cord was in the floor. In an interview on 01/11/2024 at 1:30 PM with ADM revealed he was not aware of the call lights were not within reach of the residents. The ADM stated that not having the call light within reach would cause several issues for the resident may try and get up and fall. In an interview on 01/11/2024 at 1:45 PM with CNA A revealed that she did not know the call lights were not within reach for Resident #1 or Resident #2. Revealed to CNA that there were 2 residents out of 10 residents that did not have call light within reach. CNA A revealed that Resident #1 does get up and walk around. Ask CNA A what could happen if call light was not within reach of resident who needed assistance? CNA A revealed resident could try and get up and fall, may be sick and need assistance, or may just need water. CNA A revealed she would make sure all call lights were within reach. Review of the facility's policy Answering the Call Light. implemented on September 21, 2022, indicated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

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 one (Resident #3) of 5 residents observed for infection control. Resident #3's urinal with urine was left on top of Resident #3's bedside tray table which the resident used to eat meals on every day. This failure could place residents at risk of cross-contamination and the spread of infection. Findings included: Review of Resident #3's face sheet dated 01/11/2024 reflected a [AGE] year-old male admitted on [DATE] with the diagnoses of Chronic kidney disease, stage 3 unspecified (Longstanding disease of the kidneys leading to renal failure); Acquired absence of left leg below knee (below the knee amputation that involves removing the foot, ankle joint, distal tibia, fibula, and corresponding soft issue structures. Review of Resident #3's Comprehensive Care Plan revised 11/02/2023 reflected Resident #3 was at risk for activity intolerance related to imbalance between supply oxygenation needs. Interventions: included to provide assistance in self-care activities as needed. Resident would need assistance in moving items from bedside table. Review of Resident #3's MDS Assessment (Minimum Data Set) dated 12/24/23 reflected the resident's cognition was intact. BIMS Score (Brief Interview for Mental Status) was 15/15. Observation on 01/11/2024 at 12:00 PM, revealed Resident #3 in his room eating lunch, using his tray table with urinal on overbed table with urine in urinal. In an interview on 01/11/2024 at 12:00 PM with Resident #3 revealed that he did not like the urinal on the overbed table while he was eating his meals. Resident #3 expressed his frustration by commenting that there was nothing that could be done about it. In an interview on 01/11/2024 at 2:00 PM with ADM revealed he was not aware that the CNAs were not removing the urinals from the overbed tables before meals were served to male residents. The ADM will inform the DON to provide proper infection control training to all nursing staff. ADM agreed that the CNA should have removed the urinal and placed in another location before placing the lunch tray on the overbed table. Review of the facility's Infection Control policy Implemented January 2020 indicated this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 1 (Resident #7) of 12 residents and labeled in accordance with currently accepted professional principles for two (front hall medication cart and back hall medication cart) of two medication carts reviewed for labeling and storage. 1. Resident #7's had eye drops stored at the resident's nightstand and not locked in a lock box or secured in the medication cart or medication room. 2. The facility failed to ensure insulin vials were dated after they were opened. The failure could place residents at risk of unauthorized access to medications or receiving medications that were ineffective. Findings included: 1. Record review of Resident #7's face sheet revealed the resident was a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included vascular dementia (problems with reasoning, memory) and essential hypertension (high blood pressure) Record review of Resident #7's quarterly MDS dated [DATE] revealed BIMS was 0 indicating resident is rarely/never understood. It also revealed resident required assistance with 1 or more staff assistance for ADL care. Further review of the resident MDS indicated the resident's vision was impaired. Record review of Resident#7's care plan dated [DATE], revealed Resident is experiencing self-care deficits related to advance age and weakness and diagnosis. Resident #7 requires extensive assistance with ADLs. The care plan did not address self-administration of medications. Observation and interview on [DATE] at 10:45 AM revealed Resident #7 in his room sitting on his wheelchair. Observed Resident #7 to have Combigan (brimonidine tartrate/ timolol maleate ophthalmic solution 0.2%/0.5%) eye drops with an expiration date of ,d+[DATE] on his nightstand. Resident #7 stated he had always had his eye drops in his room. When asked further questions Resident #7 stopped responding to questions asked. Interview and observation on [DATE] at 1:48 PM with MA B revealed she was the medication aid for Resident #7. She stated she did not have any residents who can self-administered medications which included eye drops. MA B observed Resident #7's eye drop medications on the resident's nightstand . She stated she had already provided Resident #7 with his medications this morning and did not observe the eye drops on resident's nightstand. MA B stated she was not aware the resident had them. She stated resident did not have an order for this eye drops. MA B stated Resident #7's family had a history of providing the resident with medications without notifying the staff. She stated the risk of leaving medication unattended was that another resident might take the medications or the resident over medicating. 2. Observation on [DATE] at 1:15 PM of the front hall Medication Cart with LVN A revealed one insulin pen, Insulin basaglar (insulin glargine injection 100 units/mL) was opened, partially used, and not labeled with the open date. Interview on [DATE] at 1:20 PM with LVN A, who was the Charge Nurse for both front hall cart and back hall cart, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated, but she did not check that morning because the DON and ADON had checked the cart for the front hall, but she did not check the cart for back hall. LVN A revealed the risks of not putting the opening date was that a nurse would not know when the insulins expired, and the insulins might not be effective leading to residents having high blood sugar readings. She stated she was trained on labeling and dating medications, and it was all nurses' responsibility to check the carts to ensure medications and insulins were labeled and had an opening date before administering. Observation on [DATE] at 1:30 PM of the back hall Medication Cart with LVN A revealed four insulin pens, Insulin basaglar, insulin lispro, insulin Lantus and insulin Novolog opened, partially used, and not labeled with the open date. Interview on [DATE] at 1:40 PM with the ADON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated nurses are expected to check the carts every shift. The ADON stated she was responsible of monitoring the nurses every month. She stated she had checked the cart for front hall on [DATE] and had tasked LVN A to check the cart for back hall for open dates. She stated she had done training with LVN A on checking of the carts since she was a new nurse and the trainings were requested and not provided . She said if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication and the medication being ineffective leading to high blood sugar levels. Interview on [DATE] at 11:04 AM with the DON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication, leading to high blood sugar levels. She stated it was the responsibility of the DON and ADON to monitor the carts for labeling once a week and charge nurses to check the cart Mondays and Fridays for labelling. She stated she has trained the nurses on putting the open dates on insulin after they were opened. The DON stated she did not have any residents who can self-administered medications which included eye drops. The DON stated MA B made her aware of the eye drops that were found in Resident #7 room. She stated the family had a history of bringing medications to the resident without notifying them. The DON stated they have notified and educated the family on not bringing medications to the resident. The DON stated the risk of leaving medications or eye drops in residents' rooms could cause residents to over medicate and it was unsafe. Review of the facility's Administering Medication policy, dated [DATE], reflected the following: Medications cannot be left at bedside, for resident to take later. If a resident refuses medication and/or wishes to take at later time. The individual administering the medications shall initial and circle the MAR space provided for that drug and dose. Review of the facility's Insulin Administration policy, dated [DATE], reflected: .4.check expiration date if drawing from an opened multi dose vial. If opening new vial, record expiration date, and time on the vial (follow the manufacturers recommendations for expiration after opening). 44140

Based on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for five of five residents reviewed for food and nutrition services. The Dietary Manager failed to prepare and serve the pureed lunch meal on 10/19/23 in a manner to conserve nutrition, flavor, and palatability. The failure could place residents at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Observation of the Dietary Manager making pureed lunches on 10/19/23 at 10:37 AM revealed the Dietary Manager put herbed chicken breast in the blender, added one tablespoon of chicken flavored base in the blender, one slice of white bread, and then he blended. The Dietary Manger then was observed to add three eight-ounce cups of water to the chicken and blended the mixture. The pureed herbed chicken breast appeared to have a mashed potato consistency. Interview and record review with the Dietary Manager on 10/19/23 at 11:40 AM revealed the facility had five residents, who required a pureed diet. He stated he reviewed the recipe prior to cooking the food to he had all the ingredients that were needed. Review of the recipe for the pureed herbed chicken breast revealed it did not indicate that water was supposed to be added. The Dietary Manager stated he misread the recipe. The Dietary Manger stated by adding water to the pureed food it may result in the residents not receiving all the nutrients. Observation on 10/19/23 at 12:10 PM revealed two residents in the dining area eating the puree lunch meal as prepared by the Dietary Manager with the added water. Review of the facility's recipe for Pureed Herbed Chicken Breast from the Dining RD 2023 Menu revealed the following: Ingredients: Herbed Chicken Breast, Bread, [NAME] sliced, *Water, *Base, Chicken Combine chicken base and water to make chicken broth. Place prepared chicken and bread in a washed and sanitized food processor. Gradually add broth and blend until smooth. Note: 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Review of the facility's policy Portion Control policy, dated 10/01/18, revealed it did not address pureed meals.

Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #11) of 5 resident reviewed for respiratory care. The facility failed to follow physician orders for Resident #11 to receive oxygen at a rate of two liters per minute. This failure could place residents who received oxygen therapy at risk of respiratory complications. Findings included: Record review of Resident #11's face sheet revealed the resident was a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #11 had diagnoses which included pneumonia (infection that affects one or both lungs), and essential hypertension (high blood pressure) Record review of Resident #11's quarterly MDS dated [DATE] revealed BIMS at 15 indicating intact cognition. It also revealed resident required limited assistance with 1 staff assistance for ADL care. Further review of the resident MDS indicated the resident was on oxygen therapy. Record review of Resident#11's care plan dated 04/20/23, revealed Resident #11 requires oxygen therapy. Resident in on O2@2L via NC. Goal: Resident will not experience respiratory distress x next 90 days. Approach: Administer oxygen as ordered. Record review of Resident#11's physician order revealed oxygen at 2L/min continuous per NC active date 07/25/23. Record review of Resident # 11's TAR dated October revealed O2 at 2L/min continuous per NC every shift order date 07/25/23. During an observation and interview on 10/17/23 at 11:08 AM, Resident #11's was lying in bed and was receiving oxygen via nasal cannula. Observed oxygen concentrator dated 10/16/23 next to his bed and oxygen concentrator was set between 3L and 4L. Resident #11 said he did not change the oxygen setting on the concentrator. He said his oxygen setting should be set to 3 Liters. He stated the nurses were the ones who set the oxygen rate for him. Resident #11 could not recall who was the last nurse who adjusted his oxygen rate. Resident #11 denied any distress at this time. During an observation and interview on 10/18/23 at 1:43 PM revealed Resident #11's lying in bed and was receiving oxygen via nasal cannula. Observed oxygen concentrator next to his bed and oxygen concentrator was set between 3 and 4L. Resident #11 denied any distress at this time. Interview on 10/18/23 at 1:43 PM with LVN A revealed she had been employed for a week. She stated was the nurse assigned to Resident #11. She stated she could not recall if Resident #11 was on continues oxygen. She stated she does check Resident #11 O2 in the morning. She stated she could not recall how many liters Resident #11 oxygen should be set on. She stated for the week she had been employed she had not adjusted Resident #11 oxygen concentrator. LVN A and Surveyor reviewed Resident #11 physician orders and LVN A stated resident had an order for two liters. LVN A stated the nurses were responsible for setting the oxygen rate on the concentrators. She stated if the resident was receiving more than what was ordered the risk to the resident could be respiratory issues. Interview and observation on 10/18/23 at 2:23 PM, ADON revealed Resident #11's had an order for oxygen to be set at 2 liters. Observed ADON enter Resident #11's room and stated resident's oxygen concentrator was set to 3.5 liters, and she turned it to 2 liters. She stated the resident should be on 2 liters, not 3.5 liters. The ADON asked Resident #11 if he had adjusted the oxygen concentrator and resident stated he had not touched it. The ADON stated the nurses were responsible to ensure residents who were receiving oxygen therapy were receiving the correct amount. She stated her expectations were for her nurses to follow physician orders . She stated it was her responsibility and the DON to ensure staff are following physician orders. She stated risk of not following physician orders could cause nose bleeds. Interview on 10/19/23 at 11:13 AM, the DON revealed her expectation was for her nurses to know and to check the oxygen concentrator to ensure the correct amount was being administered. She stated she was notified by the ADON that Resident #11 was not receiving the correct amount of oxygen. The DON stated she held her nurses accountable for doing their job correctly. She stated the risk of not providing the correct amount of oxygen was that it could cause brain damage or respiratory distress. Record review of the facility's Oxygen Administration policy, dated September 2017, reflected the following: .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent (5%) or greater for one staff (LVN A) which resulted in a 14.29% medication error rate after 28 opportunities with 4 errors for one of four residents (Resident #22) reviewed for medications. 1. The facility failed to ensure LVN A administered all the crushed medication in the medication cups without leaving residue for Resident #22. 2. LVN A failed to follow the physician orders for flushing Resident #22's gastrostomy tube with 5-10 mL of water between medication when she administered medication. These failures could put residents at risk for not receiving the correct dose of medication and getting intended therapy. Findings included: Review of Resident #22's Quarterly MDS assessment dated [DATE], revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE]. Resident #22 had diagnoses which included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol) and nontraumatic subdural hemorrhage is a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull). Resident #22 had a BIMS status score of 99 indicating cognition was severely impaired. Review of Resident #22's October 2023 MAR revealed physician orders to administer medications via g- tube (a tube inserted through the wall of the abdomen directly into the stomach). Flush tube with 5-10mL of water between medication administration. Review of Resident #22's August physician orders revealed the following medications were prescribed: - Multivitamin with Minerals (supplements), - Loratadine 10mgs (used to treat allergies), - Memantine 10mgs (used to treat memory loss which is one of the main symptoms of dementia), - Zinc 50mgs (use help immune system and metabolism functions), - Baclofen 10 mg (muscle relaxant), - Miralax 17 gm (laxative that provides relief from occasional constipation), - Senna 8.6 mg (laxative), and - Calcium carbonate -vitamin d3m 600-10mcg (400 unit) (used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets.) to be crushed. Observation on 10/18/23 beginning at 8:55 AM revealed LVN A crushed the following medications to administer to Resident #22 via g-tube in separate medication cups: - Baclofen 10 mg, - Multi-Vitamin with minerals 1 tablet, - MiraLAX 17 gm, -Zinc 50mgs, -Memantine 10mgs, -Loratadine 10mgs, - Senna 8.6 mg, and - Calcium with Vitamin D (calcium carbonate-vitamin d3) 600-10mcg (400 unit). LVN A was observed mixing medications with 5 ml water in each cup with crushed medication. She administered each of these eight medications via g-tube flushing the g-tube between each medication administration with 30 ml of water. Four cups were noted to have medication residue remaining in the cups. Interview with LVN A on 10/18/23 at 9:35 AM revealed she was aware for good results she was supposed to stir the medication well and administer the whole dose to the resident, but she did not do that. She stated she tried as much as she could to administer the whole dose, but residuals were left in the cups. She stated she was supposed to give all the contents in the cup for Resident #22 to get the full dose of those medications. She stated failure to administer the full doses to Resident #22 would lead to Resident #22 not getting the therapy needed. She stated she had been trained on g-tube medication administration. LVN A stated she was flushing with 30 mL between each medication because she did not check the orders, but she was aware she was supposed to check orders with each medication administration. She stated failure to check the orders for the flushes can lead to fluid overload on Residnet#22. LVN A stated she was having difficulties going through the MARs/TARs since she was new nurse, but she stated she had been trained on how to navigate. Interview with the DON on 10/18/23 at 10:07 AM revealed her expectation was that nurses should try to give as much as possible of all the content in the medication cups. The DON also stated LVN A was supposed to follow the physician orders on flushes between the medications because failure could cause fluid overrode on Resident #22. She stated she had done training on medication administration through g-tubes with all nurses. She stated failure to administer the full dose could lead to Resident #2 not getting the right therapy, and the medications would not be effective. Record review of facility's General Guidelines for Administering Medication through an Enteral Tube policy and procedure, revised August 2022, reflected the following: .23. Dilute the crushed or split medication with 15-30 mL water (or prescribed amount). If administering more than one medication, flush with 15 mL (or prescribed amount) water between medications. The policy did not address cups are rinsed to get all the medications

Based on observations and interviews the facility failed to ensure total privacy for residents in 14 (Rooms 1, 2, 3, 5, 6, 8, 9, 10, 11, 29, 30, 34, 35, and 36) of 25 resident rooms reviewed for privacy. The facility failed to provide privacy curtains to ensure resident privacy in Rooms 1, 2, 3, 5, 6, 8, 9, 10, 11, 29, 30, 34, 35, and 36. This failure placed residents at risk of decreased self-worth by being exposed during resident care. Findings included: Observation on 06/21/23 starting at 9:10 AM of Rooms 1, 2, 3, 5, 6, 8, 9, 10, 11, 29, 30, 34, 35, and 36 revealed privacy curtains were hung from the ceiling to provide residents of the A bed with total privacy, there was no curtain hung at the end of the B bed to provide that resident with total privacy. Observations of the rooms revealed there was no track on the ceiling to enable a curtain to be hung at the end of the B bed. Interview on 06/21/23 at 1:00 PM, Resident #1 stated he used a bedside commode, and he did not like that he was visible from the hallway, and it was embarrassing to him. Interview on 06/21/23 at 1:10 PM, Resident #2 stated there had never been a curtain at the end of her bed and she did worry sometimes that someone could walk in and see her exposed. Interview on 06/21/23 at 1:20 PM, LVN A stated double occupied rooms could not provide complete privacy for the resident in the B bed because the room lacked a curtain at the end of the B bed. She stated there had never been a curtain in place for as long as she knew. She stated staff would close the door and pull the middle curtain to provide some privacy. Interview on 06/21/23 at 1:24 PM, the Housekeeping Supervisor stated he was responsible for changing out privacy curtains when they were dirty. He stated he had never seen a curtain at the end of the B bed of the rooms. Interview on 06/21/23 at 1:30 PM, the Administrator stated he was aware that each resident required total privacy when care was being provided but he did not know that there needed to be a curtain at the end of the B bed. Interview on 06/21/23 at 1:40 PM, the DON stated total privacy to her meant that the resident could not be viewed while they were exposed during cares, especially during peri care. Interview on 06/21/23 at 1:45 PM, LVN B stated residents should have total privacy when care was being provided. LVN B stated privacy included closing the door and closing off the bed with a curtain.

Based on interview and record review, the facility failed to honor the residents right to formulate an advance directive for 2 (Resident's #1 and #39) of 8 residents reviewed for advanced directives. 1. The facility failed to ensure Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility failed to ensure Resident #39's code status was documented in her medical record. These failures could place residents with a wish for a DNR status at risk of not having their wishes known, respected, and implemented in an emergency. Findings included: 1. Review of Resident #1's Face Sheet, undated, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. Review of Resident #1's current Care Plan, dated as Last Care Conference [DATE], revealed problem areas including Cognitive Loss/Dementia resulting in impaired decision making, and Responsible Agent chooses Full Code. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #39's Face Sheet, undated, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's Admission MDS assessment dated [DATE] revealed a BIMS score of 13, indicating intact cognition. Review of Resident #39's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's current Care Plan dated as created [DATE] revealed resident has chosen DO NOT RESUSCITATE status. During an interview on [DATE] at 10:40 a.m. the MDS Coordinator said she had spoken with Resident #39 and the resident had told her she had a DNR status. The MDS Coordinator said that information was in the hospital paperwork, and that was why she put that information on the resident's care plan. During an interview on [DATE] at 8:50 a.m. the ADON said Resident #1's code status was a Full Code based on a Full Code order dated February 2022 on admission. She said the facility did not have a signed DNR for him and said she had told the resident's family member that the facility needed a signed DNR. The ADON said she knew the resident's family had made arrangements for him regarding his code status. She said she believed the resident's family member had signed an OOH-DNR on [DATE], and the doctor put the order in the electronic record. The ADON said she would say there was some confusion regarding Resident #1's code status. She said the DON looked at the MD orders when they were put in the system, and the DON and herself were both responsible for looking back at the doctor's orders. The ADON said Resident #39 had a code status of Full Code. She said if the facility did not have a signed DNR, the resident was automatically a Full Code. She said she did not see the code status addressed in Resident #39's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the facility did not accept OOH-DNR's, and Resident #39 would need to sign a DNR form. The ADON said that oversight was her responsibility, and as the ADON she tried to look at every new admission to follow-up on this. The ADON said a potential problem with a resident's code status not being accurate in the medical record could be confusion if the resident were to go into [CONDITION(S)]. The ADON said if the resident were to go into [CONDITION(S)], the staff would have to perform CPR if there was not a document indicating they were a DNR. She said if a resident had a DNR wish, that (receiving CPR) would be a problem. An interview with the DON on [DATE] at 9:28 a.m. revealed the MD told her he had written the DNR order on [DATE] for Resident # 1 because it had been discussed; she said Resident #1 was confused, and officially Resident #1 was a Full Code. She said she could understand the confusion regarding resident's code status in the EHR. She said they were trying to get witnesses to sign the DNR document and had not been aware that it had not been completed. She said the facility did not accept OOH-DNR's, they were not valid at the facility, so a resident was a Full Code until a status was entered and the facility had the necessary paperwork. The DON said Resident #39 was a Full Code. She said the resident's code status was missed on the admission paperwork, and until the paperwork was there, a resident was a Full Code. The DON said the facility had a remote SW who usually addressed the resident's code status. The DON said since the SW worked part-time, she would say everybody had responsibility to ensure a resident had an accurate code status documented. She said the IDT team should be looking at the issue as they reviewed a resident's paperwork. The DON said a potential problem with a resident's code status not being accurately addressed could be the staff possibly performing CPR on a resident that didn't want it, and the resident's wishes would not be met. Review of the facility's policy titled Advance Directives, dated [DATE], revealed .The facility and company will recognize each patient's/resident's right to self-determination and their right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation (CPR), and the right to execute (or not execute) advanced medical directives such as Living Wills, agent designations, do-not-resuscitate directives, etc.Upon admission to the facility, the Admissions Coordinator will .Interview each patient/resident OR their legal representative/family members to determine whether or not the patient/resident has executed an advance directive of any type

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #13) of four residents reviewed for pharmacy services. The facility failed to have Resident #13's physician ordered Hydrocodone-Acetaminophen 10-325 mg (a narcotic analgesic used to treat pain) available and to administer it as needed after his admission. RN C and LVN D failed to properly assess Resident #13's pain level and report it to his attending physician and/or representative, therefore he had unrelieved pain for more than ten hours while they awaited the triplicate and delivery of the Hydrocodone-Acetaminophen. These failures placed 38 residents on a pain management program at risk for unrelieved pain and a decreased quality of life. Findings included: Resident #13's MDS Assessment, dated 04/17/17, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. He was cognitively intact and was on scheduled and PRN pain medication regimen. The pain assessment interview was not conducted. The staff assessment for pain reflected he had vocal complaints of pain daily. Resident #13's physician's start-up orders, signed 04/10/17, reflected [DIAGNOSES REDACTED]. There was an order, dated 04/07/17, for Hydrocodone-Acetaminophen 10/325 mg one tablet by mouth every six hours as needed for pain. There were also orders, dated 04/07/17, for Acetaminophen 325 mg two tablets by mouth every four hours as needed for pain, methocarbamol 500 mg one tablet by mouth three times a day for muscle pain, and gabapentin 300 mg one capsule by mouth four times daily for neuropathy. Resident #13's care plan, dated 04/18/17, reflected he was a risk for increased pain/discomfort. The goal was to maintain at or below acceptable pain level with pain medication or other interventions over the next 90 days. The interventions were to monitor for signs/symptoms of increased pain .allow resident to verbalize feeling of pain or discomfort .pain assessment completed per policy and notify MD if medication is ineffective and if pain level exceeds set limit. Interview with LVN D on 04/18/17 at 9:45 AM revealed Resident #13 admitted to the facility about two weeks ago. She said he was interviewable, as he was alert and oriented to person, place and time. She said he had pain related to recent amputation of two toes and it was controlled with PRN pain medication. Interview with Resident #13 on 04/18/17 at 3:47 PM revealed he admitted to the facility on a 04/07/17 around 8:00 PM. He said he told staff he was in severe pain and requested his hydrocodone-acetaminophen but he was told that the doctor was not able to order it. Resident #13 said he went without that pain medication for several hours and he was not able to sleep, as he was in an 8 or 9 out of 10 pain level. He said he cried out in pain, told staff about his pain, but no alternatives were offered until about 6:00 AM or 7:00 AM. He said that was when tramadol was administered to him and he was able to sleep after that. He said he stayed in bed until the facility obtained his hydrocodone-acetaminophen and administered it before noon the next day. He said he suffered from pain in his lower extremities related to previous falls, fractures, surgeries, infections, and a current wound. He said his tolerable pain level was a seven and anything above that affected his daily activities and mood. Resident #13's hospital records, dated 04/06/17 through 04/07/17, reflected the PRN hydrocodone-acetaminophen was administered every six hours and the last administration was on 04/07/17 at 3:05 PM prior to his discharge. Resident #13 would have been eligible for another dose if needed in the facility at 9:05 PM, 3:05 AM, and 9:05 AM. None of which were administered, due to the medication not being available, despite Resident #13 requests for this medication. The documents reflected Resident #13 had gabapentin 600 mg capsule (for neuropathic pain) administered on 04/07/17 at 8:38 AM, a daily transdermal lidocaine patch (for pain) administered on 04/07/17 at 8:40 AM and a fentanyl 72 hour transdermal 25 mcg/hr patch (for pain) administered on 04/06/17 at 10:30 PM. Interview with RN C on 04/18/17 at 4: 23 PM revealed she was the charge nurse when Resident #13 admitted to the facility on [DATE] around 8:00 PM. She said Resident #13 reported mild pain to her shortly after 8:00 PM and asked her for the hydrocodone-acetaminophen but since it was not available, she told him she would contact the MD and offered the PRN acetaminophen 325 mg tablet in the meantime, however he refused the acetaminophen. RN C said no PRN pain medications were administered during her shift. She said she did not feel it was necessary to escalate the issue regarding Resident #13's hydrocodone-acetaminophen not being available because he refused the acetaminophen 325 mg tablets. RN C said she recalled observing a medium sized pain patch (lidocaine) on Resident #13's leg. Review of RN C documentation on Resident #13's nurses' notes, 24 hour reports, and pain assessments, dated 04/07/17 at 10 PM and 11:35 PM, reflected no complaints of pain. In a later interview with RN C, on 04/18/17 at 2:51 PM, revealed she did not document Resident #13 complaint of pain after 8:00 PM because she did not write her notes until 11:30 PM and only documented the more recent information regarding pain at 11:35 PM. She said around 10:00 PM or 11:00 PM she offered a snack to Resident #13 but he refused. She said during this interaction she asked him How are you? and he replied Okay so she interpreted that to mean he was not in any pain and documented accordingly. She said she did not actually follow-up or ask him specifically about his earlier complaints of pain or allow him to scale his current pain level. She said she spoke to the MD on 04/07/17 around 10:30 PM or 11:00 PM to confirm orders and request the triplicate for the hydrocodone-acetaminophen. She said she did not report any complaints of pain from Resident #13 because the MD did not ask. RN C said the MD told her he would sign/send the triplicate the following morning. RN C said looking back at the situation, she felt that would have been an appropriate to reassess Resident #13 for pain, notify the MD of Resident #13 complaints of pain and also notify the DON about the MD's response about signing the triplicate in the morning. RN C said she felt the PRN acetaminophen 325 mg was adequate to control Resident #13's pain while awaiting the hydrocodone-acetaminophen delivery. Interview with LVN D on 04/19/17 at approximately11:00 AM revealed she was the charge nurse for Resident #13 on 04/07/17 from 10:00 PM to 6:00 AM. She said when she arrived at 10:00 PM, RN C told her she had attempted to call the physician assistant to confirm the orders but he/she did not answer. LVN D said she suggested for RN C to contact the MD directly, which she did. She said she heard RN C confirm all orders and request a triplicate for the hydrocodone-acetaminophen. LVN D said after RN C hung up the phone, she told her the MD said he would send the triplicate the following morning. LVN D said shortly after 10:00 PM, she did her rounds and met/introduced herself to Resident #13. She said he asked about his pain medication and told her he could not sleep without his hydrocodone-acetaminophen. LVN D said Resident #13 told her he had pain in his legs and toes so she assessed it as moderate pain, but did not actually ask him to rate his pain level at that time. LVN D said around 2:00 AM, Resident #13 complained of pain and she told him his hydrocodone-acetaminophen was not available because the triplicate would be sent in the morning. She said she assessed his pain at that time and asked him where was his pain was, which he replied he had moderate pain in his leg, so she offered and administered his PRN acetaminophen 325 mg two tablets. She said she called the pharmacy and inquired about the hydrocodone-acetaminophen but they told her there was no triplicate sent yet. LVN D said around 5:00 AM, Resident #13 was self-propelling himself in his wheelchair, upset, yelling, and asking for his hydrocodone-acetaminophen. She said she did not assess his pain level at that time because he was trying to exit the building. She said she went to intervene and he told her that he called his sister to help him get his hydrocodone-acetaminophen medication from his car which was at the airport. LVN D said she was able to redirect him and around 6:00 AM the pharmacy delivered some of his medication, not including the hydrocodone-acetaminophen, and he agreed to take his medications which included gabapentin for neuropathy and methocarbamol for muscle pain at that time. She said around that time she tried to call the DON but there was no answer. She said shortly after that the oncoming nurse, LVN E, arrived and successfully got ahold of the DON and took over the situation as it was the end of her shift. LVN E said she recalled observing a small pain patch (fentanyl) on Resident 13's arm upon his admission, however the date was unclear to her and she replaced it three days later. Resident #13's nurses' notes, dated 04/08/17, reflected at 2:20 AM LVN D documented c/o (complain) of moderate pain, Tylenol (acetaminophen) 325 mg 2 tabs equal to 650 mg administered and encouraged resident to relax and try to sleep while we are waiting for the MD to fax the triplicate to the pharmacy for his hydrocodone . Resident #13's MAR, undated but provided as April 2017 by the DON, reflected acetaminophen 325 mg 2 tablets was administered on 04/08/17 but no specific time was documented. Interview with CNA E via telephone on 04/19/17 at 5:29 PM revealed he was assigned to care for Resident #13 on 04/07/07 from 10:00 PM to 04/08/17 6:00 AM. She said he pressed his call light twice that night, once at midnight and again later on saying he was in severe pain, a lot of pain. CNA E said he requested a certain pain medication but she did not recall the name of it but she reported that information to LVN D, and she went to his room to talk to him about his pain medication situation. CNA E said she checked on him routinely at 10 PM, 12 AM, 2AM, and 4 AM and he was lying awake in bed each time, however she was unsure if he was already awake or if he woke up when she knocked and turned on the light each time. CNA E said on 04/08/17 at around 6:00 AM, she saw him in the hall way and he appeared upset. She said she heard him say he could not sleep all night due to pain. Interview with LVN F via telephone on 04/19/17 at 5:41 PM revealed he was the charge nurse for Resident #13 on 04/08/17 from 6:00 AM to 2:00 PM. He said when he arrived at 6:00 AM; Resident #13 was at the nursing station complaining of pain to his bilateral lower extremities. LVN F said Resident #13 was really angry and upset saying he was really in pain and that the acetaminophen was not effective. LVN F said he asked Resident #13 to rate his pain level and his response was a ten out of a ten scale. LVN F said LVN D informed him Resident #13 had a pain management issue because his hydrocodone- acetaminophen was not available due to not having a triplicate. He said LVN D told him that she administered acetaminophen and was waiting for the hydrocodone-acetaminophen triplicate. LVN F said he called the DON around 6:00 AM and informed her of situation with Resident #13 and she was able to obtain a telephone order for tramadol and follow up with the MD about the triplicate for the hydrocodone- acetaminophen. He said he administered the tramadol to Resident #13 from the emergency kit around 6:30 AM and it was effective because he was able to go to sleep shortly after. LVN F said around 10:30 AM, the pharmacy delivered Resident #13's hydrocodone- acetaminophen and he awoke him and administered it at that time. Resident #13's telephone orders, dated 04/08/17, reflected at 7:30 AM LVN F wrote the telephone order for tramadol 50 mg two tablets by mouth twice a day and every six hours as needed until Norco (hydrocodone- acetaminophen) available. Resident #13's MAR, undated but provided as April 2017 by the DON, reflected the Tramadol was administered on 04/08/17 at 7:30 AM. The emergency kit log for tramadol 50 mg reflected two tablets were obtained for Resident #13 on 04/08/17 at 7:30 AM by LVN F. Resident #13's triplicate, dated 04/08/17, reflected the MD signed the order for Hydrocodone-Acetaminophen on 04/08/17. Resident #13's pharmacy manifest, dated 04/08/17, reflected the hydrocodone-acetaminophen was delivered at 10:00 AM. Resident #13's Controlled Drug Record for hydrocodone-acetaminphen, dated 04/08/17, reflected 120 tablets were dispensed and the first dose was logged out on 04/08/17 at 10:30 AM. Interview with the DON on 04/18/17 at 4:45 PM revealed she was made aware of the situation regarding Resident #13 on 04/08/17 at 6:29 AM (Canadian time, as she was out of the country). She said she missed one call from LVN D then right after LVN F called her. She said LVN F reported Resident #13's complaints of pain and told her the hydrocodone-acetaminophen was not delivered. She said she concluded that the MD did not send the triplicate to the pharmacy so she called him and asked him to send it and she also obtained a telephone order for tramadol to administer from the emergency kit while the facility waited for the hydrocodone-acetaminophen delivery. The DON said she should have been called earlier regarding this situation, especially on 04/07/17 at 10:30 PM-11:00 PM when the MD told RN C that he would send the triplicate the following morning or when staff realized the hydrocodone-acetaminophen did not arrive with the pharmacy delivery on 04/08/17 at 12:00 AM-1:00AM. Interview with the MD via telephone on 04/20/17 at 10:55 AM revealed staff called him on 04/07/17 during the night and told me they were unable to reach the physician assistant. He said he did not recall if staff told him Resident #13 was having pain, but he said if they did he would have ordered a pain medication that was available in the emergency kit. He said he confirmed the Resident #13's orders and told staff he would send the triplicate (for the hydrocodone-acetaminophen) to the pharmacy, but he did not recall when he said he would do that because he was awoken from his sleep. He said the next morning on 04/08/17; the DON called him and told him they were waiting on the triplicate so he ordered tramadol while he sent the triplicate to the pharmacy. Review of the facility's Pain Management policy, revised November 2013, reflected It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life. The procedures included promoting residents self-reporting as the most reliable indicator of pain, physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain, and resident with unrelieved pain be evaluated by the nurse and the physician notified. Review of the facility's Medication Orders - Ordering and Receiving policy, revised March 2013, reflected It is the policy of this home to order and reorder medications appropriately and in a timely manner. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the MDS Coordinator on 04/18/17, reflected 38 residents were on a pain management program.

Based on interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #13) of four residents reviewed for pain management. The facility failed to have Resident #13's physician ordered [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg (a narcotic [MEDICATION NAME] used to treat pain) available and to administer it as needed after his admission. RN C and LVN D failed to properly assess Resident #13's pain level and report it to his attending physician and/or representative, therefore he had unrelieved pain for more than ten hours while the facility awaited the triplicate and delivery of the [MEDICATION NAME]-[MEDICATION NAME]. These failures placed 38 residents on a pain management program at risk for unrelieved pain and a decreased quality of life. Findings included: Resident #13's MDS Assessment, dated 04/17/17, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. He was cognitively intact and was on scheduled and PRN pain medication regimen. The pain assessment interview was not conducted. The staff assessment for pain reflected he had vocal complaints of pain daily. Resident #13's physician's start-up orders, signed 04/10/17, reflected [DIAGNOSES REDACTED]. There was an order, dated 04/07/17, for [MEDICATION NAME]-[MEDICATION NAME] 10/325 mg one tablet by mouth every six hours as needed for pain. There were also orders, dated 04/07/17, for [MEDICATION NAME] 325 mg two tablets by mouth every four hours as needed for pain, [MEDICATION NAME] 500 mg one tablet by mouth three times a day for muscle pain, and [MEDICATION NAME] 300 mg one capsule by mouth four times daily for [MEDICAL CONDITION]. Resident #13's care plan, dated 04/18/17, reflected he was a risk for increased pain/discomfort. The goal was to maintain at or below acceptable pain level with pain medication or other interventions over the next 90 days. The interventions were to monitor for signs/symptoms of increased pain .allow resident to verbalize feeling of pain or discomfort .pain assessment completed per policy and notify MD if medication is ineffective and if pain level exceeds set limit. Interview with LVN D on 04/18/17 at 9:45 AM revealed Resident #13 admitted to the facility about two weeks ago. She said he was interviewable, as he was alert and oriented to person, place and time. She said he had pain related to recent amputation of two toes and it was controlled with PRN pain medication. Interview with Resident #13 on 04/18/17 at 3:47 PM revealed he admitted to the facility on a 04/07/17 around 8:00 PM. He said he told staff he was in severe pain and requested his [MEDICATION NAME]-[MEDICATION NAME] but he was told that the doctor was not able to order it. Resident #13 said he went without that pain medication for several hours and he was not able to sleep, as he was in an 8 or 9 out of 10 pain level. He said he cried out in pain, told staff about his pain, but no alternatives were offered until about 6:00 AM or 7:00 AM. He said that was when [MEDICATION NAME] was administered to him and he was able to sleep after that. He said he stayed in bed until the facility obtained his [MEDICATION NAME]-[MEDICATION NAME] and administered it before noon the next day. He said he suffered from pain in his lower extremities related to previous falls, fractures, surgeries, infections, and a current wound. He said his tolerable pain level was a seven and anything above that affected his daily activities and mood. Resident #13's hospital records, dated 04/06/17 through 04/07/17, reflected the PRN [MEDICATION NAME]-[MEDICATION NAME] was administered every six hours and the last administration was on 04/07/17 at 3:05 PM prior to his discharge. Resident #13 would have been eligible for another dose if needed in the facility at 9:05 PM, 3:05 AM, and 9:05 AM. None of which were administered, due to the medication not being available, despite Resident #13 requests for this medication. The documents reflected Resident #13 had [MEDICATION NAME] 600 mg capsule (for neuropathic pain) administered on 04/07/17 at 8:38 AM, a daily [MEDICATION NAME] (for pain) administered on 04/07/17 at 8:40 AM and a [MEDICATION NAME] 72 hour [MEDICATION NAME] 25 mcg/hr patch (for pain) was administered on 04/06/17 at 10:30 PM. Interview with RN C on 04/18/17 at 4: 23 PM revealed she was the charge nurse when Resident #13 admitted to the facility on [DATE] around 8:00 PM. She said Resident #13 reported mild pain to her shortly after 8:00 PM and asked her for the [MEDICATION NAME]-[MEDICATION NAME] but since it was not available, she told him she would contact the MD and offered the PRN [MEDICATION NAME] 325 mg tablet in the meantime, however he refused the [MEDICATION NAME]. RN C said no PRN pain medications were administered during her shift. She said she did not feel it was necessary to escalate the issue regarding Resident #13's [MEDICATION NAME]-[MEDICATION NAME] not being available because he refused the [MEDICATION NAME] 325 mg tablets. RN C said she recalled observing a medium sized pain patch ([MEDICATION NAME]) on Resident #13's leg. Review of RN C documentation on Resident #13's nurses' notes, 24 hour reports, and pain assessments, dated 04/07/17 at 10 PM and 11:35 PM, reflected no complaints of pain. In a later interview with RN C, on 04/18/17 at 2:51 PM, revealed she did not document Resident #13 complaint of pain after 8:00 PM because she did not write her notes until 11:30 PM and only documented the more recent information regarding pain at 11:35 PM. She said around 10:00 PM or 11:00 PM she offered a snack to Resident #13 but he refused. She said during this interaction she asked him How are you? and he replied Okay so she interpreted that to mean he was not in any pain and documented accordingly. She said she did not actually follow-up or ask him specifically about his earlier complaints of pain or allow him to scale his current pain level. She said she spoke to the MD on 04/07/17 around 10:30 PM or 11:00 PM to confirm orders and request the triplicate for the [MEDICATION NAME]-[MEDICATION NAME]. She said she did not report any complaints of pain from Resident #13 because the MD did not ask. RN C said the MD told her he would sign/send the triplicate the following morning. RN C said looking back at the situation, she felt that would have been an appropriate to reassess Resident #13 for pain, notify the MD of Resident #13 complaints of pain and also notify the DON about the MD's response about signing the triplicate in the morning. RN C said she felt the PRN [MEDICATION NAME] 325 mg was adequate to control Resident #13's pain while awaiting the [MEDICATION NAME]-[MEDICATION NAME] delivery. Interview with LVN D on 04/19/17 at approximately11:00 AM revealed she was the charge nurse for Resident #13 on 04/07/17 from 10:00 PM to 6:00 AM. She said when she arrived at 10:00 PM, RN C told her she had attempted to call the physician assistant to confirm the orders but he/she did not answer. LVN D said she suggested for RN C to contact the MD directly, which she did. She said she heard RN C confirm all orders and request a triplicate for the [MEDICATION NAME]-[MEDICATION NAME]. LVN D said after RN C hung up the phone, she told her the MD said he would send the triplicate the following morning. LVN D said shortly after 10:00 PM, she did her rounds and met/introduced herself to Resident #13. She said he asked about his pain medication and told her he could not sleep without his [MEDICATION NAME]-[MEDICATION NAME]. LVN D said Resident #13 told her he had pain in his legs and toes so she assessed it as moderate pain, but did not actually ask him to rate his pain level at that time. LVN D said around 2:00 AM, Resident #13 complained of pain and she told him his [MEDICATION NAME]-[MEDICATION NAME] was not available because the triplicate would be sent in the morning. She said she assessed his pain at that time and asked him where was his pain was, which he replied he had moderate pain in his leg, so she offered and administered his PRN [MEDICATION NAME] 325 mg two tablets. She said she called the pharmacy and inquired about the [MEDICATION NAME]-[MEDICATION NAME] but they told her there was no triplicate sent yet. LVN D said around 5:00 AM, Resident #13 was self-propelling himself in his wheelchair, upset, yelling, and asking for his [MEDICATION NAME]-[MEDICATION NAME]. She said she did not assess his pain level at that time because he was trying to exit the building. She said she went to intervene and he told her that he called his sister to help him get his [MEDICATION NAME]-[MEDICATION NAME] medication from his car which was at the airport. LVN D said she was able to redirect him and around 6:00 AM the pharmacy delivered some of his medication, not including the [MEDICATION NAME]-[MEDICATION NAME], and he agreed to take his medications which included [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for muscle pain at that time. She said around that time she tried to call the DON but there was no answer. She said shortly after that the oncoming nurse, LVN E, arrived and successfully got ahold of the DON and took over the situation as it was the end of her shift. LVN E said she recalled observing a small pain patch ([MEDICATION NAME]) on Resident 13's arm upon his admission, however the date was unclear to her and she replaced it three days later. Resident #13's nurses' notes, dated 04/08/17, reflected at 2:20 AM LVN D documented c/o (complain) of moderate pain, Tylenol ([MEDICATION NAME]) 325 mg 2 tabs equal to 650 mg administered and encouraged resident to relax and try to sleep while we are waiting for the MD to fax the triplicate to the pharmacy for his [MEDICATION NAME] . Resident #13's MAR, undated but provided as April 2017 by the DON, reflected [MEDICATION NAME] 325 mg 2 tablets was administered on 04/08/17 but no specific time was documented. Interview with CNA E via telephone on 04/19/17 at 5:29 PM revealed he was assigned to care for Resident #13 on 04/07/07 from 10:00 PM to 04/08/17 6:00 AM. She said he pressed his call light twice that night, once at midnight and again later on saying he was in severe pain, a lot of pain. CNA E said he requested a certain pain medication but she did not recall the name of it but she reported that information to LVN D, and she went to his room to talk to him about his pain medication situation. CNA E said she checked on him routinely at 10 PM, 12 AM, 2AM, and 4 AM and he was lying awake in bed each time, however she was unsure if he was already awake or if he woke up when she knocked and turned on the light each time. CNA E said on 04/08/17 at around 6:00 AM, she saw him in the hall way and he appeared upset. She said she heard him say he could not sleep all night due to pain. Interview with LVN F via telephone on 04/19/17 at 5:41 PM revealed he was the charge nurse for Resident #13 on 04/08/17 from 6:00 AM to 2:00 PM. He said when he arrived at 6:00 AM; Resident #13 was at the nursing station complaining of pain to his bilateral lower extremities. LVN F said Resident #13 was really angry and upset saying he was really in pain and that the [MEDICATION NAME] was not effective. LVN F said he asked Resident #13 to rate his pain level and his response was a ten out of a ten scale. LVN F said LVN D informed him Resident #13 had a pain management issue because his [MEDICATION NAME]- [MEDICATION NAME] was not available due to not having a triplicate. He said LVN D told him that she administered [MEDICATION NAME] and was waiting for the [MEDICATION NAME]-[MEDICATION NAME] triplicate. LVN F said he called the DON around 6:00 AM and informed her of situation with Resident #13 and she was able to obtain a telephone order for [MEDICATION NAME] and follow up with the MD about the triplicate for the [MEDICATION NAME]- [MEDICATION NAME]. He said he administered the [MEDICATION NAME] to Resident #13 from the emergency kit around 6:30 AM and it was effective because he was able to go to sleep shortly after. LVN F said around 10:30 AM, the pharmacy delivered Resident #13's [MEDICATION NAME]- [MEDICATION NAME] and he awoke him and administered it at that time. Resident #13's telephone orders, dated 04/08/17, reflected at 7:30 AM LVN F wrote the telephone order for [MEDICATION NAME] 50 mg two tablets by mouth twice a day and every six hours as needed until [MEDICATION NAME] ([MEDICATION NAME]- [MEDICATION NAME]) available. Resident #13's MAR, undated but provided as April 2017 by the DON, reflected the [MEDICATION NAME] was administered on 04/08/17 at 7:30 AM. The emergency kit log for [MEDICATION NAME] 50 mg reflected two tablets were obtained for Resident #13 on 04/08/17 at 7:30 AM by LVN F. Resident #13's triplicate, dated 04/08/17, reflected the MD signed the order for [MEDICATION NAME]-[MEDICATION NAME] on 04/08/17. Resident #13's pharmacy manifest, dated 04/08/17, reflected the [MEDICATION NAME]-[MEDICATION NAME] was delivered at 10:00 AM. Resident #13's Controlled Drug Record for [MEDICATION NAME]-acetaminphen, dated 04/08/17, reflected 120 tablets were dispensed and the first dose was logged out on 04/08/17 at 10:30 AM. Interview with the DON on 04/18/17 at 4:45 PM revealed she was made aware of the situation regarding Resident #13 on 04/08/17 at 6:29 AM (Canadian time, as she was out of the country). She said she missed one call from LVN D then right after LVN F called her. She said LVN F reported Resident #13's complaints of pain and told her the [MEDICATION NAME]-[MEDICATION NAME] was not delivered. She said she concluded that the MD did not send the triplicate to the pharmacy so she called him and asked him to send it and she also obtained a telephone order for [MEDICATION NAME] to administer from the emergency kit while the facility waited for the [MEDICATION NAME]-[MEDICATION NAME] delivery. The DON said she should have been called earlier regarding this situation, especially on 04/07/17 at 10:30 PM-11:00 PM when the MD told RN C that he would send the triplicate the following morning or when staff realized the [MEDICATION NAME]-[MEDICATION NAME] did not arrive with the pharmacy delivery on 04/08/17 at 12:00 AM-1:00AM. Interview with the MD via telephone on 04/20/17 at 10:55 AM revealed staff called him on 04/07/17 during the night and told me they were unable to reach the physician assistant. He said he did not recall if staff told him Resident #13 was having pain, but he said if they did he would have ordered a pain medication that was available in the emergency kit. He said he confirmed the Resident #13's orders and told staff he would send the triplicate (for the [MEDICATION NAME]-[MEDICATION NAME]) to the pharmacy, but he did not recall when he said he would do that because he was awoken from his sleep. He said the next morning on 04/08/17; the DON called him and told him they were waiting on the triplicate so he ordered [MEDICATION NAME] while he sent the triplicate to the pharmacy. Review of the facility's Pain Management policy, revised November 2013, reflected It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life. The procedures included promoting residents self-reporting as the most reliable indicator of pain, physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain, and resident with unrelieved pain be evaluated by the nurse and the physician notified. Review of the facility's Medication Orders - Ordering and Receiving policy, revised March 2013, reflected It is the policy of this home to order and reorder medications appropriately and in a timely manner. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the MDS Coordinator on 04/18/17, reflected 38 residents were on a pain management program.

Based on interview, observation and record review, the facility failed to provide emergency and routine dental services to meet the needs of two (Residents #5 and #16) of the 16 sampled residents reviewed for dental services. 1) Resident #5 began to act out on 04/29/12 by screaming, kicking and yelling. On 05/01/12, LVN V decided his pain may be due to infected teeth and may have been the reason for his acting out. Resident #5 was sent to the hospital ER for care of infected teeth and gums. The hospital ER provided a telephone number with instructions to call within 48 hrs for dental care. This was not done. It was determined he needed 17 teeth removed, and it would need to be done surgically and under general anesthesia due to his behaviors. As of 06/21/12, he had still not received the surgery to remove the infected teeth. 2) Resident #16's physician had been requesting dentures for the resident since 10/26/11. As of 06/20/12, Resident #16 still did not have dentures. 3) The SW stated she did not know how to get dental services for Residents #5 and #16. These facility failures affected Residents # 5 and #16, leaving them without badly needed dental services, resulting in oral pain for Resident #5 and placing both residents at risk for tooth pain, difficulty chewing, weight loss, poor oral hygiene, depression and anxiety. These failures could affect the facility's other 58 residents in the facility. Findings included: 1) The quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed under the Oral/Dental Status Mouth or facial pain, discomfort or difficulty with chewing was not checked. Review of Resident #5's admission MDS assessment dated [DATE] revealed under Oral/Dental, his status was identified as "Obvious or likely cavity or broken natural teeth." Review of nurses notes dated for 04/29/12 for Resident #5 revealed beginning at 6:30 AM, "Res. in bed yelling, kicking and screaming Admin, [MEDICATION NAME] 0.5 ML IM for agitation...." The nurses notes had a total of 15 entries describing his behaviors as kicking, screaming, yelling and what she did for the resident. She called Dr. U and received orders for [MEDICATION NAME] 1 mg, two by mouth every four hours as needed and [MEDICATION NAME] 5 mg (one ml) IM injection n every four hours "to calm resident down...." There was an attempt to send Resident #6 to the Psychiatric Hospital to get an evaluation but the hospital declined to take him in part due to "Beyond their scope of practice." Review of nurses notes dated 05/01/12 at 11:30 AM by LVN V revealed Resident #5's family member was notified he was "experiencing a great deal of tooth pain may be reason he is acting outing (sic) ___(with) his yelling episodes." The family member said she would call the hospital "again and try to schedule an appointment." Review of Resident #5's nurses notes dated 05/01/12 at 12:36 PM revealed his family member called back for a referral letter to get him an appointment at the hospital dental clinic to fix his teeth. The family member had also called Dr. W's office to request the same, and "they called in a referral letter too and promised to follow up on the matter. The resident has been screaming in pain today though he had PRN pain meds given and ABT has been ordered by Dental Office...." Resident #5's physicians telephone orders dated 05/01/12 reflected an order to rinse his mouth with [MEDICATION NAME] 0.12% two times a day for two weeks and [MEDICATION NAME] 250 mg one by mouth three times a day for ten days for the [DIAGNOSES REDACTED]. Review of Resident #5's nurses notes dated 05/02/12 at 5:30 AM revealed, "[MEDICATION NAME] gel applied to (L) wrist for Agitation/Yelling and screaming." Notes for 1:56 PM: "Resident was given medicine for his teeth pain and...He was also given PRN meds to calm him down for yelling...." Notes for 11:30 PM: "Resident screaming/yelling and agitating (sic) throwing both arms and legs, applied to (L) wrist [MEDICATION NAME] gel 2 mg/ml...." Review of Resident #5's nurses notes dated 05/04/12 at 2:05 AM "Resident screaming/yelling...." Review of Resident #5's nurses notes dated 05/05/12 at 6:30 AM revealed: "Slept good __(without) distress until this time when he started yell and/scream...." Review of Resident #5's nurses notes dated 05/05/12 at 2:30 PM revealed: "Res. screaming and yelling....Asked resident if in pain. Res. noded (sic)." Resident #5's nurses notes dated 05/06/12 at 11:00 AM reflected: "Res. yelling...Asked pt in pain. Res. noded (sic) head...." Further review of Resident #5's nurses notes for the following days revealed he continued to receive antibiotics for "suspected tooth infection" and his behaviors of yelling, screaming and kicking had declined. Review of Resident #5's nurses notes dated 05/10/12 at 3:00 PM revealed: "Res. noted to have swelling to face. MD notified. Order to send to ____ hosp...." Review of Resident #5's nurses notes dated 05/10/12 at 11:15 PM revealed he was back from the hospital with no new orders. Resident #5's ER summary paperwork dated 05/10/12 reflected [DIAGNOSES REDACTED]. Further review of the ER summary paperwork revealed under future orders: "Referral-Dentistry Clinic" above was written "Referral Orders - Please call _____(telephone number) to schedule your appointment within 48 hours." Review of the website: http://www.med.nyu.edu/content?ChunkIID= on 07/03/12 revealed "Aphthous ulcers are also known as canker sores. They are painful, temporary sores that may occur anywhere in the mouth." Review of Resident #5's physicians telephone orders dated 05/11/12 revealed an order for [REDACTED]. Review of Resident #5's nurses notes for the days following the emergency room visit revealed he continued on the [MEDICATION NAME] for the ordered number of days and he had fewer to no episodes of behaviors. There was no notation of calling the Dental Clinic for a follow up appointment. Review of Resident #5's nurses notes dated 05/22/12 at 3:00 PM revealed a new order was received for [MEDICATION NAME] 250 mg one three times a day for ten days for the [DIAGNOSES REDACTED]. Review of Resident #5's nurses notes from 05/22/12 to present revealed no mention of a follow-up appointment being made for the Dental Clinic. Review of the NP's progress notes for Resident #5 dated 05/04/12 revealed she was there to follow up on staff concerns of Resident #5's increased agitation and anxiety. She added a note at the bottom of the page indicating the increased agitation and anxiety might be secondary to an infection. Staff had also informed the NP Resident #5 had refused to be catheterized for a Urinary Analysis with Culture and Sensitivity. The NP ordered the [MEDICATION NAME] for a probable tooth infection. The NP also noted that psych was working with him. Review of Resident #5's Care Plan Conference Notes dated and signed by LVN V on 03/15/12 revealed under comments she had spoken with Resident #5's family member via telephone and they (family member) were to contact the hospital concerning a Dental appointment. There was no mention of a dentist or dental appointment under the Social Services section. Review of Resident #5's Care Plan Conference Notes dated 06/14/12 revealed "Awaiting Dental extraction." There was no mention of this in the Social Services section. Review of Resident #5's SW notes dated 06/14/12 revealed, "Res. has complaints of pain in teeth. Res's ____ (family member) is working on getting Res on ____ (health insurance) so the teeth can be extracted under general anesthesia. ____ (Dr. W) has seen resident but is unable to pull the teeth in facility due to Res non-funded dental status." Review of Resident #5's SW notes dated 06/21/12 revealed she had called Resident #5's family member to check on the status of the health insurance. The SW note reflected the family member was frustrated as the hospital always had a reason "to request more information before making a decision about care." The SW notes further reflected the family member had also told the SW they had been working with Dr. W's office and they had "re-submitted the info twice now." Further review revealed the SW called Dr. W's office and they confirmed "the facts about having submitted it twice." The SW's note further reflected, "Unfortunately Res will have to wait on the process to solidify so res can get the 17 teeth removed surgically. Res's ____ (family member) and ___ at ____ (Dr. W's) office will con't to f/u on status." During an interview with the SW on 06/21/12 at 2:35 PM, she said Resident #5 was on Medicaid "however he doesn't have the dental coverage." When asked about emergency dental care through DADS, she had no knowledge there was a form which she needed to fill out for emergency dental care through DADS. She said she did not talk to the DADS. The SW said she had spoken to Dr. W's office, and because of his mental condition, he needed general anesthesia. She informed the surveyor she had spoken to Resident #5's family member and they had re-submitted the paper work to the hospital's insurance program. When asked if she had ever contacted the Medicaid Eligibility Worker, she said she never did as she did not know the process for Medicaid Dental Service as she had never worked for a Nursing Facility before and was still learning. She informed the surveyor it was her understanding once someone was on Medicaid, "they" determine what services the person gets and she did not know how it was determined. She reported she had tried to file the paper work required to the hospital and had been informed she could not do it as it had to be filed by Resident #5's POA or by himself. 2) The quarterly MDS assessment dated [DATE] reflected Resident #16, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed under the Oral/Dental Status broken or loosely fitting or full or partial dentures was not checked. Review of a physician's progress note dated 10/26/11 for Resident #16 revealed, "_____ (Resident #16) still needs his bottom teeth. It's not clear what the hold-up is. It would be nice if we could facilitate this." Review of a physician's progress note dated 12/28/11 for Resident #16 revealed, "He's (Resident #16) getting some dental work done and should soon be able to smile again without being self-conscious." Review of a physician's progress note dated 02/08/12 for Resident #16 revealed, "Still no teeth!" Review of a physician's progress note dated 03/14/12 for Resident #16 revealed, "Needs his teeth!" Review of a physician's progress note dated 04/18/12 for Resident #16 revealed, "No progress with teeth." Review of a physician's progress note dated 05/30/12 for Resident #16 revealed, "Still no teeth." During an interview on 06/22/12 at 10:50 AM, the surveyor queried the SW if she had assisted in setting up dental care for Resident #16. The SW responded, "I don't know. I don't really have to time to chart." The SW stated the ____ Dental group came in and did a full dental sweep on 02/02/12 because there had not been a SW at the facility in a long time. The SW reviewed notes provided by the dental hygienist on 02/02/12 and next to Resident #16's name, it was reflected "Exam recommendations 'no'." The SW, as she was looking through the dental book she kept, said Resident #16 had a dental exam due on 10/11, but "I don't think anyone was keeping up with this book." During an observation of Resident #16 on 06/22/12 at 10:58 AM with the SW, the SW stated Resident #16 did not have upper or lower dentures in his mouth. During an interview on 06/22/12 at 11:00 AM with CNA E, who took care of Resident #16, she stated she had never seen any dentures for Resident #16. Review of Resident #16's SW notes revealed no mention of dentures from 01/19/12 through 06/21/12. Review of Resident #16's facility record revealed a green sheet of paper labeled "Dental Consults" with no dental consults behind it. 3) Review of the facility's current policy "Dental, Providing Services" dated January 2005 revealed the following: "Policy: The facility will assure that the resident receives dental services inclusive of routine services. Procedure: 1. The Administrator will assure that there is a qualified and licensed dentist available to meet the dental needs of the resident. 2. The Administrator will assure that all dental care needed is provided for; however, the facility may charge for services not covered under Medicare or Medicaid provisions. 3. The DON or designee will assure that the resident is provided with dental care; emergency, non-emergency and routine care in a reasonable time frame. 4. The Administrator or designee will assist the resident in procuring outside community services to render financial assistance for dental care." 4) The CMS-672 (Resident Census and Conditions of Residents) dated 06/20/12 and signed by the DON reflected the census was 60 residents.

Based on interview, observation and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical well-being for two (Residents #5 and #16) of 16 sampled residents reviewed for dental services. 1) Resident #5 began to act out on 04/29/12 by screaming, kicking and yelling. On 05/01/12, LVN V decided his pain may be due to infected teeth and may have been the reason for his acting out. Resident #5 was sent to the hospital ER for care of infected teeth and gums. The hospital ER provided a telephone number with instructions to call within 48 hrs for dental care. This was not done. It was determined he needed 17 teeth removed, and it would need to be done surgically and under general anesthesia due to his behaviors. As of 06/21/12, he had still not received the surgery to remove the infected teeth. 2) Resident #16's physician had been requesting dentures for the resident since 10/26/11. As of 06/20/12, Resident #16 still did not have dentures. 3) The SW stated she did not know how to get dental services for Residents #5 and #16. These facility failures affected Residents # 5 and #16, leaving them without badly needed dental services, resulting in oral pain for Resident #5 and placing both residents at risk for tooth pain, difficulty chewing, weight loss, poor oral hygiene, depression and anxiety. These failures could affect the facility's other 58 residents in the facility. Findings included: 1) The quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed under the Oral/Dental Status Mouth or facial pain, discomfort or difficulty with chewing was not checked. Review of Resident #5's admission MDS assessment dated [DATE] revealed under Oral/Dental, his status was identified as "Obvious or likely cavity or broken natural teeth." Review of nurses notes dated for 04/29/12 for Resident #5 revealed beginning at 6:30 AM, "Res. in bed yelling, kicking and screaming Admin, Haldol 0.5 ML IM for agitation...." The nurses notes had a total of 15 entries describing his behaviors as kicking, screaming, yelling and what she did for the resident. She called Dr. U and received orders for Ativan 1 mg, two by mouth every four hours as needed and Haldol 5 mg (one ml) IM injection n every four hours "to calm resident down...." There was an attempt to send Resident #6 to the Psychiatric Hospital to get an evaluation but the hospital declined to take him in part due to "Beyond their scope of practice." Review of nurses notes dated 05/01/12 at 11:30 AM by LVN V revealed Resident #5's family member was notified he was "experiencing a great deal of tooth pain may be reason he is acting outing (sic) ___(with) his yelling episodes." The family member said she would call the hospital "again and try to schedule an appointment." Review of Resident #5's nurses notes dated 05/01/12 at 12:36 PM revealed his family member called back for a referral letter to get him an appointment at the hospital dental clinic to fix his teeth. The family member had also called Dr. W's office to request the same, and "they called in a referral letter too and promised to follow up on the matter. The resident has been screaming in pain today though he had PRN pain meds given and ABT has been ordered by Dental Office...." Resident #5's physicians telephone orders dated 05/01/12 reflected an order to rinse his mouth with Peridex 0.12% two times a day for two weeks and Amoxicillin 250 mg one by mouth three times a day for ten days for the [DIAGNOSES REDACTED]. Review of Resident #5's nurses notes dated 05/02/12 at 5:30 AM revealed, "Ativan gel applied to (L) wrist for Agitation/Yelling and screaming." Notes for 1:56 PM: "Resident was given medicine for his teeth pain and...He was also given PRN meds to calm him down for yelling...." Notes for 11:30 PM: "Resident screaming/yelling and agitating (sic) throwing both arms and legs, applied to (L) wrist Ativan gel 2 mg/ml...." Review of Resident #5's nurses notes dated 05/04/12 at 2:05 AM "Resident screaming/yelling...." Review of Resident #5's nurses notes dated 05/05/12 at 6:30 AM revealed: "Slept good __(without) distress until this time when he started yell and/scream...." Review of Resident #5's nurses notes dated 05/05/12 at 2:30 PM revealed: "Res. screaming and yelling....Asked resident if in pain. Res. noded (sic)." Resident #5's nurses notes dated 05/06/12 at 11:00 AM reflected: "Res. yelling...Asked pt in pain. Res. noded (sic) head...." Further review of Resident #5's nurses notes for the following days revealed he continued to receive antibiotics for "suspected tooth infection" and his behaviors of yelling, screaming and kicking had declined. Review of Resident #5's nurses notes dated 05/10/12 at 3:00 PM revealed: "Res. noted to have swelling to face. MD notified. Order to send to ____ hosp...." Review of Resident #5's nurses notes dated 05/10/12 at 11:15 PM revealed he was back from the hospital with no new orders. Resident #5's ER summary paperwork dated 05/10/12 reflected [DIAGNOSES REDACTED]. Further review of the ER summary paperwork revealed under future orders: "Referral-Dentistry Clinic" above was written "Referral Orders - Please call _____(telephone number) to schedule your appointment within 48 hours." Review of the website: http://www.med.nyu.edu/content?ChunkIID= on 07/03/12 revealed "Aphthous ulcers are also known as canker sores. They are painful, temporary sores that may occur anywhere in the mouth." Review of Resident #5's physicians telephone orders dated 05/11/12 revealed an order for [REDACTED]. Review of Resident #5's nurses notes for the days following the emergency room visit revealed he continued on the Amoxicillin for the ordered number of days and he had fewer to no episodes of behaviors. There was no notation of calling the Dental Clinic for a follow up appointment. Review of Resident #5's nurses notes dated 05/22/12 at 3:00 PM revealed a new order was received for Amoxicillin 250 mg one three times a day for ten days for the [DIAGNOSES REDACTED]. Review of Resident #5's nurses notes from 05/22/12 to present revealed no mention of a follow-up appointment being made for the Dental Clinic. Review of the NP's progress notes for Resident #5 dated 05/04/12 revealed she was there to follow up on staff concerns of Resident #5's increased agitation and anxiety. She added a note at the bottom of the page indicating the increased agitation and anxiety might be secondary to an infection. Staff had also informed the NP Resident #5 had refused to be catheterized for a Urinary Analysis with Culture and Sensitivity. The NP ordered the Amoxicillin for a probable tooth infection. The NP also noted that psych was working with him. Review of Resident #5's Care Plan Conference Notes dated and signed by LVN V on 03/15/12 revealed under comments she had spoken with Resident #5's family member via telephone and they (family member) were to contact the hospital concerning a Dental appointment. There was no mention of a dentist or dental appointment under the Social Services section. Review of Resident #5's Care Plan Conference Notes dated 06/14/12 revealed "Awaiting Dental extraction." There was no mention of this in the Social Services section. Review of Resident #5's SW notes dated 06/14/12 revealed, "Res. has complaints of pain in teeth. Res's ____ (family member) is working on getting Res on ____ (health insurance) so the teeth can be extracted under general anesthesia. ____ (Dr. W) has seen resident but is unable to pull the teeth in facility due to Res non-funded dental status." Review of Resident #5's SW notes dated 06/21/12 revealed she had called Resident #5's family member to check on the status of the health insurance. The SW note reflected the family member was frustrated as the hospital always had a reason "to request more information before making a decision about care." The SW notes further reflected the family member had also told the SW they had been working with Dr. W's office and they had "re-submitted the info twice now." Further review revealed the SW called Dr. W's office and they confirmed "the facts about having submitted it twice." The SW's note further reflected, "Unfortunately Res will have to wait on the process to solidify so res can get the 17 teeth removed surgically. Res's ____ (family member) and ___ at ____ (Dr. W's) office will con't to f/u on status." During an interview with the SW on 06/21/12 at 2:35 PM, she said Resident #5 was on Medicaid "however he doesn't have the dental coverage." When asked about emergency dental care through DADS, she had no knowledge there was a form which she needed to fill out for emergency dental care through DADS. She said she did not talk to the DADS. The SW said she had spoken to Dr. W's office, and because of his mental condition, he needed general anesthesia. She informed the surveyor she had spoken to Resident #5's family member and they had re-submitted the paper work to the hospital's insurance program. When asked if she had ever contacted the Medicaid Eligibility Worker, she said she never did as she did not know the process for Medicaid Dental Service as she had never worked for a Nursing Facility before and was still learning. She informed the surveyor it was her understanding once someone was on Medicaid, "they" determine what services the person gets and she did not know how it was determined. She reported she had tried to file the paper work required to the hospital and had been informed she could not do it as it had to be filed by Resident #5's POA or by himself. 2) The quarterly MDS assessment dated [DATE] reflected Resident #16, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed under the Oral/Dental Status broken or loosely fitting or full or partial dentures was not checked. Review of a physician's progress note dated 10/26/11 for Resident #16 revealed, "_____ (Resident #16) still needs his bottom teeth. It's not clear what the hold-up is. It would be nice if we could facilitate this." Review of a physician's progress note dated 12/28/11 for Resident #16 revealed, "He's (Resident #16) getting some dental work done and should soon be able to smile again without being self-conscious." Review of a physician's progress note dated 02/08/12 for Resident #16 revealed, "Still no teeth!" Review of a physician's progress note dated 03/14/12 for Resident #16 revealed, "Needs his teeth!" Review of a physician's progress note dated 04/18/12 for Resident #16 revealed, "No progress with teeth." Review of a physician's progress note dated 05/30/12 for Resident #16 revealed, "Still no teeth." During an interview on 06/22/12 at 10:50 AM, the surveyor queried the SW if she had assisted in setting up dental care for Resident #16. The SW responded, "I don't know. I don't really have to time to chart." The SW stated the ____ Dental group came in and did a full dental sweep on 02/02/12 because there had not been a SW at the facility in a long time. The SW reviewed notes provided by the dental hygienist on 02/02/12 and next to Resident #16's name, it was reflected "Exam recommendations 'no'." The SW, as she was looking through the dental book she kept, said Resident #16 had a dental exam due on 10/11, but "I don't think anyone was keeping up with this book." During an observation of Resident #16 on 06/22/12 at 10:58 AM with the SW, the SW stated Resident #16 did not have upper or lower dentures in his mouth. During an interview on 06/22/12 at 11:00 AM with CNA E, who took care of Resident #16, she stated she had never seen any dentures for Resident #16. Review of Resident #16's SW notes revealed no mention of dentures from 01/19/12 through 06/21/12. Review of Resident #16's facility record revealed a green sheet of paper labeled "Dental Consults" with no dental consults behind it. 3) Review of the facility's current policy "Dental, Providing Services" dated January 2005 revealed the following: "Policy: The facility will assure that the resident receives dental services inclusive of routine services. Procedure: 1. The Administrator will assure that there is a qualified and licensed dentist available to meet the dental needs of the resident. 2. The Administrator will assure that all dental care needed is provided for; however, the facility may charge for services not covered under Medicare or Medicaid provisions. 3. The DON or designee will assure that the resident is provided with dental care; emergency, non-emergency and routine care in a reasonable time frame. 4. The Administrator or designee will assist the resident in procuring outside community services to render financial assistance for dental care." 4) The CMS-672 (Resident Census and Conditions of Residents) dated 06/20/12 and signed by the DON reflected the census was 60 residents.