Every finding on record at Carillon Inc

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 3 of 3 residents (Residents #3, #66 and #85) and 2 of 2 (RN A and RN B) staff reviewed for infection control. The facility failed to use EBP during wound care for 3 Residents (Residents #3, #66 and #85). This failure could place residents at risk for spread of infection and cross contamination. Findings include: Resident #3 Record review of Resident #3's clinical record revealed a face sheet, dated 06/17/2026, which indicated the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #3's diagnoses included Alzheimer's disease (cognitive loss), prostate cancer, depression (mental health condition), hypertension (high blood pressure) and peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #3's comprehensive MDS assessment, dated 04/15/2026, revealed his BIMS score of 05 which indicated his cognition was severely impaired. MDS section M - Skin Condition revealed resident #3 had one stage 3 pressure ulcer. Record review of Resident #3's care plan dated 04/22/2026 revealed a focus area for wound management - stage 3 pressure injury to the right glute with intervention to provide wound care per treatment orders. Record review of Resident #3's physician orders dated 06/17/2026 revealed an order Wound Care - cleanse right glute with NS, pat dry and apply Polymem DOT MWF every day shift every Mon, Wed, Fri for wound care, dated 06/03/2026. During an observation on 06/16/2026 at 10:14 a.m. RN B provided wound care for Resident #3. RN B entered Resident #3 room with no PPE on. No visible PPE outside of Resident #3's room. There was no visible signage on or around Resident 3's room to indicate transmittable based precautions were in place for Resident #3. Resident #66 Record review of Resident #66's clinical record revealed a face sheet, dated 06/17/2026, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #66's diagnoses included left femur fracture, muscle weakness, and hypertension (high blood pressure). Review of Resident #66's comprehensive MDS assessment, dated 05/19/2026, revealed his BIMS score of 12 which indicated her cognition was moderately impaired. MDS section M - Skin Condition revealed Resident #66 had one unstageable -deep tissue injury. Record review of Resident #66's care plan dated 05/15/2026 revealed a focus area for wound management - unstageable to left heel with intervention to provide calcium alginate to left heel and cover with silicone every day. Record review of Resident #66's physician orders dated 06/17/2026 revealed an order Wound Care - cleanse left heel with wound cleanser and pat dry. Apply calcium alginate and cover with silicone dressing every day shift for wound care, dated 06/10/2026. During an observation on 06/16/2026 at 01:40 p.m. RN A provided wound care for Resident #66. RN A entered Resident #66 room with no PPE on. No visible PPE outside of Resident #66's room. There was no visible signage on or around Resident 66's room to indicate transmittable based precautions were in place for Resident #66. Resident #85 Record review of Resident #85's clinical record revealed a face sheet, dated 06/17/2026, which indicated the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #85's diagnoses included Alzheimer's disease (cognitive loss), edema (swelling), diabetes (high blood sugar), and hypertension (high blood pressure). Review of Resident #85's quarterly MDS assessment, dated 05/11/2026, revealed his BIMS score of 09 which indicated his cognition was moderately impaired. MDS section M - Skin Condition revealed resident #85 was at risk for pressure ulcers. Record review of Resident #85's care plan dated 05/28/2026 revealed a focus area for wound management - venous ulcer to bilateral legs intervention to provide calcium alginate and cover with silicone dressing every day. Record review of Resident #85's physician orders dated 06/17/2026 revealed an order Wound Care - cleanse 2 right lower legs wounds and 1 left lower leg with NS, pat dry and apply calcium alginate and cover with silicone dressing every day shift for wound care, dated 06/15/2026. During an observation on 06/16/2026 at 02:10 p.m. RN A provided wound care for Resident #85. RN A entered Resident #85 room with no PPE on. No visible PPE outside of Resident #85's room. There was no visible signage on or around Resident 85's room to indicate transmittable based precautions were in place for Resident #85. During an interview on 06/16/2026 at 03:30 p.m., RN A stated Residents #66 and #85 were not on EBP. She stated the wounds were not infection. She stated Resident #66 wound to left heel was open and had some drainage. She stated Resident #85 wounds to lower bilateral legs were open and weeping from edema. She stated she had been trained in EBP. She stated the ADON and DON make rounds to monitor for compliance with EBP. She stated the potential negative outcome of not following EBP could be introducing infection to the wounds. During an interview on 06/16/2026 at 03:41 p.m., RN B stated EBP was needed for Resident #3 because his wound was not infected. She EBP was only needed with complex wounds that require multi layered dressings. She stated she had been trained in EBP. She stated Resident #3 wound was open with a little drainage. She stated the potential negative outcome of not following EBP could be transferring infection to the residents or staff. She stated if the resident was on EBP they would have a sign at their door and PPE outside their room the door. During an interview on 06/17/2026 at 10:30 a.m., the DON stated she was not sure what type of wounds Residents #3, #66 or #85 had. She stated ADON would be better to answer that question. She stated Residents #3, #66 and #85 were not on EBP because they did not have infection or a complex wound dressing. She stated Residents #3, #66 and #85 had simple dressing. She stated a simple dressing was one layer dressing and a complex dressing was two or more layers. She stated residents placed on EBP had indwelling tubes (foley, central lines, picc lines), complex wound dressing, wound vacs or anyone with infections. She stated the purpose of EBP was to protect the residents from infections from other residents. She stated IP was responsible for making sure EBP was in place for residents who needed EBP. She stated all staff were trained in EBP. She stated the potential negative outcome of not following EBP could be transmitting infectious disease to another resident. During an interview on 06/17/2026 at 10:45 a.m., the ADON stated Resident #3 had a stage 3 pressure ulcer on right glute that was open. He stated Resident #66 had an unstageable pressure ulcer on her left heel that was now open. He stated Resident #85 had venous statis ulcer on bilateral legs and wounds were open. He stated Residents #3, #66 and #85 all had simple dressings and EBP was not needed. He stated residents who needed EBP were residents with complex wound dressings that have 2 or more layers and infection. He stated the clinical team wrote the facility enhanced barrier protection policy. He stated the purpose of EBP was to prevent transmitting MDROs from resident to resident. He stated the IP and any nursing staff were responsible for making sure EBP was put in place. He stated all staff have been trained. He stated the potential negative outcome could be spreading infection to residents. During an interview on 06/17/2026 at 11:16 a.m., the ADM stated he refers all wounds and EBP to clinical staff. He stated the purpose of EBP was to prevent the spread of infectious body fluids and disease to residents or staff. He stated he was not aware EBP was not used for Residents #3, #66 and #85. He stated all staff have been trained in EBP. He stated the clinical team was responsible for making sure EBP was put in place. He stated the potential negative outcome could be other residents exposed to infectious disease due to nurse spreading infection to other residents and staff. During an interview on 06/17/2026 at 12:18 p.m., the IP stated she was not sure what type of wound Residents #3, #66 and #85 had. She stated, The purpose of EBP was to keep the residents protected from what could be on our clothes and what germs we have on us. She stated she reviews the weekly wound log provided by ADON to determine who needs EBP. She stated she accesses the residents' wounds and if no complex wound dressing, only needs simple wound dressing, no infection or MDROs the resident would not need EBP. She stated she does not consider wound classification as needed for EBP. She stated she looks at the characteristics of the wound and if the wound was stable, covered and drainage was controlled she doesn't consider EBP. She stated all staff had been trained in EBP. She stated she was responsible for making sure residents who need EBP have the signs and PPE supplies. She stated, I am not sure how the federal regulation read but if a resident has a colonized infection in wound at the moment, do you keep them on EBP for life or was it at the discretion of the facility policy. She stated the facility policy for EBP was reviewed annually. Record review facility policy titled Enhanced Barrier Precautions revised dated November 11, 2025, revealed the following:Policy Statement - Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.Policy Interpretation and Implementation .1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident .3. EBPs are indicated for residents with:a. Foley cathetersb. Complex/infected woundsc. PICC/CVL linesd. Drains (JP, pleurex, etc.) .8. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.9. PPE is available near or outside the resident rooms. Record review facility sign titled Enhanced Barrier Precautions, undated revealed the following: .Providers and staff must also:Wear gloves and gown for the following High-Contact Resident Care Activities.Wound Care: any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to make information on how to file a grievance or complaint available to the residents for 10 of 10 confidential residents reviewed for grievances. The facility failed to ensure 10 of 10 residents were provided, through postings in prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life. Findings include: In Interviews at an undisclosed date and time, 10 of 10 confidential residents stated they did not know they could file a Grievance anonymously; they did not recall the Grievance procedure being discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. The residents stated they did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Observations of prominent postings on 06/16/2026 at 4:25pm; the facility did not include instructions regarding the Grievance procedure with the prominent postings. Interview with the ADM on 06/17/2026 at 10:15am; the ADM stated he was the Grievance Officer for the facility. The ADM stated the Grievance form was available on a shelf on the wall by the downstairs elevator; he stated the forms can also be obtained by any staff member. The ADM stated he assigned grievances to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form, and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook for 3 plus years. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance and he discussed Grievances in daily IDT meetings. The ADM stated he would also meet with the complainant to ensure they were satisfied with the resolution, if needed. The ADM stated he and the management team were responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council; the ADM agreed the availability of the Grievance forms, the Grievance procedure, and procedure for submitting a Grievance form anonymously should be explained to Residents at admission and continually discussed in monthly Resident Council meetings. The ADM stated the potential negative outcome for Residents not being educated on the Grievance process was unsatisfied Residents. Record Review of the Grievance Policy last updated in January 2024 reflected: Policy Statement:It is a policy to thoroughly investigate all residents and families' grievances/complaints. Resolution will be documented on the facility grievance/concern form. Policy Interpretation and Implementation: Federal and state law guarantee the right to submit a formal grievance to all residents of this facility. Grievance forms will be kept in the foyer on each floor of the facility.Any staff member may assist a family member or resident with completing the form.Completed forms will be given to the social services department. Appropriate staff member will complete the investigations.After the investigation is completed it will be documented on the grievance form; the completed form will be submitted to the ADM.

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 facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the garbage can used for food waste was covered unless in use. 3) The DC failed to wear a hair restraint to cover his mustache. These failures could place residents at risk for food-borne illness and cross contamination.The findings included: During kitchen tour observations on 06/15/2026 that began at 9:32 a.m. and concluded at 10:33 a.m., revealed the following: -Garbage can, next to food prepping table, was uncovered and not in use. -The DC was not wearing hair restraint to cover his mustache area. Walk-in Freezer -What resembled scones, cookie doughs, apple scones, cinnamon rolls and white chocolate scones in different clear plastic bags, all with no label and no use by date. Walk-in Refrigerator -What resembled whipped topping in a clear plastic bag, with no use by date. During an interview on 06/17/2026 at 10:32 a.m., the EC stated, I am responsible for putting the labels and dating (use by date) on all food items, as well as all other kitchen staff, everyone is responsible for monitoring the labels and dating of all food items. He stated that kitchen staff were in a hurry, so they forgot to label the food items. The EC stated, yes, I came across the food and general kitchen sanitation policy(s) and have been trained on such task. He further stated they didn't think it needed to be covered when asked about the open garbage can next to the food prepping table. The EC stated that the DC was one of their new hires and that he must have removed the hair restraint and forgotten to put it back. He further stated, these failures, unlabeled food items, the food would have been dangerous for residents to eat and not covering the garbage can, not wearing the hair restraint could lead to food contamination. During an interview on 06/17/2026 at 11:04 a.m., the DC stated, I am responsible for putting the labels and dating (use by date) on all food items, as well as all other kitchen staff, all the kitchen staff were responsible for monitoring the labels and dating of all food items, residents could get very sick from such failure. He stated, I guess, some of us just forgot to label and date the food items and I have been trained on such task, equally seen both the food storage and kitchen sanitation policies. The DC stated he had just gotten out of the bathroom and had forgotten to use the hair restraint, a little stuff like that could have slipped off one's mind easily. He further stated, he did not know that the garbage can not in use were not covered, such failures could cause food contamination. During a telephone interview on 06/17/2026 at 11:21 a.m., the RD stated that the DM and kitchen staff were responsible for those tasks, labeling/dating of food items, while the DM should be the one monitoring such tasks. She stated, she thought they had been trained on such, because the kitchen experienced issues with food labeling and dating previously. The RD stated maybe the kitchen staff missed them, or not sure why food items were not labeled/dated and such failure could cause food borne illness and poor food quality. She further added that when not in use, the garbage can be covered, she did not know why the can was not covered and DC should wear hair restraint. She further added, the hair would have gotten into the food and the garbage can; that was a sanitation issue to her, and these could have led to food contamination. During an interview on 06/17/2026 at 11:31 a.m., the DM stated, I am responsible for putting the date (use by date) and labelling of all food items alongside with the rest of the kitchen staff, and I don't know why the kitchen staff forgot to do that. He stated he had been trained on such tasks and had come across food storage and kitchen policies, and all the kitchen staff were responsible for monitoring, dating and labelling of all the food items in the kitchen. He stated, the residents could get sick from such undated or unlabeled food items. He further stated that the garbage can next to the prepping table should have been covered when not in use, he did not know why it was not, such failure could lead to food contamination. He stated, the DC thought that he doesn't need to have hair restraint, but he should have had it on. He stated the negative outcome would still be food contamination. During an interview on 06/17/2026 at 12:01 p.m., the ADM stated, It should be the kitchen staff who opened that particular food item, that is responsible for dating and labelling that, while the DM will be monitoring such task. He stated they could be serving the residents expired food items which could lead to food borne illness. He stated, at this point, he couldn't say why, but the kitchen staff might have been in a rush; ultimately, the food items should have been labeled and dated. He further stated that, the kitchen staff have been trained and were continuously re-educated throughout the year and I have not seen the policy(s). When asked about the open garbage can, the ADM stated, if not in use, then it should be covered, I can't tell you why the can was not covered, that is something you should speak to with the DM and such would cause potential cross contamination. He further stated that all kitchen staff should have their hair restraint while prepping, and there was no reason why DC shouldn't have been wearing the hair restraint. Record review of the facility's policy and procedure titled, Food receiving and Storage, undated, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Refrigerated/Frozen StorageAll foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Record review of the facility policy and procedure titled, Garbage Can, undated, reflected the following: Purpose: Properly dispose of garbage and clean cans in order to comply with sanitation standards. Procedure: Place new garbage bags in can and replace lid. Place garbage cans in proper place. Record review of the facility policy and procedure titled, Employees - Personal Cleanliness, undated, reflected the following: Purpose: Personal cleanliness is extremely important and the responsibility of each Food & Beverage Department staff member. Bacteria can be present on hands, skin, breath, and hair; therefore, proper cleanliness practices are vital link in the prevention of food-borne illnesses. Procedure: Food employees in food preparation areas and during food preparation should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters (dumpsters #1 and #2), in that: -The doors for dumpsters #1 and #2 were left open.-Garbage was left outside of the dumpster. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.The findings included: Observation on 06/15/2026 at 10:01 a.m., revealed the facility's dumpster area, which was in the docking area behind the kitchen had commercial-size dumpsters (#1 and #2), with open doors. Further observations revealed improperly trashed iron bars (x5) and black trash bags (x2) on the ground behind both dumpsters (#1 and #2). During an interview on 06/17/2026 at 11:47 a.m., the MM stated that anyone who used the dumpster was responsible for making sure the trash was thrown into the dumpster properly and doors closed. He added that anyone who used the dumpsters was responsible for monitoring the identified failures, closing the dumpster doors, trashing the iron bars/black trash bags on the ground behind the dumpsters properly. He further stated, because people don't do their job properly, they should be held accountable. The MM stated he had not been trained on such task and have not seen any waste disposal policy. He stated that such failures could cause the spread of rodents and environmental pollution. During an interview on 06/17/2026 at 12:01 p.m., the ADM stated, typically, I would have that carried out by the MM, it is an IDT (Inter disciplinary team) approach to make sure that the dumpster doors were closed after trashing and garbage trashed properly. He stated, at this time, they do not have anyone assigned to monitor the mentioned or identified failures. He further stated, he cannot speak to why the iron bars/black trash bags on the ground behind the dumpster were not properly trashed and dumpster doors not closed, that is due to lack of coordination. The ADM added that the staff have not been trained on such task at this time and have not come across the waste disposal policy. He further stated, staff need to have proper hand hygiene after disposing the trash before returning to resident care areas, that would be a potential infection risk. Record review of the facility policy and procedure titled, Dumpster Use and Waste Disposal Policy, undated, reflected the following: Policy Statement: All waste shall be disposed of in designated dumpsters. Dumpster areas must remain clean and free of debris, pests, and safety hazards. Dumpster lids and exterior doors leading to dumpster areas shall remain closed and secured when not in use. Procedures: 1. Waste Disposal1. Place all trash directly into designated dumpsters.2. Do not leave waste on the ground or beside dumpsters.3. Secure trash bags before disposal.5. Dispose of regulated or hazardous waste according to facility policy and applicable regulations.2. Dumpster and Door Requirements1. Dumpster lids and access doors must remain closed when not in use.2. Exterior doors to dumpster areas shall not be propped open.3. Dumpster Area Cleanliness1. Keep the dumpster area clean and free of trash, spills, odors, pests, and safety hazards.2. Clean the surrounding area as needed to maintain sanitary conditions.Monitoring and Compliance1. Facility staff shall routinely inspect dumpster areas.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 8 percent based on 2 errors out of 25 opportunities, which involved 1 (Resident #81) of 3 residents reviewed for medication administration. RN A failed to give Resident #81's medications according to physician's orders when she administered the medications Amlodipine (for blood pressure) and Losartan Potassium (for blood pressure) outside the ordered vital sign parameters. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health.Record review of Resident #81's admission Record dated 06/17/2026 revealed an [AGE] year-old female with an admission date of 03/06/2026. Resident #81 had diagnoses which included: hypotension (low blood pressure), candidiasis (fungal infection), essential primary hypertension (high blood pressure without an identifiable medical cause), Parkinsonism (a syndrome effecting motor function), and cognitive communication deficit (communication problem caused by disruption of brain function). Record review of Resident #81's Quarterly MDS assessment, dated 06/09/2026, revealed a BIMS score of 08, indicating the resident had moderate cognitive impairment. Record review of Resident #81's current physicians orders revealed an order with a start date of 03/07/2026 for Amlodipine 5 mg tablet give 1 tablet by mouth one time a day related to essential primary hypertension - hold if pulse is less than 60. Record review of Resident #81's current physicians orders revealed an order with a start date of 03/06/2026 for Losartan Potassium 50 mg tablet give 1 tablet by mouth two times a day related to essential primary hypertension - hold if pulse is less than 60. Record review of Resident #81's MAR for June 2026 revealed Amlodipine 5 mg and Losartan Potassium 50 mg were administered to Resident #81 by RN A on 06/16/2026. During a medication administration observation on 06/16/2026 at 9:14 AM for Resident #81, RN A dispensed one Amlodipine 5 mg tablet and one Losartan Potassium 50 mg tablet into a dispensing cup and entered the room of Resident #81. RN A placed a wrist blood pressure cuff to the right wrist of Resident #81 and assessed the following vital signs: blood pressure = 129/65, pulse = 57. RN A then administered the medications to Resident #81 and left the room. RN A then recorded Resident #81's blood pressure and pulse on the MAR and clicked yes to indicate the medication administration was complete. During an observation and interview on 06/16/2026 at 3:20 PM, RN A opened the MAR for Resident #81 and verified the vital signs assessed prior to the observed medication administration were as follows: blood pressure = 129/65, pulse = 57. RN A stated Resident #81 should not have been administered the Amlodipine 5 mg tablet or the Losartan Potassium 50 mg tablet, due to the resident's pulse being below the ordered parameter of 60 beats per minute. RN A stated she should have held the Amlodipine and Losartan Potassium medications, according to the physicians order. She stated she made an error and did not realize Resident #81's pulse was below the set parameters at the time of administration. RN A stated she had been trained on accurate medication administration during her nurse training. She stated the ADON made random rounds during medication pass and checked for accuracy and competency of medication administration. She stated the procedure when a medication error was made was to first check the resident and reassess vital signs, if necessary, then notify the provider and get any new orders, then notify nursing administration and pass the information on to the oncoming nurse at shift change. RN A stated she would also make an entry in Resident #81's progress notes regarding the medication error. RN A stated a potential negative outcome for administering a medication that does not follow ordered parameters was a resident could have vital signs that were outside of the ideal rate, which could cause harm to the resident. During an interview on 06/17/2026 at 8:55 AM, the DON stated she was not aware until after the observed medication pass that physicians orders had not been accurately followed. She stated all staff had been trained on accurate medication administration. The DON stated the facility utilized rounds and competency checks for monitoring and training of accurate medication administration. She stated random rounds during medication administration were conducted by nursing administration. She stated the pharmacy consultant conducted monthly competency checks for medication administration and the nurse consultant conducted quarterly competency checks during onsite visits. The DON stated her expectation of staff for accurate medication administration was 100% compliance with physicians orders and to exercise the 5 Rights of medication administration at all times. The DON stated a progress note was entered in the electronic health record once Resident #81's provider was notified of the medication error. She stated no new orders were received from the provider for Resident #81. She stated a potential negative outcome for failure to follow physicians orders during medication administration was a resident could be hospitalized or, in extreme cases, it could result in resident death. During an interview on 06/17/2026 at 11:33 AM, the ADM stated he was not aware that physicians orders for medications had not been accurately followed until after the medication observation was conducted. He stated nursing administration was responsible to assure staff were administering medications accurately and according to physicians orders. He stated the system to monitor accuracy of medication administration was by audits conducted by nursing administration, pharmacy consultants, and the nurse consultant. The ADM stated all nursing staff had been trained on accurate medication administration and received continuing education at the facility level. The ADM stated a potential negative outcome for failure to follow physicians orders during medication administration was hospitalization or other serious injuries or reactions from medications. Record review of the facility policy titled Administering Medications (Revised April 2019) revealed: Policy headingMedications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation.4. Medications are administered in accordance with prescriber orders . 11. the following information is checked/verified for each resident prior to administering medications:.b. Vital signs, if necessary.

Based on interview and record review the facility failed to transmit a completed discharge assessment that accurately reflected the residents' status for 1 of 27 sampled residents (Resident #40) whose records were reviewed, in that: Resident #40's Discharge MDS was not transmitted within 14 days of the completed date. This failure could place residents at risk by not receiving the appropriate assessments.Record review of Resident #40's admission Record dated 06/17/2026 revealed an [AGE] year-old female originally admitted to the facility on [DATE] and discharged from the facility on 01/30/2026. Resident #40 had the following diagnoses: chronic obstructive pulmonary disease (a progressive lung disease causing breathing and airflow problems), atrial fibrillation (a type of heart arrythmia), congestive heart failure (a progressive condition where the heart does not pump blood efficiently), Type II Diabetes Mellitus (a metabolic condition where the body does not process sugar effectively), and hypertension (high blood pressure). Record review of Resident #40's electronic medical record MDS tab revealed a Discharge Return Not Anticipated MDS dated [DATE] with a status of complete. The assessment history revealed the Discharge MDS had not been submitted (no batch created). Record review of Resident #40's Discharge MDS dated [DATE] revealed the following: Section A0310 Type of assessment: .F. Code 10 - Discharge assessment - return not anticipated .Section A2000 discharge date : [DATE] .Section A2300 Assessment Reference Date:Observation end date - 01/30/2026Response locked and Signed by: [Name]-former MDS Coordinator on Wed [DATE] at 03:16:39 PM During an interview on 06/17/2026 at 1:29 PM, the Clinical Reimbursement Coordinator stated the MDS Coordinator who completed Resident #40's Discharge MDS was no longer employed by the facility. She stated Resident #40 was not traditional Medicare; she was managed care and certain MDS assessments were not transmitted to CMS when a resident was on managed care. She stated Resident #40's Discharge MDS should have been submitted to CMS. The Clinical Reimbursement Coordinator stated all Discharge MDS' should be transmitted to CMS within 14 days of the completed MDS. She stated there was a box they must uncheck once the MDS was completed or it would not be transmitted to CMS. She stated the box was checked and the Discharge MDS for Resident #40 had not been transmitted to CMS. The Clinical Reimbursement Coordinator stated she would correct the Discharge MDS for Resident #40 and it would be transmitted today (06/17/2026). She stated she and another staff member were responsible for completing and transmitting MDS' and they had each been trained in completing the MDS within proper timeframes through their MDS certification and ongoing MDS training. During an interview on 06/17/2026 at 1:52 PM, the ADM stated he was not aware Resident #40's Discharge MDS had not been transmitted until today. He stated the timeframe to submit a Discharge MDS to CMS once it had been completed was (14) fourteen days. He stated the purpose of the Discharge MDS was to ensure all proper coding and financial reimbursement was correct. The ADM stated the MDS Coordinator who was responsible for completing and submitting Resident #40's Discharge MDS was no longer employed by the facility. He stated the facility hired another MDS Coordinator and she and the Clinical Reimbursement Coordinator were responsible for ensuring all MDS assessments were completed and submitted timely. The ADM stated those staff were each trained on the MDS process through formal MDS certification and annual recertification, as well as corporate training. He stated the potential negative outcome for failure to submit MDS assessments within the proper timeframe was billing errors and financial penalties. Record review of the facility policy titled, MDS Completion and Submission Timeframes (Revised July 2017) revealed: Policy StatementOur facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.Policy Interpretation and Implementation1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . Review of the RAI manual dated October 2025 revealed:. 09. Discharge assessment - Return not anticipated (A0310F=10) .Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) .

Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 6 residents (Residents #10 and #26) reviewed for advanced directives. The facility failed to ensure Residents #10 and #26 who were listed as DNR (Do Not Resuscitate), had Do Not Resuscitate forms that did not have missed required information. These failures could place residents at risk of not having their end-of-life wishes honored and incomplete records. Findings include: Resident #10 Record review of Resident #10's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included chronic kidney disease (rapid loss of kidney function) and Acute Cystitis with Hematuria (inflammation of the bladder). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #10's physician order summary, dated 06/17/26, reflected the following order: DNR-Do Not Resuscitate dated 05/01/26. Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 was usually understood (difficulty communicating some words or finishing thoughts but was able if prompted or given time). The MDS revealed Resident #10 had a BIMS score of 06 which indicated the resident's cognition was severely impaired. Record review of Resident #10's care plan, dated 04/30/26, reflected a care plan for DNR. Record review of Resident #10's DNR form dated 8/06/24 reflected the resident's signature was absent from the DNR form, the doctor signed on the signature line intended for the resident's signature. Resident #26 Record review of Resident #26's, undated, face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included Alzheimer's Disease (brain disorder, most common form of dementia) and chronic kidney disease (rapid loss of kidney function). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #26's physician order summary, dated 06/17/26, reflected the following order: DNR-Do Not Resuscitate dated 01/28/26. Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #26 was usually understood (difficulty communicating some words or finishing thoughts but was able if prompted or given time). The MDS revealed Resident #26 had a BIMS score of 3 which indicated the resident's cognition was severely impaired. Record review of Resident #26's care plan, dated 05/05/26, reflected a care plan for DNR. Record review of Resident #26's DNR form dated 09/25/25 reflected Resident #26 signed on the signature line for a legal guardian, agent, or proxy. The physician's signature, date, printed name, and license number was missing. During an interview on 06/17/26 at 11:35am with the SW, she stated the DNR was not valid if it's not filled out correctly. She stated the social services department was responsible for ensuring DNRs were completed correctly. She verified missing information on DNR for Residents #10 and #26. She stated DNRs were monitored for accuracy during every care plan meeting. She stated the reason the DNR's were not complete was human error. She stated she was trained on DNRs. The SW stated the potential negative outcome for residents if a DNR was not completed correctly was catastrophic, very bad. During an interview on 06/17/26 at 11:55am with the ADM, he stated the DNR was not valid if not filled out correctly. He stated the IDT team was responsible for making sure the DNR was completed accurately. He stated DNRs were audited for accuracy when obtained and upon admission. He verified missing information on the DNR for Residents #10 and #26. He stated he did not know why the information was missing or incorrect. He stated the potential negative outcome was the residents' wishes were not followed. He stated he was trained in how to complete DNRs and his expectations were for them to be filled out completely and be correct. Record review of the Advanced Directives Policies and Procedures (Revised 2001) reflected the following: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 20 confidential residents. The facility failed to ensure 12 of 20 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 04/24/2025 at 3:30pm, 12 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The 12 residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 4/24/2025 at 4:45pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 4/25/2025 at 12:14pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated there was no Grievance form available for the Residents, when Residents present a Grievance issue to staff, the staff completed Grievances electronically on the Resident's behalf. The ADM stated there was no procedure for Residents to submit grievances anonymously. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated he assigns the grievance to the appropriate department, that department addresses the grievance, resolved the grievance, and explained the resolution to the complainant. The resolution was documented electronically with the original electronic Grievance. The ADM stated completed Grievances were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council. Record Review of the Grievance Policy. Policy Statement It is a policy to thoroughly investigate all resident and families' grievances/complaints. Resolution will be documented on the facility grievance/concern form. Policy Interpretation and Implementation 1. Federal and state laws guarantee the right to submit a formal grievance to all residents of this facility. 1. Grievance/complaint forms will be kept on each floor and in the social service office. 2. Any staff member may assist a family member or resident in completing the facility form. 3. Completed grievance forms will be given to the social service department. The social service department will route the grievance to the appropriate department. 4. Investigation will be completed by the appropriate staff member and follow up will be documented on the form. 5. After investigation and resolution, the completed form will be given to the administrator or designee for final review. 6. The social service director or designee will be responsible for logging all family and resident grievances in the facility grievance log. 7. Copies of the completed grievance form may be given to residents and/or family members as deemed appropriate by the facility management. 8. Incidents/complaints involving alleged resident abuse will be directed to the Administrator for proper reporting and investigation immediately.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 1 of 20 residents (Resident #40) reviewed for infection control. CNA A failed to sanitize her hands between glove changes during incontinent care for Resident #40. This failure could place residents at risk for the spread of infection and cross contamination. Findings included: Record review of Resident #40's face sheet dated 04/25/25 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses: acute respiratory failure (a condition causing inadequate oxygen in the tissues), Parkinson's Disease (a disorder of the central nervous system that affects movement), shortness of breath, and hypertension (high blood pressure). Record review of Resident #40's comprehensive care plan dated 03/04/25 revealed the resident required assistance with toileting needs and was incontinent of bowel and bladder. Record review of Resident #40's Significant Change MDS assessment dated [DATE] revealed a BIMS score of 0, indicating the resident's cognition was severely impaired. Further review of Section H-Bowel and Bladder revealed: Urinary Continence - the resident was always incontinent. Bowel Continence - the resident was always incontinent. During an observation on 04/24/25 at 10:02 AM of incontinent care for Resident #40, CNA A washed her hands, put on PPE, and performed male incontinent care. CNA A removed her gloves, put on a new pair of gloves, and applied a new brief to Resident #40. CNA A removed her PPE and washed her hands following the procedure. CNA A did not sanitize her hands between the glove change during incontinent care. During an interview on 04/24/25 at 10:50 AM, CNA A stated she did not sanitize her hands between glove changes while performing incontinent care for Resident #40. She stated she did not know why she skipped the step of sanitizing her hands. She stated, Normally, I would sanitize my hands after removing my gloves, but today I got in a hurry and forgot. CNA A stated she was trained on hand hygiene during her orientation when she was hired. CNA A stated a potential negative outcome of failure to perform hand hygiene between glove changes was cross-contamination. During an interview on 04/25/25 at 11:41 AM, the ADM stated he was not aware that staff were not observing proper hand hygiene between glove changes during resident care. He stated the DON and administrative nursing staff were responsible to assure staff were trained on proper hand hygiene. The ADM stated a potential negative outcome for failure to properly sanitize hands between glove changes was the spread of bacteria and germs. During an interview on 04/25/25 at 12:05 PM, the DON stated she was not aware that staff were not observing proper hand hygiene between glove changes during resident care. She stated she and the clinical managers were responsible to assure staff were trained on hand hygiene. She stated the facility educator was responsible to conduct staff training monthly and as needed. The DON stated the clinical managers made daily rounds on each unit to monitor staff for proper skills and training during resident care. She stated a potential negative outcome for failure to perform hand hygiene between glove changes was the spread of infection. Record review of the facility's undated policy titled, Handwashing/Hand Hygiene, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation . Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident. f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.

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 3 of 6 kitchens reviewed for dietary services. The facility failed to label and date foods stored in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations and interviews were made on [DATE] beginning at 10:15 AM during the initial observations of the kitchens: Observation on [DATE] at 10:45 AM of the 1st floor south kitchen revealed the following unlabeled and undated items: 2 individual prepared parfaits and 6 individual pureed parfaits. During an interview on [DATE] at 10:50 AM the DM stated the parfaits were prepared on [DATE]. The DM stated the parfaits were not dated with the date they were prepared since they planned to serve them the same day. The DM stated if the parfaits were not used that day there would not be a way for a someone to know what day they were prepared since they were not dated. The DM stated he would ensure all prepared food items stored in the kitchen refrigerators were dated going forward to prevent expired food from being served. Observation on [DATE] at 10:58 AM of the 2nd floor south kitchen revealed the following unlabeled and undated items: 2 individual prepared parfaits, 1 individual pureed parfait, and 7 uncooked pasteurized eggs (in a clear, unlabeled, plastic container). Observation on [DATE] at 11:29 AM of the 3rd floor south kitchen revealed the following unlabeled and undated items: 3 individual pureed parfaits. Observation on [DATE] at 11:40 AM of the 3rd floor north kitchen revealed the following unlabeled and undated items: 2 individual prepared parfaits and 1 individual pureed parfait. During an interview on [DATE] at 12:45 PM the DM stated all food in the kitchen refrigerators should have been dated with a prepared date or an expiration date. The DM stated all dietary staff were responsible for ensuring food was labeled and dated. The DM stated all dietary staff received training on food preparation and storage upon hire and again during monthly in-service trainings. The DM stated uncooked pasteurized eggs were sometimes stored in the units' kitchen refrigerators to be prepared fresh on each unit. The DM stated the uncooked pasteurized eggs were removed from a larger dated container and placed in a storage container. The DM stated the expectation was for dietary staff to rotate eggs when new eggs were brought in. The DM stated there was no system in place to verify eggs were rotated or to verify the use by date for each egg. The DM stated he planned to ensure all uncooked pasteurized eggs were stored, in each unit's kitchen refrigerator, with a use by date going forward. The DM stated he completed monthly audits on each unit's kitchen. The DM stated it was his expectation that regulations were followed, and food items were labeled and dated properly. The DM stated it was important for food times to be labelled and dated to ensure outdated food was not being served to prevent foodborne illness. The DM stated when food was not labelled and dated properly, residents were at risk of getting food poisoning. During an interview on [DATE] at 1:30 PM the ADM stated it was the facility's policy that all food items be properly labelled and dated. The ADM stated it was his expectation that all food was served fresh and stored properly. The ADM stated all dietary staff were responsible for ensuring food was stored and dated properly, and the DM was responsible for overseeing dietary staff. The ADM stated all prepared food should have been labelled and dated in each kitchen's refrigerators. The ADM stated uncooked pasteurized eggs should have been dated as well. The ADM stated all dietary staff received training pertaining to food storage and preparation upon hire and during regular in-service trainings, held by the DM. The ADM stated each kitchen was audited monthly by the DM and the facility's registered dietician. The ADM stated if food was not labelled or dated properly, residents could have potentially received food that was not appropriate for them, and residents could have received food that was not fresh and outdated which could have potentially caused illness to the resident. Record review of the undated facility policy titled Refrigerators and Freezers revealed the following documentation: Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened.

Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident reviewed for pharmaceutical services in that: The facility failed to have a system in place to ensure proper storage of medications that would prevent missing medications for Resident #1. This failure could place residents at risk of having their medications diverted and/or receiving the incorrect dosage because of improper storage. Findings included: Record review of Resident #1's face sheet dated [DATE], revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Malignant Neoplasm of spinal cord (cancerous tumors on the spinal cord), malignant neoplasm of brain, unspecified (tumors on the brain), benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland that could make urination difficult). The face sheet further revealed Resident #1 was discharged to a hospital on [DATE] at 0020 (12:20) AM. Record review of Resident #1's orders, dated [DATE], revealed an active order for Morphine Sulfate oral tablet 30 MG (Opioid medication used to treat severe pain), every 3 hours as needed for pain; Start date [DATE]. Record review of Resident #1's Medication Administration Record dated [DATE]-[DATE], revealed an active order for Morphine Sulfate oral tablet 30 MG; give by mouth every 3 hours as needed for pain; Start date [DATE]. The MAR further revealed Resident #1 received the medication on the following days: (,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]). Record review of the pharmacy shipment summary for Resident #1, dated [DATE], revealed the facility received an order on [DATE] at 19:29:47 (7:29 PM) for Morphine Sulfate IR (Immediate release) 30 MG Tablet quantity of 60. During an interview on [DATE] 8:20 AM, the ADM stated he was notified on [DATE] that LVN A noticed a card of Morphine 30 ML PRN tablets and the narcotic sheet for a deceased resident (Resident #1) were missing from the medication cart after she took the keys and responsibility for the cart from LVN B. The ADM stated LVN B had already left the facility and was contacted by NM A to return to the facility but LVN B said she was too far and asked if she could return later. The ADM stated LVN A was immediately sent for a drug test and was negative for all substances. The ADM stated LVN B was also asked to take a drug test but he did not believe she went as she was employed by an agency and was not permanently employed by the facility. The ADM stated he contacted the agency to notify them of the situation and was told LVN B was terminated. He stated LVN B would no longer be able to work at the facility. The ADM stated LVN A gave a statement of the incident and said she counted the cart with LVN B on the morning of [DATE] before LVN B left for the shift and she took responsibility for the cart. The ADM stated he had looked for the missing medications and was not able to locate it. The ADM stated Resident #1 did not return to the facility as he passed away at the hospital. Record review of letter signed by LVN A on [DATE] revealed: On Friday morning [DATE], I came to work and got report from an agency nurse. Counted the narc cart down and noticed there were cards on the left side with the count cards wrapped around them. Asked the off going nurse what those were, she stated those are that man that passed away. I counted them and wrapped them back up with the cards and rubber band. Moved my cart to the family room area and began to pass meds. Went to pull narcs out of the book for a resident with the same last initial when I noticed that something did not look right. I looked through my cart thoroughly when it finally dawned on me that Resident #1's PRN Morphine 30 MG tablets were missing along with the count sheet. I called my nurse manager and informed her and looked through the med room cart and pretty much everywhere I could have thought they might have gotten misplaced. Record review of letter signed by LVN A on [DATE] revealed: Counted cart down on Wednesday night and was accounted for 30 milligrams PRN Morphine Thursday morning and evening meds were there as well. Counted Friday and as I stated earlier, I noticed them missing around 7:15 AM to 7:30 AM Friday morning when I notified nurse manager. During an interview on [DATE] at 2:04 PM, LVN A stated she worked the 7:00 AM-7:00 PM shift. She stated she recalled counting the card of Morphine 30 MG for Resident #1 when arriving and leaving for her previous shifts on [DATE] and [DATE]. She stated she arrived for her 7:00 AM shift on Friday, [DATE] and counted the medication cart with LVN B who was leaving for her shift as they were trained to do. She stated she noticed there were medication cards separated and wrapped in the narcotics sheets and asked LVN B about them. She stated LVN B told her they belonged to the male resident that passed away (Resident #1). She stated she explained to LVN B that they must count all medications in the cart and LVN B told her she did not know that but would remember for next time. LVN A stated she and LVN B counted the medications on the medication cart and both agreed all medications had been accounted for and both signed the medication cart count log. She stated she took the keys to the medication cart and possession of the cart at that time. She stated LVN B left the facility. LVN A stated she got her blood pressure cuff ready and began to pull medications to pass out to residents when she realized the medication was missing. She stated she did not catch the missing medication during the process of counting medications with LVN B because the medication card and narcotics sheet were both missing. LVN A stated she immediately called NM A to report the missing medication who then reported it to the Interim DON. She stated they all looked for the medication and narcotics log sheet in both medication carts, in the medication destruction box, in the medication destruction cabinet, and in the sharps collection container and did not locate it. She stated she was sent for a drug test and completed it. She stated she did not know what happened to LVN B. She stated NM A may have called LVN B to return to the facility but LVN B told her she was too far out of town. She stated she had never had this happen before. She stated NM A and the ADON were responsible to remove discontinued medication and medication from discharged residents from the medication carts but was not sure how often they were required to do that. During an interview on [DATE] at 10:45 AM, NM A stated LVN A called her on [DATE] at 7:21 AM and notified her that there was a narcotics sheet and a whole card of Morphine 30ML missing from the medication cart from Resident #1's medication supply. NM A stated LVN A told her she recalled she counted them the night before ([DATE]) with LVN B. She stated LVN A told her the reason she realized the medication was missing was because when she opened the drawer, she noticed two cards of Resident #1's medications were pulled aside and were wrapped in the narcotic sheets and tied with a rubber band. She stated LVN A told her she asked LVN B why those cards were pulled asked and wrapped like that and that LVN B told her those medications belonged to the deceased resident (Resident #1). She stated LVN A stated she told LVN B that those medications still needed to be counted with all the other medications in the cart so they counted the meds, and LVN B left for the day. NM A stated LVN A told her that afterwards she remembered that Resident #1 had three cards of medications in the cart and went back to check and that was when she discovered the card of Morphine 30 MG pills were missing and reported it to her. She stated she called LVN B and asked her to come back to the facility at about 7:45 AM and explained to her that she needed to return to the facility because there was a whole card of missing narcotics and LVN B told her she was an hour out of town. NM A stated she told LVN B she would check on it and call her back. She stated then LVN B texted her at 7:53 AM and asked if she could come back later that night, as she was coming back to town to work at another facility but that she needed to go to sleep. NM A stated she checked the pharmacy records to see what had been filled and determined the facility received the prescription on [DATE] and that that card had 60 pills. She stated the MAR indicated Resident #1 had only taken ten or eleven of those pills. NM A stated she reported the incident to the ADM and the Interim DON and they all searched for the pills and did not find them. She stated she also went to the Medical Records department to see if they had taken the narcotic sheet but did not locate it. She stated she called LVN C who was the regular night nurse and told her he last saw the medication in the medication cart on the night of [DATE]-[DATE], when he sent Resident #1 to the hospital. NM A stated no one else would have had access to that medication cart during that shift besides LVN B because she was the only nurse working on that shift along with two CNA's. She stated CNA's did not have keys to the medication carts. NM A stated Resident #1 went to the hospital on [DATE] and passed away on [DATE]. She stated they place a bed hold for 3 days when a resident discharges and during that time the medications were also left in the medication cart. She stated she was responsible to remove discontinued medications and medications that belonged to residents that discharged from the medication cart. NM A stated she should have removed the medications that belonged to Resident #1 from the medication cart on [DATE] when he passed away but did not know why she did not. She stated a potential negative outcome of medications not being removed timely was that they could be stolen by someone. She stated medications were supposed to be removed from the cart when residents discharged or when they pass away. She stated she should have taken them out of the cart. She stated the ADM asked her why she did not remove the medications from the cart but she did not know why and was not able to provide an answer to him. During an interview on [DATE] at 2:21 PM, LVN C stated he usually worked the night shift from 7:00 PM-7:00 AM. He stated he worked the night shift on [DATE], which was the night Resident #1 was sent to the hospital. He stated he was trained to always count the medications on the medication cart when arriving and leaving his shifts with the nurse he received the cart from and passed the cart to. He stated he recalled seeing Resident #1's Morphine 30 MG when leaving his shift at 7:00 AM. He stated he thought he passed the medication cart to LVN A that morning. He stated he was off work the next two days and learned Resident #1 passed away at the hospital when he returned to work on [DATE]. LVN C stated the reason he recalled seeing that medication on the Tuesday-Wednesday night was because he had to move Resident #1 to another room that night due to there being an issue with his bedroom heater and he also recalled Resident #1 was acting odd. He stated Resident #1 could have received that medication at 12:00 AM but he did not give it to him because Resident #1 did not complain of pain and then shortly after, Resident #1 was sent to the hospital due to being lethargic and he appeared to be declining. He stated he also recalled giving the medication to Resident #1 the night before. LVN C stated Resident #1 passed away the next day ([DATE]). LVN C stated he did not know which nurse worked the night shift on Wednesday and Thursday night. He stated he was told about the medication being missing when he returned to work on Friday. During an interview on [DATE] at 5:07 PM, LVN B stated she was employed through an Agency and worked at the facility on days she was assigned to work there. LVN B stated she last worked at the facility last week. LVN B stated she received a call from NM A on [DATE] who told her there was a medication missing from the medication cart and did not get signed out. LVN B stated NM A asked her if she remembered what medication was in the cart. LVN B stated she told NM A that she put aside the medications that belonged to the deceased resident that was in the hospital. LVN B stated she asked NM A if she could go back tomorrow because she lived in another state and 1.5 hours away. LVN B stated NM A replied she would call her back and never heard back from NM A. LVN B stated she told NM A that all the medication was there when she counted it with LVN A. She stated LVN A did not say anything to her about there being missing medication, so as far as she knew, it was correct, and then LVN A took the keys and medication cart from her. LVN B stated she went home after they signed the logbook. LVN B stated she was trained to pull medications that belonged to discharged residents and wrap the narcotic sheet around the card with a rubber band and put it at the back of the narcotics drawer. She stated there were two medication cards she wrapped that belonged to Resident #1 and she put them in the back of the drawer. She stated she had not been assigned to work at the facility since then. She stated the facility reported her to the agency she worked for and they ended her employment. She stated she explained to the agency that she and LVN A counted the medication cart before she left the facility like they were trained and that the count was correct and LVN A took possession of the cart. LVN B stated she would never take a medication cart from another nurse if the medication cart was wrong. LVN B stated had possession of two medication carts that night. She stated she did not know the exact name of the medication that was missing. During an interview on [DATE] at 11:45 AM, the Interim DON stated she staff were trained to lock medication carts and the monitor that displays the medication administration record every time they walk away from them. She stated staff should never leave a medication cart unlocked. She stated the off going and oncoming nurse must count the narcotics in the medication carts together when changing shifts and/or exchanging the cart. She stated staff must reach out to the nurse manager, the ADON, and to the Interim DON when there was a discrepancy on the count of the narcotics. The interim DON stated she did not know what the policy for removing discontinued medications and medications that belonged to discharged residents from the medication carts. She stated she did not know who was responsible for removing those medications from the medication carts. She stated she was made aware that a card of Morphine 30 MG tablets was missing from the medication cart on Friday ([DATE]) by NM A. The Interim DON stated she thought the medication was discovered to be missing when staff were in the process of removing discontinued and medications that belonged to discharged residents from the medication cart. She stated she was working on developing a new protocol to remove medications from those two categories from the medication carts within 24 hours, but she did not know what the system was prior. She stated she was not aware of a system in place to ensure missing medications did not go unnoticed when the narcotic sheet and the whole medication card was gone. The Interim DON stated staff received ongoing training from the ADM, the DON, and the nurse educator. She stated she was not sure if staff received training on PRN medications. She stated she was not sure who was responsible to ensure the medication count was correct before exchanging a medication cart with another staff. She stated she expected staff to ensure the medications were counted correctly and all medications were accounted for before passing on the cart. She stated it was okay for LVN B to go home for the day once she and LVN A agreed the count was correct and both signed the medication count log. The Interim DON stated a potential negative outcome of Resident #1's Morphine being taken could have been that he would not have received this medication and his pain would not have been addressed appropriately. During an interview on [DATE] at 12:04 PM, the ADM stated they were not able to locate Resident #1's Morphine. He stated staff must lock the medication carts anytime they were not using it and anytime they did not have their eyes not on the cart. The ADM stated both the oncoming and off going staff were trained to count all narcotics in the medication carts and compare the number amount of medication counted to the narcotic log sheet. The ADM stated if the numbers did not match, then this must be reported and investigated immediately. He stated the narcotics were double locked on the cart. He stated only the charge nurse on the shift had access to the medication carts and the keys to them. He stated there was only one set of keys to each medication cart. He stated discontinued medications and medications that belonged to discharged residents should be removed from the medication carts immediately but not later than three days afterwards. The ADM stated the ADON was the only person that had access to the drug destruction bin besides the consultant pharmacist. The ADM stated the DON was responsible to ensure all discontinued medications and medications that belonged to discharged residents were accounted for and destroyed properly. He stated the ADON and NM A were responsible to ensure all medication carts were free and clean of discontinued medications and medications that belonged to discharged residents. He stated he was not aware that Resident #1's medication was missing until he was notified the morning of [DATE]. He stated both the oncoming and off going staff were responsible to ensure the medication count was verified and correct. He stated the oncoming staff should ensure the cart was correct before accepting a cart and the off going staff was responsible to ensure the medication count was correct. He stated he expected staff to ensure the medication count was correct. He stated it was technically okay for LVN B to go home once she and LVN A agreed the medication count was correct and LVN A took the keys and accepted the cart. The ADM stated the pharmacist would have discovered Resident #1's medication to be missing during their monthly rounds of audits on all medications however there was no other system in place to catch missing medications from the carts when both the narcotic sheet and the medication card were missing besides those audits. He stated staff were trained on PRN medications and narcotic medications after this incident. The ADM stated a potential negative outcome could have been that Resident #1 would not have had access to the care he needed to manage his pain as Morphine was typically prescribed to resident's that had chronic pain. The ADM stated Resident #1 had chronic pain related to cancer. The ADM stated however, the missing medication did not affect Resident #since he passed away at the hospital and did not return to the facility. He stated Resident #1 received the medication during the time he was at the facility. The ADM stated another potential negative outcome was that the diversion would go unnoticed and residents would be short of the medication they needed to maintain their pain free life. Record Review of the facility provided policy, Discarding and Destroying Medications, undated, revealed in part: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately. c. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. d. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action is indicated. 13. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the attending physician may choose not to discharge the resident with those medications. Policy Interpretation and Implementation 6. Should the facility contract with a DEA-registered collector, controlled substances may be disposed of in an authorized collection receptacle located at the facility. a. If a resident is transferred to another facility or dies while he or she is in lawful possession of controlled substances, the facility may dispose of the controlled substance(s) by depositing in the authorized on-site collection receptacle. c. Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 6 medication carts (Cart 4S1 and Cart 4S2) observed in the facility. The facility failed to ensure medication cart 4S1 and medication cart 4S2 on the fourth floor were secured when unattended on 2/25/25. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation and interview on 2/25/25 at 2:18 PM medication carts 4S1 and 4S2 were observed in the 4th floor dining area with the locks popped out on both medication carts. RN A was observed walking towards from a hallway on the other side of the floor. RN A approached the medication carts and stated she was the charge nurse on the floor and was assigned to both medication carts. RN A pulled on all the drawers and all of drawers opened except the drawer that narcotic medications were stored in. Various cards and bottles of medications and medical supplies were observed in the drawers of the medication carts that opened. During an interview on 2/25/25 at 2:19 PM, RN A stated she was in the process of passing medications from two medication carts and she left both medication carts (Cart 4S1 and Cart 4S2) unlocked. RN A stated she received in-service trainings on PRN medications and drug diversion a week or two ago. RN A stated she was coming from a resident's room that she was administering a covid test and wound care on. She stated she was trained to lock the medication cart every time she was not standing in front of it. RN A stated a potential negative outcome was that someone could take medications and anything else that was in the cart and then residents would no longer have their medications they needed. She stated she was not aware she left the carts unlocked. She stated she did not think about it in that moment. She stated she was responsible to ensure medication carts were locked. During an interview on 2/28/25 at 11:45 AM, the Interim DON stated she staff were trained to lock medication carts and the monitor that displays the medication administration record every time they walk away from them. She stated staff should never leave a medication cart unlocked. The Interim DON stated she was not aware nurses were leaving medication carts unlocked while unattended. She stated the system for ensuring carts were not left unlocked was to educate the staff. The Interim DON stated staff received ongoing training from the ADM, the DON, and the nurse educator. She stated she did not know the last time staff were trained on locking the medication carts. She stated the nurse that had possession of the medication cart was responsible to ensure it was locked. She stated she expected staff to lock unattended carts. The Interim DON stated a potential negative outcome of medication carts being left unlocked while unattended was that medications could be taken from the cart which would then cause the residents to not get the medications they need. During an interview on 2/28/25 at 12:04 PM, the ADM stated staff must lock the medication carts anytime they were not using it and anytime they did not have their eyes not on the cart. He stated the narcotics were double locked on the cart. He stated only the charge nurse on the shift had access to the medication carts and the keys to them. He stated there was only one set of keys to each medication cart. He stated he was not aware nurses were leaving medication carts unlocked and unattended. He stated staff were trained by the NM A to not leave medication carts unlocked and they also talk with staff about it regularly during rounds. He stated he expected staff to lock the medication cart. The ADM stated a potential negative outcome of leaving a medication cart unlocked was that residents could access carts and take something or resident's medications could be misappropriated by staff or visitors. The ADM stated it could cause a resident to be affected financially because their property would be stolen and they may not have enough medication to last them through the number of days they were expected to. The ADM stated another potential negative outcome was that the diversion would go unnoticed and residents would be short of the medication they needed to maintain their pain free life. Record Review of the facility provided policy, Administering Medications, undated, revealed in part: Policy heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 5 residents (Resident #1) reviewed for quality of life. The facility failed to ensure Resident #1 was provided assistance with eating during the lunch meal and dinner meal on 10/12/2024, while the resident was on in-room isolation. This failure could place residents at risk for decreased food intake, weight loss, decline in health, and a decreased quality of life. The findings included: Record review of the face sheet, dated 10/25/2024, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: heart failure (condition in which the heart does not pump blood adequately), psychotic disorder with delusions (condition affecting brain function with altered perception of reality), cognitive communication deficit (communication difficulty caused by cognitive impairment), hypertension (high blood pressure), anemia (low levels of healthy red blood cells that carry oxygen), and hypokalemia (low potassium level). Record review of Resident #1's admission MDS assessment, dated 09/08/2024, revealed Resident #1 had a BIMS score of 00, which indicated severely impaired cognition. The MDS revealed Resident #1 usually required set up or clean up assistance for eating. The MDS revealed Resident #1 was on a mechanically altered diet. Record review of the current care plan for Resident #1, date initiated 9/11/2024 and revised on 9/20/2024, revealed a focus area indicating the resident required assistance with daily adl's due to end of life care, with a goal stating the resident will have all needs met through the next target date of 12/31/2024, and the intervention and tasks included assess resident current functional level with gg scores eating 5. The care plan also revealed a focus area indicating the resident was at risk for nutritional deficits related to end of life care. The plan stated the resident was on a regular diet, minced and moist Level 5 (dysphagia mesh altrd/grind) texture and regular/thin liquids (level 0) consistency with a spill cup to be used for liquids. The focus area stated the resident required cuing assistance with meals. The goal for this focus area stated the resident will have optimum nutrition level as evidence by not losing or gaining significant weight through the next review date of 12/31/2025. The interventions and tasks for this focus area stated the resident should have a diet per physician's order, food preferences should be discussed with the resident and her requests should be honored, and the resident's weight should be checked weekly. The care plan stated Resident #1 required assistance with ADL's due to end of life care. The interventions included: identify resident's level of assistance needed and complete resident Kardex, resident summary or nursing assistant assignment sheet for delivery of care. The care plan for ADL assistance contained coding information from the MDS for all ADL's and stated gg scores eating 5 under interventions. The care plan did not define the score. Record review of the order summary report, dated 10/24/2024, revealed Resident #1 had an order for regular diet with mechanically altered texture, thin liquids consistency, and spill cup to be used for liquids. Record review of Resident #1's Dietary/Nutrition Profile, dated 9/11/24, revealed the resident required supervision and touching assistance for eating. During an observation of the noon meal on 10/25/24 at 11:51 AM, Resident #1 was seated at the assistive feeding table wearing a clothing protector and holding a beverage. CNA A stated Resident #1's food had been cut up for her at the beginning of the meal. Resident #1 had consumed approximately fifty percent of her meal and was being encouraged by CNA A to continue eating. Resident #1 was observed to require frequent staff cueing to eat her meal. During an interview on 10/25/24 at 12:08 PM with CNA A, she stated she had been caring for Resident #1 since the resident was admitted a couple of months ago. CNA A stated Resident #1 always required assistance with cutting her food and required frequent cueing throughout the meal to stay on task to eat. She stated, at times, Resident #1 would require assistance from staff to begin eating her meal by feeding her a few bites to get her started. During an interview on 10/25/24 at 12:11 PM with LVN A, she stated Resident #1 was initially placed at an independent feeding table but had to be moved to an assistive feeding table within a couple of weeks after admission due to not eating well on her own. LVN A stated Resident #1 required verbal cueing throughout the meal to eat. During an interview on 10/25/24 at 3:11 PM with CNA B, she stated she worked PRN in the facility. She stated she was assigned to Resident #1 on 10/12/24, which was her first full shift working in the memory care unit. She stated Resident #1 was on isolation on the day she was assigned to her, and she brought Resident #1 her lunch tray and dinner tray during her shift. CNA B stated Resident #1 was sitting up in her chair when she brought her lunch to her room. She stated meals were being served in Styrofoam boxes at that time due to isolation precautions. She stated she opened the box for Resident #1 and showed her where her silverware was and left the room. CNA B stated she was not the one who picked up Resident #1's lunch tray and did not know how much food Resident #1 had consumed at lunch. CNA B stated she brought Resident #1 her dinner tray but did not provide eating assistance to the resident. She stated she picked up Resident #1's dinner tray and stated she did not eat much-maybe a bite or two of the meal. CNA B stated she was not aware that Resident #1 required assistance with meals. She stated she had been trained to obtain information about the resident's ADL needs by asking other staff members, but it was not reported to her that Resident #1 required assistance during meals. During an interview on 10/25/24 at 1:03 PM with the ADM, he stated the procedure to ensure dependent residents are provided adequate care, according to their needs was to train staff on proper ADL care and provide staff with accurate information for the level of care each resident required. He stated the DON, MDS nurse and nurse managers were responsible to ensure dependent residents needs were met and information was accurate for each resident's required level of assistance. The ADM stated his expectation of staff was to provide care as planned for each resident. He stated a potential negative outcome for failure to provide adequate care to a dependent resident was that the resident would not receive proper care. During an interview on 10/25/24 at 1:19 PM with the DON, she stated charge nurses, the nursing team and the DON were responsible to assure that dependent residents needs are being met, according to their plan of care. She stated the system for monitoring that dependent residents' needs were being met was for nurse management to conduct rounds twice per week and perform random audits of the health care record. She stated staff were trained to use their preceptors as the primary information source for obtaining current information about a dependent resident's needs. The DON stated since the incident with Resident #1, staff had been retrained to use the Kardex system to obtain information regarding needs of dependent residents. She stated new staff were now being trained to use the Kardex system. The DON stated her expectation from staff for providing ADL care for dependent residents was to perform accurate care every two hours and as needed. She stated a potential negative outcome for failure to provide adequate care to a dependent resident was a decline in the resident's health status and potential harm, which is what we try to prevent. Record review of the facility provided policy titled Assistance with Meals, revised March 2022, revealed: Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Dining Room Residents: . 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity .

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #1's activities of daily living and nutritional needs, specific to assistance needed during meals. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #1 Record review of the face sheet, dated 10/25/2024, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: heart failure (condition in which the heart does not pump blood adequately), psychotic disorder with delusions (condition affecting brain function with altered perception of reality), cognitive communication deficit (communication difficulty caused by cognitive impairment), hypertension (high blood pressure), anemia (low levels of healthy red blood cells that carry oxygen), and hypokalemia (low potassium level). Record review of Resident #1's admission MDS assessment, dated 09/08/2024, revealed Resident #1 had a BIMS score of 00, which indicated severely impaired cognition. The MDS revealed Resident #1 usually required set up or clean up assistance for eating. The MDS revealed Resident #1 was on a mechanically altered diet. Record review of Resident #1's Nutritional Assessment, dated 09/11/2024, revealed under H. Oral Status, 2. Eating, Supervision and touching assistance is marked. Record review of the current care plan for Resident #1, date initiated 9/11/2024 and revised on 9/20/2024, revealed a focus area indicating the resident required assistance with daily adl's due to end of life care, with a goal stating the resident will have all needs met through the next target date of 12/31/2024, and the intervention and tasks included assess resident current functional level with gg scores eating 5. The care plan also revealed a focus area indicating the resident was at risk for nutritional deficits related to end of life care. The plan stated the resident was on a regular diet, minced and moist Level 5 (dysphagia mesh altrd/grind) texture and regular/thin liquids (level 0) consistency with a spill cup to be used for liquids. The focus area stated the resident required cuing assistance with meals. The goal for this focus area stated the resident will have optimum nutrition level as evidence by not losing or gaining significant weight through the next review date of 12/31/2025. The interventions and tasks for this focus area stated the resident should have a diet per physician's order, food preferences should be discussed with the resident and her requests should be honored, and the resident's weight should be checked weekly. The care plan stated Resident #1 required assistance with ADL's due to end of life care. The interventions included: identify resident's level of assistance needed and complete resident Kardex, resident summary or nursing assistant assignment sheet for delivery of care. The care plan for ADL assistance contained coding information from the MDS for all ADL's and stated gg scores eating 5 under interventions. The care plan did not define the score. During an observation of the noon meal on 10/25/24 at 11:51 AM, Resident #1 was seated at the assistive feeding table wearing a clothing protector and holding a beverage. CNA A stated Resident #1's food had been cut up for her at the beginning of the meal. Resident #1 had consumed approximately fifty percent of her meal and was being encouraged by CNA A to continue eating. Resident #1 was observed to require frequent staff cueing to eat her meal. During an interview on 10/26/2024 at 1:02 PM, the ADM stated care plans were developed by the MDS nurse after the IDT team met to discuss the resident's needs. The ADM stated the DON was responsible for ensuring the care plan was completed and accurate. The ADM stated the IDT was responsible for monitoring the accuracy of the care plan, and all staff were responsible for reporting any changes and/or updates that were needed. The ADM stated the DON or designee was responsible for ensuring staff were trained on the resident's care plan. The ADM stated the expectation was for the care plan to be accurate. The ADM stated, if a care plan was not accurate or current, the resident was at risk for not receiving the care they need to obtain an optimal quality of life. During an interview on 10/26/2024 at 1:16 PM, the DON stated care plans were developed by the MDS nurse and the DON was responsible for ensuring they were completed and accurate. The DON stated care planning would have started on the day of admission and included the floor nurse who assessed the resident as well. The DON stated care plans were then completed within 7 days of admission and were usually completed by the MDS nurse. The DON stated changes were required to be updated on a resident's care plan as soon as the change was noticed. The DON stated she was not aware Resident #1's care plan was not accurate and consistent with her nutritional and adl needs. The DON stated staff were usually trained by the MDS nurse on care plans and they should have been updated with any changes to a resident's care plan immediately. The DON stated there was a stand-down meeting every day at 4 pm with all departments to go over any needs for residents and to update staff on what was completed for care planning. The DON stated assessments were also made at admission for care planning. The DON stated a resident was at risk of receiving unsatisfactory care if their care plan was not completed or accurate, and their care may not be to the fullest potential. During an interview on 10/26/2024 at 1:30 PM, the MDS coordinator stated she was responsible for completing and updating care plans for residents, and the DON was responsible for ensuring she completed and updated all care plans. The MDS coordinator stated a baseline care plan was developed within 48 hours of admission, and a comprehensive care plan was completed within 7 days of admission. The MDS coordinator stated care plans were updated frequently for any acute changes, and changes were updated immediately, as seen, or as reported. The MDS coordinator stated she trained staff on resident's care plans. The MDS coordinator stated she completed Resident #1's care plan, and the care plan should have reflected Resident #1's nutritional assessment. The MDS coordinator stated she was made aware, within a week of admission, that Resident #1 needed more assistance with meals and required cuing and supervision while eating. The MDS coordinator verified this was on Resident #1's nutritional assessment. The MDS coordinator stated, a resident's care plan not being accurate or consistent could result in the nursing staff not being aware of the resident's functional status, and Resident #1's inaccurate care plan could have resulted in Resident #1 experiencing weight loss. Record review of the facility's undated policy titled, Resident Care Plan Policy - Comprehensive, Person-Centered with a reviewed date of October 2024, reflected the following: Policy Statement: A comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy and Procedures: Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Care plan interventions are chosen only after a proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessment of residents is ongoing, and care plans are revised as information about the resident and resident conditions change. The interdisciplinary team reviews and updates the care plan: When the desired outcome is not met;

Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 22 residents (Residents #48 and #56) reviewed for care plans as follows: Facility failed to develop a care plan for Residents #48 and #56 for current advanced directives. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #48 Record review of the admission record for Resident #48, dated 03/20/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: essential hypertension (high blood pressure), mild protein-calorie malnutrition (poor food intake) and muscle weakness. Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #48 was understood and had a BIMS score of 10 indicating that the resident's cognition was moderately impaired. Record review of the order summary report for Resident #48, dated 03/20/24, revealed there were orders for Do Not Resuscitate (DNR) consent on file with a start date of 02/06/24. Record review of the current care plan for Resident #48, undated, revealed there was a focus area: [Resident #48] has an Advanced Directive and has documentation in their medical record r/t Code status: Full Code; Goal: [Resident #48's] wishes will be honored and maintained through next review date; Interventions/Tasks: Honor the resident choice for code status Resident #56 Record review of the admission record for Resident #56, dated 03/20/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified severe protein-calorie malnutrition (poor food intake), cerebral infarction (stroke), and dysphagia (difficulty swallowing). Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #56 was usually understood and had a BIMS score of 10 indicating that the resident's cognition was moderately impaired. Record review of the order summary report for Resident #56, dated 03/20/24, revealed the following order: Do No Resuscitate (DNR) with a start date of 05/02/23. Record review of the current care plan for Resident #56, undated, revealed there was no specific care plan regarding advanced directives. During an interview on 03/21/24 at 9:48 AM, SW A and SW B stated they were both responsible for ensuring the resident's current advanced directives are in the care plan. SW A and SW B stated they were unsure why Resident #48 and Resident #56 did not have their current advanced directives care planned. SW A and SW B stated the care plans are reviewed every 3 months for accuracy and these care areas must have been missed. SW A and SW B stated the potential negative outcome to the residents was they were at risk for not having their wishes met. During an interview on 03/21/24 at 10:01 AM, the ADM stated the social workers and the MDS nurses are responsible for ensuring all care areas for residents are in the care plan. The ADM stated she did not know why Resident #48 and Resident #56 did not have a current care plan for their advance directives. The ADM stated the social workers are trained to ensure the advanced directives are care planned. The ADM stated the potential negative outcome to the residents was the staff may not follow the residents wishes. Record review of the facility policy titled, Resident Care Plans, undated, reflected the following: Standard: An individualized interdisciplinary plan of care will be developed for each resident. Purpose: To assist the resident in achieving his or her optimal level of functioning consistent with the physician's plan of medical care. Guideline: 1. Assessment data is collected for analysis and integration to identify and prioritize each resident's care needs. Advanced directives are considered during this process

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 22 residents (Resident #34) reviewed for PRN psychotropic medications. Resident #34 continued to have a PRN order for Lorazepam 0.5mg after 14 days without a duration. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Resident #34 Record review of Resident #34's face sheet, dated 03/19/24, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include colon cancer, major depressive disorder (mental illness), and anxiety (feeling of fear and worry). Record review of Resident #34's quarterly MDS, dated [DATE], reflected Resident #34's BIMS was a 10 which indicated Resident #34 had moderate cognitive impairment. The MDS further reflected Resident #34 had a diagnosis of anxiety disorder and was taking antianxiety medication. Record review of Resident #34 care plan dated 01/12/24 reflected a care plan related to anxiety and Lorazepam medication. Interventions to administer medications, assist with positive coping skills, encourage resident to express feeling and monitor/document mood. Record review of Resident #34's physician order summary dated 03/19/24 reflected an order start date 10/22/23 with an indefinite end date for Lorazepam Intensol Oral Concentrate 2 mg/ml, give 0.25 ml by mouth every 1 hours as needed for anxiety and restlessness related to malignant neoplasm of colon. Record review of Resident #34's PRN MAR dated 03/19/24 reflected Lorazepam Intensol Oral Concentrate 2 mg/ml give 0.25 ml by mouth every 1 hours as needed for anxiety and restlessness related to malignant neoplasm of colon. Start Date 10/22/23 - open ended. No medication was administered for the month of March. Record review of Resident #34's pharmacy review titled Note to attending physician/prescriber dated 02/06/24 reflected Resident #34 was receiving lorazepam Intensol 0.5 mg (0.25ml) every 1 hours PRN anxiety and restlessness and order began on 10/22/23. Physician response - Anxiety tx - used PRN for comfort. Reassess in 6 months. During an interview on 03/20/24 at 03:45 PM with the DON, she stated Resident #34 had an order for Lorazepam PRN with no duration. She stated PRN psychotropic medications must have a stop dated and can only be given for 14 days. She stated lorazepam was a psychotropic medication. She stated she was responsible for monitoring PRN psychotropic orders for stop dates. She stated the reason why Resident #34 does not have a stop date was because she thought the pharmacy review done on 2/6/24 was sufficient. She stated the order was not changed to include a duration. She stated the physician stated he would reassess Resident #34 in 6 months. She stated she had been trained on PRN psychotropic medications. She stated psychotropic medication monitoring was important to ensure residents were not being given unnecessary medications, not being used as a restraint and to make sure residents have the proper diagnosis. She stated the potential negative outcome could be resident declining and interfering with ADL's and resident being over medicated. During an interview on 03/21/24 at 09:35 AM with RN A, she stated PRN psychotropic medications were to have a 14 day stop date. She stated the reason Resident #34 lorazepam did not have a stop date was because the pharmacy recommendation state he would revaluate in 6 months. She stated there was no new order to change or add a duration. She stated Resident #34's lorazepam order did not have a duration or stop date. She stated she had been trained on PRN psychotropic medications. She stated the potential negative outcome could be overuse of medications or used as a chemical restraint. She stated monitoring and revaluation was necessary to ensure the medication was medically necessary and to make sure the resident was not over medicated. During an interview on 03/21/24 at 09:45 AM with ADM, she stated the DON was responsible for monitoring PRN psychotropic for proper documentation and duration. She stated monitoring PRN psychotropic medications was important to ensue residents need the medication and were not overmedicated. She stated all nurses have been trained on PRN psychotropic medications. She stated the potential negative outcome could be residents being over medicated. Record review of the facility policy titled Psychotropic Medication Use dated July 2022 reflected the following: Policy Statement: Resident will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for pain management. The facility failed to assess, reassess, and/or take steps to manage Resident #1's pain when she presented with symptoms of pain. On 01/26/24 at 04:14 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/27/24 at 4:48 PM, the facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place the resident at risk of a decrease in quality of life due to pain. Findings included: Record review of Resident #1's face sheet, 01/25/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include cognitive communication deficit, dementia (loss of cognitive/memory function). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section J0200: Should pain Assessment be conducted. Yes All associated areas associated with pain were blank. J1700 Fall history. All areas following were blank. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #1 Care plan revealed the following: Initiated 12/12/23 Revised: 12/12/23. Focus: Resident #1 had a communication problem Goal: Resident #1 will be able to make basic needs known on a daily basis Intervention: Anticipate and meet needs. Initiated 12/12/2023 Revised 12/12/23. Focus: Resident #1 has an impaired cognitive function/dementia or impaired thought processes. Dementia Initiated 1/23/24 Revised: 1/25/24. Focus: The resident had potential/actual impairment to skin integrity: abrasion 1/19/24 Resident #1 had reddened area to forehead and old bruise/skin tear to left wrist. There was no care plan for falls at the time of record review. Record review of Resident #1's physician order dated 01/25/24 revealed the following: Order date: 01/10/24 Portable x-ray. Left rib series 2 view. Symptoms of bruising. Order date/ Start Date: 1/19/24. Monitor left wrist and abrasion to forehead every shift. Order date/ Start date: 11/30/23. Pain Assessment every 6 hours Order date/ Start date: 11/30/23. Tylenol Extra Strength Oral Tablet 5000 MG. Give 1000 mg by mouth every 6 hours as needed for pain. Order date/ Start date: 01/12/24. Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain related to pain unspecified joint. Record review of Resident #1's Pain level Summary, dated 1/26/24, revealed: 01/03/24-01/15/24 pain level a numerical rate of 0. 01/15/24 08:38 AM pain level at a numerical rate of 2. 01/15/24 12:59 -01/26/24 05:58 pain level a numerical rate of 0. Record review of Resident #1's MAR/TAR revealed the following: Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain in unspecified joint; start date 01/12/24: administered at 09:00 AM from 01/13/24-01/25/24; administered 09:00 PM 01/12/24-01/25/24. Tylenol Extra Strength Oral Tablet 1000 MG. Give 1000 mg by mouth every 6 hours as needed for pain.; start date 11/30/23: Was not administered 01/01/24-01/24/24; Administered 01/25/24; Not administered on 01/26/24. Record review of Resident #1's progress notes revealed the following: 01/04/24 at 11:15 AM Author: RN I Was notified by staff that when they went to help Resident #1 out of bed this morning that she non-verbally indicated pain to her left lower side and that she did not want to get up after that. Asked Resident #1 if she was experiencing any pain, she stated she was not. Did a physical assessment and Resident #1 recoiled when that area was physically touched. Notified Physician's team who came by the floor shortly after to inquire about the situation and to assess Resident #1. No orders given at this time. 01/07/24 at 6:14 PM Author: LVN L Resident pleasantly confused and C/O right side flank pain. 01/08/24 at 3:39 PM Author LVN O Notified Physician team of lab results and that resident is having weakness and still having left sided pain and a little nausea and not eating or drinking. Family Member A called and wanted Doctors to see resident and assess resident. Family Member A wants doctor to call her while doctor is here. Encouraged resident to eat and drink. Family Member A voices that she always had a hard time getting doctor to call her and may have to change to another doctor out of facility. 11:15 (am) Resident c/o pain under left breast. Nurse took Tylenol to resident for pain then resident refused. Tylenol and voices she was not having any pain. Care provider encouraged resident to take Tylenol. resident took medication at 14:15 (2:15pm) Physician C here and assessed resident, resident denied pain voicing she is not having pain and has not had any pain. 1/10/24 at 9:14 PM Author Nurse Manager M Resident has green/yellow bruising to left lower back. notified Physician team about pain to residents back and Family Member A wanting x-rays done. Physician team ordered rib series of the left side. x-rays returned and sent to physician team. 01/12/24 at 10:05 PM Author: Nurse Manager M Skin on 1/10/24 at 1249 (12:49pm). Nurse was notified that resident had large bruise to her side/back. Resident could not recall any fall or injury to that area. Notified Family Member A. Root Cause: fall 01/19/24 at 6:30 AM Author: RN Z LATE ENTRY Note Text: At 06:30 CNA F came to inform this nurse that while she was assisting resident to change the brief, she has notice resident's forehead is redden. And resident has old, scabbed wound and old bruised on the left wrist. Resident does not seem to be in pain. Asked resident what happened to her forehead, did you fall? Resident answered NO. Last night, all night, resident was sleeping in her bed, making frequent routine rounds did not hear any falls or noises. Resident is stable, went back to sleep. At 0635, called and spoke with Family Member A, informed her about the redness on her forehead and old healed bruised on left wrist. At 06:36, texted Physician B pager, no answer. At 06:40, paged again, still no answered. At 06:54, texted to inform the Physician Team on call phone. 1/19/2024 07:10, The Physician Team texted back in response. Physician B himself called back and spoke with this nurse that he will make round to see resident today and will address the issues with Family Member A. Record review of the facility policy, Pain Management (07/01/2018), revealed the following: Key Components a pain screen is completed on every resident upon admission. For all residents with pain or diagnosis that is likely to cause pain, there is a care plan with risk factors identified. All residents regardless of risk are assess each shift for pain. All pain medications have been associated diagnosis. The community has a pain scale and is used appropriately for both cognitively intact and cognitively impaired residents. The goal of all pain management is what the resident and family member wish and is documented. All PRN pain medications are documented for nursing standards with date time reason and effect using numeric value. Position is called prompting for unrelieved pain. The resident representative is notified within 24 hours of introduction of opioid pain medication or pain that is not being relieved. Assistant is in place to allow staff to report residents in pain promptly. Policy It is the commitment of the Health Center that pain will be relieved or reduced to an acceptable level of comfort, as determined by the resident, when able in order to improve their health, independence, and quality of life. It is the policy of the Health Center that each resident will be assessed using our interdisciplinary approach with regard to the level of pain or discomfort experience. Reviewing both medical and social history and all diagnosis which may indicate the potential for pain or discomfort, ongoing assessments will be performed together the data needed to maintain pain management for each resident. Objective To promote prompt and effective assessments, diagnosis and treatment of a resident who experiences pain or discomfort. Pain will be based on the residence verbal and nonverbal expressions of pain. Pain Management Components include, but are not limited to, the following: Pharmacological interventions was ordered by the physician. During an interview on 01/25/24 at 1:33 PM, Family Member A stated that although she received a picture of the bruise, it was not the first issue. She stated the first issue was Resident #1 complaining of pain. She said she thought it was abdominal pain based on the way the previous caregiver described it. She said Resident #1 hurt when she moved. She said on 01/04/24, Care Giver E was not present, but there was a different one. She said she reported the pain to RN I. She said it was her understanding that there was a member of the physician team on the memory unit, but her mother was not seen. She said RN I went into the room and asked Resident #1 about pain, and Resident #1 stated she did not have pain. Family member A stated this was when she was mad because they reported the pain for Resident #1. She said the next day, Friday, 01/05/24, was when she was on the phone with Resident #1. She said the staff were attempting to get Resident #1 up, and this was when she heard Resident #1 holler out because she was in pain. She said this concerned her greatly because Resident #1 had a high pain tolerance, and for her to holler out, it must have been bad. She said she was so shocked that she called the nurse to try and get the doctor to see her. She said she believed she reached out to RN I. She said she was told that the doctor did not see Resident #1 because they thought it was a UTI and they were just going to take a UA from Resident #1. She also said the physician team thought it was musculoskeletal (pain associated with arthritis). She stated that she attempted to follow up on the UA sample on Saturday (01/06/24) but could not contact anyone. She said she attempted to contact the nurse 20 or 30 times with no luck. She said she was originally told that the doctors do not come out on the weekend but was then told by another staff that the doctor had seen her mother. She said she found out from a couple of sources that when the doctor came the previous week, the doctor spoke with the facility nurse but did not examine Resident #1. She said she was told that they took the UA on 01/06/24. She said she had requested to the nurse RN I that blood be taken but was told that blood could not be taken over the weekend. She said she attempted to get the results the weekend of 01/6/24 and 01/07/24 and was told that the UA had been mislabeled and would have to try to get another sample. She said the staff on 01/07/24 was finally able to get a UA. She said she was told by the staff on 01/07/24 that they could draw blood on the weekends but that RN I did not write this request down. She said it was Monday (1/08/24) when they received the results of the UA. She said she tested positive for a UTI and was started on an antibiotic. She stated she was told on Tuesday that the physician would be at the facility to see Resident #1. She stated she arranged for her cousin to be at the facility. She stated her cousin was present when the doctor came. According to her cousin, the physician did not lift Resident #1 shirt or undress her to examine her. She stated she was told that the physician patted around on her a few times. She said that on 01/07/24, she was told by the nurse on duty that Resident #1 had pain under her rib. She said on Monday she wanted Resident #1 to have x-rays done on 01/08/24 but was told that Resident #1 would have to go to the hospital. She later found out that x-rays could be taken on the memory unit. She said although Resident #1 said she did not have pain, she started asking her in diverse ways to determine if she had pain. She said she would have to ask Resident #1 if it hurt when she moved; that was how she determined Resident #1 was experiencing pain. She said she does not believe Resident #1 received any pain medication. She said she was unaware of Resident #1 receiving any medication until Wednesday (01/10/24) or Thursday (01/11/24). She said after receiving a copy of the MAR, she became aware that Resident #1 had standing orders for Tylenol. She stated she was not made aware of this medication order. She said no one knows what happened to Resident #1 but that, according to the physicians, their best guess was a fall, especially after the second injury. She said she asked Resident #1 if she had fallen, and she was told, No, not that I know of. During an interview on 01/25/24 at 3:15 PM, RN I stated she did not know much about Resident #1. She stated she may be susceptible to falling. She stated if she fell or was in pain, she would not say anything because Resident #1 does not like people fussing over her. She stated the last thing she remembered was Resident #1 not eating breakfast, and Family Member A wanted to ensure a tray was saved. She said the only time Resident #1 complained about the pain was when an x-ray was conducted, the doctor came out, and this was when Resident #1 had fractured ribs. She said Family Member A was concerned about Resident #1 receiving a UA, but she was able to provide a sample, and it turned out she had a UTI. She said she could not say an actual timeline because she had worked a lot with many residents. She said it was believed that the fractured ribs came from a fall. During an interview on 01/25/24 at 3:40 PM, CNA J stated she did not know what was happening with Resident #1. She stated it was her understanding that the overnight shift does not bother the residents as much. They check their briefs and try not to wake them. She stated on 01/05/24, she went to the room to get Resident #1 up, and she did not want to get up. She said Resident #1 was acting cranky the morning of 01/05/24. She said she was concerned. She said Resident #1 was on the phone with her daughter. She stated she went to get CNA K for assistance. She said it took her and CNA K to get Resident #1 to the restroom. She said at this time, Resident #1 was extensive, and normally, she was limited. She said Resident #1 normally does not require much assistance as she did on 01/05/24. She said when she got to the restroom, she lifted her shirt but did not see anything. She said Resident #1 was in pain the entire weekend. She stated that they had to baby Resident #1 all weekend. She stated that she did not know if Resident #1 received any pain medication. She stated they were very concerned about her condition. She said they reported it to RN I on Friday (01/05/24) and Saturday (01/06/24). She stated on Sunday that the nurse was LVN L, but she was unsure. She reported to the nurse each time Resident #1 was in pain. During an interview on 01/25/24 at 3:56 PM, CNA K stated that regarding Resident #1, she had no idea how she got the fractures. She stated she did write a statement and gave it to nurse manager M. She stated the first set of fractures or injuries had occurred a few weeks ago. She stated that Resident #1 was complaining of side pain. She stated that she may be a little off on the date but was sure she told RN I. She stated on 01/05/24, she helped Resident #1's shower. She stated she assessed her body as they showered, and there were no bruises. She stated Resident #1 was in a lot of pain. She stated this was also reported to RN I. She stated Resident #1 and continued to complain of pain on her left side. She said the bruise did not show up during the time of the shower. She said it was the following Wednesday (01/10/24) when they noticed bruising. RN I looked at it and did not appear to be heavily concerned, but as a newer CNA, she followed the lead of her nurse. She said she did not know if Resident #1 received any pain medication. She stated that on all three days, she notified the nurse every time she complained of pain. She stated she did not document each time that she expressed the pain. She did not have a reason. She stated that they are able to document pain and skin issues in things such as bruises at least once a day. She said she did not document skin issues. She stated that Resident #1 was okay and comforted by the hot water during the shower. She stated that it took two staff to shower her; normally, it does not. She said you could see she was in pain because of facial grimacing. She stated that Resident #1 was a total assist over the weekend. She stated that each time, she did express the pain of Resident #1 to the nurse. She stated that sometimes, RN I was so calm that some things that require extra observation or attention may be overlooked, but she followed her nurse's lead. During an interview on 01/25/24 at 4:49 PM, Nurse Manager M stated that on 01/04/24, she went to complete her rounds in the memory unit. She stated that RN I was on the floor and that Resident #1 was complaining of flank (side) pain. She said when she arrived, one of the resident doctors was in the room, but she did not remember the doctor's name. She said she was unaware if she received pain medications that day. She said she did not receive any reports over the weekend that Resident #1 was in pain. She stated the following Monday (1/12/24), LVN O stated the doctor saw Resident #1 over the weekend. She was told that the doctor palpated her abdomen, and Resident #1 did not wince or make any signs of pain, so nothing was done. She said on Tuesday 10th, she received a call from RN I that staff discovered a bruise on her lower back. She stated she observed the bruise, and it looked old. She stated she notified the DON and ADM at this time. Family Member A was upset and suggested that an x-ray be conducted. RN, I had already messaged the physician team as well. The x-ray series was conducted, and that was when they found out about the fractured ribs. During an interview on 01/25/24 at 5:07 PM, Resident #1 stated she was not in pain. She stated she had never fallen. She stated the sore on her forehead had been there for a while, and the skin tear on her left arm also had been there. She was unable to tell the state investigator where the injuries came from. She stated that she had never fractured ribs, and the staff must have reported the incorrect information. An observation was made on 01/25/24 at 5:07 PM of Resident #1's forehead. There was a small red abrasion on her forehead. There was a small skin tear on her left wrist but no bruising. The state investigator observed Resident #1's back and showed no bruising. The state investigator observed a thin floor mat propped up on the wall. During an interview on 01/26/24 at 6:45 AM, CNA S stated that when they came back from their day off, she was told that Resident #1 had fractured ribs. She said before the identification of the fractured ribs, she was aware that Resident #1 had complained of side pain. She said the sitter had set her up, and Resident #1 had yelled out. She said she was unsure of the date, but whatever day it was, the nurse assessed Resident #1, and Resident #1 was tender near her ribs. She said she, as the CNA, was not instructed to do anything different. During an interview on 01/26/24 at 7:15 AM, CNA T stated she was aware of Resident #1's pain two weeks ago. She stated she remembered telling LVN O, and the response was to get a UA. She said that she was not aware of the date of the pain. She said she was unsure if it was before the fracture date. She said she was unaware of what caused the fractures. She said there were no falls during their shift or rotation. She said that Resident #5 bruise had to have happened on her days off. During an interview on 01/26/24 at 7:25 AM, LVN O stated one of Resident #1 sitters came and told one of the CNAs that Resident #1 had yelled out. She stated she went to assess her and mashed on her chest areas. She said Resident #1 was tender near her breast area. She stated she had an additional person come and asses her, but she could not remember who it was. She said she had asked the physicians about an x-ray but was told they did not need one because they thought it was a UTI. She said she went off duty, and when she returned, she found out that there was an x-ray obtained, and Resident #1 had a fracture. She was unsure of the exact date. She stated that Resident #1 did not say she was hurting, but she grimaced a little. She said she did not remember giving Resident #1 any medication. She stated the reason she did not give any medication was because when she was tender, she could not tell if it was because she was in pain, if it was the pressure she applied, or if it was the location on her breast. During an interview on 01/26/24 at 7:35 AM, RN I stated regarding Resident #1 that she could not remember if she administered any pain medication to Resident #1. She stated she had seen a lot of residents since then. She stated that if she administered medication, it would be on the MAR. She stated if she attempted to administer medication to Resident #1, that too would be on the MAR. During an interview on 01/26/24 at 9:15 AM, the DON stated she stated that regarding Resident #1, she noticed that Resident #1 grimaced with pain. She did not specify the date when she observed the grimace. She stated the day the bruise was noticed; the color of the bruise was yellow and scattered. She stated that the color of the bruise indicated that it had been there for a while. She stated the color of the bruise indicated that it had been there for 5-7 days. She stated she had been seen by the provider at least twice. She stated that although the private provider provides showers, the facility staff was supposed to assist. She stated when she conducted her investigation, she noticed that no pain medication was given. She stated that she ordered scheduled Tylenol for Resident #1. She stated when she assessed the resident (date not disclosed) that the resident verbally stated she did not have pain but expressed a facial grimace, which indicated Resident #1 did not know how to answer the question. She stated Resident #1 was in the memory unit and that Resident #1 had a cognitive deficit. She stated the fracture was reported to the state because it was an extensive injury, and Resident #1 could not tell us what happened. During an interview on 01/26/24 at 9:20 AM, Nurse Manager M stated that she was unaware of anyone reporting pain to her. She said she could not 100 percent say how Resident #1 received her fracture. She said when a bruise was yellow in tint, it was 5-7 days long. During an interview on 01/26/24 at 10:12 AM, the ADM stated regarding Resident #1 that the potential negative outcome is that if her pain or the resident's pain is not addressed, it can place the resident in a predicament where she could be experiencing constant pain or more pain. She stated the resident could have an underlying issue that was missed because the pain was not being addressed appropriately. She stated the pain was reported to the physician. She stated she was told that Resident #1 refused pain medication. She stated the physician team was originally looking to see if she had a UTI. She stated once they found out she had a UTI, then that was what was being addressed. She stated she was unaware that Resident #1 had pain before the identification of the fracture. She stated she expected pain medication to be administered if a resident was in pain and the dose reflected on the MAR. She stated the refusal of medication should also be reflected on the MAR. She stated there was a system in place to monitor pain. She stated the nursing staff should be monitoring pain two times a day. She said staff should be asking residents if they are in pain. She stated that all pain should be reported at shift change. He stated staff should follow up to see if any treatment was effective, and the nurse managers should be notified. She stated that if the resident was reporting pain or staff was indicating pain; there should be a change on the pain scale in the EMR system. She stated she had been trained in pain management. She stated she did not observe Resident #1 in pain. She stated they all are responsible for pain management, but the DON oversaw. During an interview on 02/01/24 at 3:30 PM, Physician B stated his physician team was notified at 11:30 AM and went to see the resident. The complaint was pain in the lower trunk area. He stated Resident #1 was not in her room due to being in the assisted living portion of the facility with her daughter. He stated he had no names of the nurses who notified his team. He stated they looked at the symptoms of a UTI and wanted to rule that out first. He stated once the UA came back positive, they prescribed antibiotics. He stated the pain was described vaguely over the phone. He stated because the pain scales revealed 0 and no pain medication was given, he stated they considered everything was good. He stated the resident was seen by his team members multiple times, and no expression of pain was observed. He said that although Resident #1 expressed some tenderness during one examination, there was no reason to give Tylenol because there was no indication such as bruising. He stated when the nurse identified the bruise, it was described as yellow. He stated this color would have indicated that the bruise would have been there for at least a week. He stated because of the bruise and the request from Family member A was why the x-ray was conducted. He stated he also checked Resident #1 for pain, and because of his assessment, there was no pain. He stated he felt the Tylenol should have been scheduled rather than PRN because residents with dementia may not be able to attest to pain accurately. He stated that the testimony of the family and the staff was critical because it is difficult to gauge the quantity of pain. He stated fractured ribs were not a serious injury because the rib was not broken, and it was typically treated with pain management. He stated the pain was not treated prior because the physician team did not have any evidence of pain. He stated that with Resident #1's second set of injuries, he did not get an x-ray because Resident #1 could not move her hand. When the state surveyor asked about Resident #1 ability to function even through fractured ribs and if this would not be considered with the new injuries, Physician B stated he agreed and believed he later ordered an x-ray. He was unable to confirm if the x-ray had occurred and the outcome. He stated no one ever reported that she went from being a limited assist to an extensive. He stated that they would have treated the situation differently if this had been reported. He stated all decisions were made based on the documentation and physical assessments of Resident #1. The ADM and Interim ADM were notified on 01/26/24 at 4:14 PM and an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was submitted by the facility and was accepted on 01/27/24 at 09:45 AM and indicated the following: The facility failed to identify, treat, monitor and manage the resident's pain to the extent possible. Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 1/26/2024) Resident # 1 was re-assessed for pain, the physician was updated with the results of the pain assessment and the plan of care for resident was reviewed and revised. The Director of Nursing or designee completed a pain assessment on all residents to identify any unmet pain needs/changes in pain. The residents' physicians were updated with the results of the pain assessment if new or worsening pain was identified. In response to the above-described pain assessment, pain regimen was reviewed and changed for residents as warranted. The care plans of residents directly affected by the deficient practice were updated to reflect new/revised resident specific pain management interventions. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 1/26/24) All the Facility's policies and procedures regarding pain/pain management were reviewed/revised. The Director of Nursing or designee educated all licensed nurses on appropriate pain management prior to their next shift. Education included review of the Facility's policy and procedure on pain and pain management and immediately notifying the physician. Education also included to assess for pain when it has been reported by family, non-licensed staff, and family caregivers immediately, administer pain medication as appropriate and according to physician orders. Contact physician as needed for additional interventions. Licensed nurses demonstrated pain assessment competency prior to their next shift. The Director of Nursing or designee will conduct compliance audits weekly for four weeks, then once per month for three months. Audits will consist of review of pain assessments and daily exception report. A QAPI PIP will be initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 1/26/2024. Action Plan to Ensure Relevant Recommendations are Followed: Action/Task; Person assigned; date completed. Complete pain assessment on resident # 1 and revise plan of care; DON/Nurse Managers; 1/26/24 Complete pain assessment on all residents; DON/Nurse Managers; 1/26/24 Notify physician of pain assessment findings/adjustment in pain medication; DON/Nurse Managers; 1/26/24 Update care plans to reflect pain assessment findings/pain medication adjustment, DON/MDS/Nurse Managers Review/modify current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm; Administrator/Director of Nursing/Regional Nurse Consultant; 1/26/24. Educate necessary staff on the Facility's procedures with return demonstration, where applicable; Regional Nurse Consultant/Administrator/DON; 1/26/24 Document PIP implementation, PIP progress, and QAA Committee Meeting Minutes where PIP is discussed; DON/Administrator. On 01/27/24 at 4:48 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews that occurred on 01/27/24 at starting 4:24 PM and ending at 4:49 PM, CNA T, CNA S, CNA K and LVN O who all worked in the memory unit were able to describe what pain management was and the importance. They were able to give possible signs of pain and describe how they would monitor pain. They were able to express the importance of documentation and the expectation tha [TRUNCATED]

Based on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 6 of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for neglect in that: The ADM and the DON failed to report Resident #1's injuries of unknown origin that were first identified on 01/19/24. Those injuries included an abrasion to the forehead, bruising and skin tear to the left wrist and bruising to her eye. The ADM and the DON failed to report Resident #1's misappropriation of items (apple watch, wallet, and purse). The ADM and the DON failed to report Resident #2's unwitnessed fall that caused her to be transported by EMS to the hospital with a horizontal laceration below vertical surgical wound to her right knee. The ADM and the DON failed to report Resident #3's allegation that Resident #6 had pushed him. The ADM and the DON failed to report Resident #3's resident to resident altercation where staff observed him being slapped by Resident #6. The ADM and the DON failed to report Resident #4's injury of unknow origin that revealed a bruise to her left inner arm. The ADM and the DON failed to report Resident #5 injury of unknow origin that revealed a bruise and skin tear to her left elbow. The ADM and the DON failed to report Resident #6 resident to resident altercation where she was observed by staff slapping Resident #3. These failures could place residents at risk of allegations not being reported and residents being at risk for emotional and physical abuse and exposure to alleged perpetrators. Findings Included: Record review of Resident #1's face sheet, 01/25/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include cognitive communication deficit, dementia (loss of cognitive/memory function). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section J0200: Should pain Assessment be conducted? Yes All associated areas associated with pain were blank. J1700 Fall History All areas following were blank. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #1's Care plan revealed the following: Initiated 12/12/23 Revised: 12/12/23. Focus: Resident #1 had a communication problem Goal: Resident #1 will be able to make basic needs known on a daily basis Intervention: Anticipate and meet needs Initiated 12/12/2023 Revised 12/12/23. Focus: Resident #1 has an impaired cognitive function/dementia or impaired thought processes. Dementia Initiated 1/23/24 Revised: 1/25/24. Focus: The resident had potential/actual impairment to skin integrity: abrasion 1/19/24 Resident #1 had reddened area to forehead and old bruise/skin tear to left wrist. There was no care plan for falls at the time of record review. Record review of Resident #1 physician order dated 01/25/24 revealed the following: Order date: 01/10/24 Portable x-ray. Left rib series 2 view. Symptoms of bruising. Order date/ Start Date: 1/19/24. Monitor left wrist and abrasion to forehead every shift. Order date/ Start date: 11/30/23. Pain Assessment every 6 hours Order date/ Start date: 11/30/23. Tylenol Extra Strength Oral Tablet 5000 MG. Give 1000 mg by mouth every 6 hours as needed for pain. Order date/ Start date: 01/12/24. Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain related to pain unspecified joint. Record review of Resident #1 Pain level Summary, dated 1/26/24, revealed: 01/03/24-01/15/24 pain level a numerical rate of 0. 01/15/24 08:38 AM pain level at a numerical rate of 2. 01/15/24 12:59 -01/26/24 05:58 pain level a numerical rate of 0. Record review of Resident #1 MAR/TAR revealed the following: Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain in unspecified joint; start date 01/12/24: administered at 09:00 AM from 01/13/24-01/25/24; administered 09:00 PM 01/12/24-01/25/24. Tylenol Extra Strength Oral Tablet 1000 MG. Give 1000 mg by mouth every 6 hours as needed for pain.; start date 11/30/23: Was not administered 01/01/24-01/24/24; Administered 01/25/24; Not administered on 01/26/24. Record review of Resident #1 progress notes revealed the following: 01/04/24 at 11:15 AM Author: RN I Was notified by staff that when they went to help Resident #1 out of bed this morning that she non-verbally indicated pain to her left lower side and that she did not want to get up after that. Asked Resident #1 if she was experiencing any pain, she stated she was not. Did a physical assessment and Resident #1 recoiled when that area was physically touched. Notified Physician's team who came by the floor shortly after to inquire about the situation and to assess Resident #1. No orders given at this time. 01/07/24 at 6:14 PM Author: LVN L Resident pleasantly confused and C/O right side flank pain. 01/08/24 at 3:39 PM Author LVN O Notified Physician team of lab results and that resident is having weakness and still having left sided pain and a little nausea and not eating or drinking. Family Member A called and wanted Doctors to see resident and assess resident. Family Member A wants doctor to call her while doctor is here. Encouraged resident to eat and drink. Family Member A voices that she always had a hard time getting doctor to call her and may have to change to another doctor out of facility. 11:15 (am) Resident c/o pain under left breast. Nurse took Tylenol to resident for pain then resident refused. Tylenol and voices she was not having any pain. Care provider encouraged resident to take Tylenol. resident took medication at 14:15 (2:15pm) Physician C here and assessed resident, resident denied pain voicing she is not having pain and has not had any pain. 1/10/24 at 9:14 PM Author: Nurse Manager M Resident has green/yellow bruising to left lower back. notified Physician team about pain to residents back and Family Member A wanting x-rays done. Physician team ordered rib series of the left side. x-rays returned and sent to physician team. 01/12/24 at 10:05 PM Author: Nurse Manager M Skin on 1/10/24 at 1249 (12:49pm). Nurse was notified that resident had large bruise to her side/back. Resident could not recall any fall or injury to that area. Notified Family Member A. Root Cause: fall 01/19/24 at 6:30 AM Author: RN Z LATE ENTRY Note Text: At 06:30 CNA F came to inform this nurse that while she was assisting resident to change the brief, she has notice resident's forehead is redden. And resident has old, scabbed wound and old bruised on the left wrist. Resident does not seem to be in pain. Asked resident what happened to her forehead, did you fall? Resident answered NO. Last night, all night, resident was sleeping in her bed, making frequent routine rounds did not hear any falls or noises. Resident is stable, went back to sleep. At 0635, called and spoke with Family Member A, informed her about the redness on her forehead and old healed bruised on left wrist. At 06:36, texted Physician B pager, no answer. At 06:40, paged again, still no answered. At 06:54, texted to inform the Physician Team on call phone. 1/19/2024 07:10, The Physician Team texted back in response. Physician B himself called back and spoke with this nurse that he will make round to see resident today and will address the issues with Family Member A. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #1 bruise incident (bruise) 1/10/24 Resident #1 Skin incident (redness) 1/19/24 Record review of Resident #2's face sheet, 01/26/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include joint subsequent encounter (active treatment to an injury or injury that is in the recovery phase), displaced fracture od second cervical vertebra, cognitive communication deficit, unsteadiness on feet, weakness, muscle weakness. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately intact. Section J1700. Fall History Did the resident have a fall anytime in the last month prior to admission/entry or reentry: Yes. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry: Yes. J2100. Recent Surgery requiring SNF Care Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay: Yes. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #2 Care plan revealed the following: Initiated 01/04/24 revised 01/16/24. Focus: Resident #2 is at risk for impaired skin integrity due to recent fall with fracture. admitted with wound to the right knew. Goal: Resident # 2 will have intact skin, free of redness, blisters, or discoloration through review date. Initiated 01/04/24. Focus: Resident #2 is at risk for falls due to recent history of falls. Goal: Resident #2 will be free of falls through the review date. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #2 was not on the incident accident report. Record Review of Resident #2 Progress notes revealed the following: 1/17/2024 at 7:06 PM Author: LVN AA hospitalized Evidence of pain: yes, to right knee Injury assessment: right knee laceration with copious amount of blood Signs/symptoms relevant to injury: pain to right knee Modes of transportation: ambulance Nursing Comments: CNA called nurse to inform of call patient on floor patient did not hit head, she fell forward on knee from toilet in an attempt to clean self. CNA was outside door. patient was on floor laying under sink. EMS called and transported to the Hospital. Record review of hospital records dated 01/17/24 and discharge date of [DATE] revealed the following: History of present illness: Resident #2 had a right distal femoral replacement (total knee replacement) on 12/27/24. Resident #2 family member claimed resident fell in the shower. Skin Horizontal laceration with clotted blood below vertical surgical wound to the right knee. Record review of Resident #3's face sheet, 01/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, mood disorder, muscle weakness, cognitive communication deficit, unsteadiness on feet, and repeated falls. Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately intact. J1700. Fall History: No data in this section. J1800. Falls since admission. Has the resident had any falls since admission/entry or reentry or prior assessment: Yes. J1900 Number of Falls since Admission or Reentry or Prior assessment No Injury Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #3's Care plan revealed the following: Initiated 06/23/23 Revised on 01/06/23. Focus: Resident #3 is at risk for falls. Gait/balance problems. Ensure resident has walker when ambulating. 1/04/24: Resident is noted to have a fall- Redness noted to back. Goal: [NAME] will be free of falls through the review date. Initiated 07/21/23 Revised 07/21/23. Focus: Resident #3 has impaired cognitive status- has impaired decision making, poor safety awareness Goal: Resident #3 will maintain current level of cognitive function through the review date. Interventions: Communicate with the resident /family/ caregivers regarding resident's capabilities and needs. No care plan at the time of record review regarding his interactions with Resident #6. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Unwitnessed fall 01/04/24 Unwitnessed fall 01/08/24 Record review of Resident #3's progress notes revealed the following: 01/04/24 at 2:49 PM Author: LVN BB Staff heard a thud and noted resident on floor in resident's wife's room. Resident assisted to walker x2 assist. V/S and neuro checks initiated. Noted no reaction to light to both eyes. Skin assessment completed. Noted redness to middle of back. Notified family and doctor. No new orders at this time. 1/05/24 at 2:36 PM Author: Nurse Manager X IDT unwitnessed fall on 1/4/24. Skin assessment completed and no new orders. There was no progress note for the fall that occurred on 01/08/24. The following are notes post fall on 01/08/24: 1/09/24 at 2:36 PM Author: Nurse Manager X CNA reported patient was having a lot of pain to his left lower back from his fall on 1/8/2024. I notified physician's team and doctor came and did an exam on the area and in his assessment, patient did not have any bony tenderness there. He said continue Tylenol PRN if patient has pain. No x-ray ordered at this time. 1/12/24 at 1:45 PM Author Nurse Manager X IDT unwitnessed fall on 1/8 Resident was seen on the floor by the window in a sitting position. I was sitting at the nurse's station on the computer. Resident #3 was sitting on the floor near the window in his bedroom. Assessed resident, got some help and using safety technique we helped the resident transfer back into his recliner. Resident stated he had gotten up from recliner to walk over to get his walker when suddenly he lost his balance and fell near the window and scraped his back with the wooden bench. Doctor and family notified of fall. No recent falls, infections, or wounds. No supplements needed. Root cause: [NAME] not within reach/resident lost balance. Implementation: Make sure walker is within reach. No progress notes regarding allegation that someone pushed Resident #1 and no progress note reflecting the resident-to-resident altercation. Record review of Resident #4's face sheet, 01/26/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (memory deficit) and mood disorder. Record review of Resident #4's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section A Acute Onset Mental Status Change: No evidence of an acute change in mental status. Section E: Behavior: No potential indicator of psychosis E0200. Behavioral Symptom Physical, verbal, and other behavioral symptoms: 1. Behavior of this type occurred 1-3 days. E0300. Overall Presence of behavioral Symptoms: Yes E0800. Rejection of Care: 1. Behavior of this type occurred 1 to 3 days. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #4 Skin Tear incident (bruise) 1/25/24 Record review of Resident #4's progress notes revealed the following: 01/25/24 at 10:43 AM Author: LVN N Staff reported while changing resident clothing that skin tear to the L arm near the antecubital region, with some bruising. No pain or discomfort. Doctor notified with no new orders. Record review of Resident #5's face sheet, 01/26/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia. Record review of Resident #5's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section E Behavior No potential indicators of psychosis. Section V: Care Area Assessment Behavior was not triggered, or care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Bruise incident (Bruise) 1/25/24 Record review of Resident #5's progress notes revealed: 1/25/24 Resident received scheduled shower, CNA notified this nurse of a bruise to right upper inner arm. No pain or discomfort. Record review of Resident #6's face sheet, 01/27/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (memory deficit), cognitive communication deficit, psychotic disorder with delusions, and dementia. Record review of Resident #6's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section E-Behavior E0100. Potential Indicators of psychosis: No data entered. E0200. Behavioral Symptoms Other behavioral symptoms not directed towards others: 1 Behavior of this type occurred 1 to 3 days. E1100. Change in behavior or other symptoms. How does residents' current behavior status, care rejection, or wandering compared to prior assessment: 2. Worse. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: No pertinent information regarding Resident #6 on this report Record review of progress notes did not reveal any information about Resident #6 having any physical altercation with anyone. During an interview on 01/25/24 at 1:07 PM, Care Giver E stated that she could not remember when she discovered the bruise. She stated she took a picture of the bruise and sent it to Family member A. She Said after looking at her phone that the date of her picture on her phone was 01/10/24. She said that she discovered the bruise because Resident #1 had a bowel movement, and she had her seated on the toilet. She said that when Resident #1 leaned over to grab toilet paper, she noticed a bruise on the left side of her back. She said she grabbed the phone, took a picture, and sent it to Family member A. She stated she then reported it to the nurse's station. She stated Family Member A must have called everyone. She stated that before the bruise, she had been unaware of any falls. She said that CNA J told her that Resident #1 had been complaining of pain for weeks. The Care Giver stated that she was unaware of any pain Resident #1 may have had as she did not complain. She stated she worked Monday through Friday and did a split shift. She said her hours were 8:00 AM to 2:00 PM and then 4:00 PM to 8:00 PM. She stated she was notified that Resident #1 had three fractured ribs. She stated that Resident #1 had another incident. She stated when she came to work Monday, 01/22/24, she had a black eye, scratch, and small bruise on her left arm and a red spot on her forehead. She said she did not know where those injuries came from. She said that she did not remember seeing those injuries when she worked on Friday, 01/19/24. She said Resident #1 did not have a roommate. She said Family Member A placed a camera in Resident #1 room. She said she did not report the second set of injuries to anyone because Family Member A was present, and the doctor said the injuries seemed to be consistent with a fall. The Caregiver stated she was not questioned about the first bruise, fractured ribs, or the second set of injuries on Resident #1. During an interview on 01/25/24 at 1:33 PM, Family Member A stated that although she received a picture of the bruise, it was not the first issue. She stated the first issue was Resident #1 complaining of pain. She said she thought it was abdominal pain based on the way the previous caregiver described it. She said Resident #1 hurt when she moved. She said on 01/04/24, Care Giver E was not present, but there was a different one. She said she reported the pain to RN I. She said it was her understanding that there was a member of the physician team on the memory unit, but her mother was not seen. She said RN I went into the room and asked Resident #1 about pain, and Resident #1 stated she did not have pain. Family member A stated this was when she was mad because they reported the pain for Resident #1. She said the next day, Friday, 01/05/24, was when she was on the phone with Resident #1. She said the staff were attempting to get Resident #1 up, and this was when she heard Resident #1 holler out because she was in pain. She said this concerned her greatly because Resident #1 had a high pain tolerance, and for her to holler out, it must have been bad. She said she was so shocked that she called the nurse to try and get the doctor to come and see her. She said she believed she reached out to RN I. She said she was told that the doctor did not see Resident #1 because they thought it was a UTI and they were just going to take a UA from Resident #1. She also said the physician team thought it was musculoskeletal (pain associated with arthritis). She stated that she attempted to follow up on the UA sample on Saturday (01/06/24) but could not contact anyone. She said she attempted to contact the nurse 20 or 30 times with no luck. She said she was originally told that the doctors do not come out on the weekend but was then told by another staff that the doctor had seen her mother. She said she found out from a couple of sources that when the doctor came the previous week, the doctor spoke with the facility nurse but did not examine Resident #1. She said she was told that they took the UA on 01/06/24. She said she had requested to the nurse RN I that blood be taken but was told that blood could not be taken over the weekend. She said she attempted to get the results the weekend of 01/6/24 and 01/07/24 and was told that the UA had been mislabeled and would have to try to get another sample. She said the staff on 01/07/24 was finally able to get a UA. She said she was told by the staff on 01/07/24 that they could draw blood on the weekends but that RN I did not write this request down. She said it was Monday (1/08/24) when they received the results of the UA. She said she tested positive for a UTI and was started on an antibiotic. She stated she was told on Tuesday that the physician would be at the facility to see Resident #1. She stated she arranged for her cousin to be at the facility. She stated her cousin was present when the doctor came. According to her cousin, the physician did not lift Resident #1 shirt or undress her to examine her. She stated she was told that the physician patted around on her a few times. She said that on 01/07/24, she was told by the nurse on duty that Resident #1 had pain under her rib. She said on Monday she wanted Resident #1 to have x-rays done on 01/08/24 but was told that Resident #1 would have to go to the hospital. She later found out that x-rays could be taken on the memory unit. She said although Resident #1 said she did not have pain, she started asking her in diverse ways to determine if she had pain. She said she would have to ask Resident #1 if it hurt when she moved; that was how she determined Resident #1 was experiencing pain. She said she does not believe Resident #1 received any pain medication. She said she was unaware of Resident #1 receiving any medication until Wednesday (01/10/24) or Thursday (01/11/24). She said after receiving a copy of the MAR, she became aware that Resident #1 had standing orders for Tylenol. She stated she was not made aware of this medication order. She said no one knows what happened to Resident #1 but that, according to the physicians, their best guess was a fall, especially after the second injury. The physician team and facility staff feel certain that Resident #1 could get off the floor if she fell . She said she was unsure if Resident #1 could get up off the floor if she fell . She said she asked Resident #1 if she had fallen, and she was told, No, not that I know of. Family Member A said on Friday, 01/19/24, she had planned to drive to the facility to see Resident #1, and around 6:30 AM, she received a call from LVN G. She said LVN G told her that Resident #1 had a hurt wrist and red marks on her forehead. She said LVN G may have used the term bruising. She said LVN G told her that the previous night, Resident #1 had been checked on, and she was unaware of any falls or issues from the previous night. She stated LVN G wondered if Resident #1 had fallen. She said if a fall had occurred, it would have occurred on Thursday (01/18/24) because she had not heard from the caregiver. She said that they had a meeting on 01/22/24, and Physician B stated that no further evaluation needed to be done. She said it was Monday when she paid attention to the blackness on Resident #1 eye. It was concluded that Resident #1 may have had her glasses on when she fell . Family Member A stated this did not make sense to her because if she had fallen at night, she would not have had her glasses on. She said no one had confirmed what happened to Resident #1. She said she was unaware of any additional interventions since the fracture. She said she was informed that she could put cameras in the room if she wanted to. She said the meeting on 01/22/24 was when they first suggested a fall mat. She said that some items also went missing that was reported. She said Care Giver E air pods and watch went missing. She said Resident #1 Apple watch also went missing simultaneously. She said this occurred around the time of the discovery of the fractured ribs. She stated that she thought about Resident #1's purse when this happened. She stated she did not want to alert anyone to the purse because it could also get stolen. She stated she was told by staff that a police report could be filed. She stated she was told that the staff would keep an eye out for the missing items. Resident #1 purse and wallet were confirmed missing on 01/13/24. She said she had not witnessed a fall since the cameras had been placed in Resident #1 room. During an interview on 01/25/24 at 2:45 PM, CNA H stated she came in to work one day (unsure of the date), and staff stated that Resident #3 had fallen. She stated she saw the bruises on his back. She stated this was a couple of weeks ago from the interview. She stated it was an unwitnessed fall, and Resident #3 was not with it, meaning he could not tell you what happened. During an interview on 01/25/24 at 3:15 PM, RN I stated she did not know much about Resident #1. She stated she may be susceptible to falling. She stated if she fell or was in pain, she would not say anything because Resident #1 does not like people fussing over her. She stated she believed that Resident #1 was capable of getting back up if she were to fall on the floor. She stated Family Member A had had some concerns, but she would not consider them complaints. She stated the last thing she remembered was Resident #1 not eating breakfast, and Family Member A wanted to ensure a tray was saved. She said the only time Resident #1 complained about the pain was when an x-ray was conducted, the doctor came out, and this was when Resident #1 had fractured ribs. She said Family Member A was concerned about Resident #1 receiving a UA, but she was able to provide a sample, and it turned out she had a UTI. She said she could not say an actual timeline because she had worked a lot with many residents. She said it was believed that the fractured ribs came from a fall. She said the last time she was on the memory unit; she observed the abrasion on her forehead and her bruised wrist. She stated it was speculated that it was from a fall, but they did not know what caused the second care of injuries. She stated she received a report from the overnight nurse but could not remember when or which nurse gave her report. She said she was told that all notifications were made to management staff and the doctor. She said she observed Resident #1 having a full range of motion in both wrists. She stated she was unsure if any checks were done to her head. She said she was not sure why no x-rays were conducted. She stated she had been questioned about Resident #1 but not Resident #4 or Resident #5. During an interview on 01/25/24 at 3:40 PM, CNA J stated she did not know what was happening with Resident #1. She stated it was her understanding that the overnight shift does not bother the residents as much. They check their briefs and try not to wake them. She stated on 01/05/24, she went to the room to get Resident #1 up, and she did not want to get up. She said Resident #1 was acting cranky the morning of 01/05/24. She said she was concerned. She said Resident #1 was on the phone with her daughter. She stated she went to get CNA K for assistance. She said it took her and CNA K to get Resident #1 to the restroom. She said at this time, Resident #1 was extensive, and normally, she was limited. She said Resident #1 normally does not require much assistance as she did on 01/05/24. She said when she got to the restroom, she lifted her shirt but did not see anything. She said Resident #1 was in pain the entire weekend. She stated that they had to baby Resident #1 all weekend. She stated that she did not know if Resident #1 received any pain medication. She stated they were very concerned about her condition. She said they reported it to RN I on Friday (01/05/24) and Saturday (01/06/24). She stated on Sunday that the nurse was LVN L, but she was unsure. She reported to the nurse each time Resident #1 was in pain. She stated she never knew where the fractures came from. She said there was no furniture out of place when she walked into the room. She stated that resident #1 was not always steady. She said she was unsure if Resident #1 could get off the floor if she fell . She stated that the bruise on her wrist occurred the previous week. She stated that 01/19/24 Resident #1 had a bruise on her wrist. She stated that she noticed that there was blood on the bed. She stated she notified RN I. She said she could not remember what RN I responded. She said she did not see resident #1 forehead until Sunday (01/21/24). She said she did not notice her forehead. She said she noticed Resident #1 eye on 01/24/24. She said she was unsure if management knew about the second set of injuries. She said RN I and Nurse Manager M knew and did not know where those injuries came from. She stated there were no interventions put in place from the fracture, but as of 01/24/24, a format was placed in Resident #1 room. She stated Resident #1 was a proud woman, and she did sometimes get up on her own. She stated there were times when she would place her clothes next to her and walk out, and by the time she got back, Resident #1 would have already dressed. She stated that nurse manager M had spoken to her about resident #1's injuries. It is believed that she may be getting up at night. CNA J provided no information about Residents #4 and #5. During an interview on 01/25/24 at 3:56 PM, CNA K stated that regarding Resident #1, she had no idea how she got the fractures. She stated she did write a statement and gave it to nurse manager M. She stated the first set of fractures or injuries had occurred a few weeks ago. She stated that Resident #1 was complaining of side pain. She stated that she may be a little off on the dat[TRUNCATED]

Based on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 6 of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) in that: The ADM and the DON failed thoroughly investigate Resident #1's injuries of unknown origin that were first identified on 01/19/24. Those injuries included an abrasion to the forehead, bruising and skin tear to the left wrist and bruising to her eye. The ADM and the DON failed to thoroughly investigate Resident #1's misappropriation of items (apple watch, wallet, and purse). The ADM and the DON failed to thoroughly investigate Resident #2's unwitnessed fall that caused her to be transported by EMS to the hospital with a horizontal laceration below vertical surgical wound to her right knee. The ADM and the DON failed to thoroughly investigate Resident #3's allegation of Resident #6 had pushed him. The ADM and the DON failed to thoroughly investigate Resident #3's resident to resident altercation where staff observed him being slapped by Resident #6. The ADM and the DON failed to thoroughly investigate Resident #4's injury of unknow origin that revealed a bruise to her left inner arm. The ADM and the DON failed to thoroughly investigate Resident #5's injury of unknow origin that revealed a bruise and skin tear to her left elbow. The ADM and the DON failed to thoroughly investigate Resident #6's resident to resident altercation where she was observed by staff slapping Resident #3. Findings included: Record review of Resident #1's face sheet, 01/25/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include cognitive communication deficit, dementia (loss of cognitive/memory function) Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section J0200: Should pain Assessment be conducted. Yes All associated areas associated with pain were blank. J1700 Fall History All areas in this section were blank. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #1 Care plan revealed the following: Initiated 12/12/23 Revised: 12/12/23. Focus: Resident #1 had a communication problem Goal: Resident #1 will be able to make basic needs known on a daily basis Intervention: Anticipate and meet needs Initiated 12/12/2023 Revised 12/12/23. Focus: Resident #1 has an impaired cognitive function/dementia or impaired thought processes. Dementia Initiated 1/23/24 Revised: 1/25/24. Focus: The resident had potential/actual impairment to skin integrity: abrasion 1/19/24 Resident #1 had reddened area to forehead and old bruise/skin tear to left wrist. There was no care plan for falls at the time of record review. Record review of Resident #1 physician order dated 01/25/24 revealed the following: Order date: 01/10/24 Portable x-ray. Left rib series 2 view. Symptoms of bruising. Order date/ Start Date: 1/19/24. Monitor left wrist and abrasion to forehead every shift. Order date/ Start date: 11/30/23. Pain Assessment every 6 hours Order date/ Start date: 11/30/23. Tylenol Extra Strength Oral Tablet 5000 MG. Give 1000 mg by mouth every 6 hours as needed for pain. Order date/ Start date: 01/12/24. Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain related to pain unspecified joint. Record review of Resident #1 Pain level Summary, dated 1/26/24, revealed: 01/03/24-01/15/24 pain level a numerical rate of 0. 01/15/24 08:38 AM pain level at a numerical rate of 2. 01/15/24 12:59 -01/26/24 05:58 pain level a numerical rate of 0. Record review of Resident #1 MAR/TAR revealed the following: Tylenol Extra Strength Oral Tablet 500 MG. Give 500 mg by mouth two times a day for pain in unspecified joint; start date 01/12/24: administered at 09:00 AM from 01/13/24-01/25/24; administered 09:00 PM 01/12/24-01/25/24. Tylenol Extra Strength Oral Tablet 1000 MG. Give 1000 mg by mouth every 6 hours as needed for pain.; start date 11/30/23: Was not administered 01/01/24-01/24/24; Administered 01/25/24; Not administered on 01/26/24. Record review of Resident #1 progress notes revealed the following: 01/04/24 at 11:15 AM Author: RN I Was notified by staff that when they went to help Resident #1 out of bed this morning that she non-verbally indicated pain to her left lower side and that she did not want to get up after that. Asked Resident #1 if she was experiencing any pain, she stated she was not. Did a physical assessment and Resident #1 recoiled when that area was physically touched. Notified Physician's team who came by the floor shortly after to inquire about the situation and to assess Resident #1. No orders given at this time. 01/07/24 at 6:14 PM Author: LVN L Resident pleasantly confused and C/O right side flank pain. 01/08/24 at 3:39 PM Author LVN O Notified Physician team of lab results and that resident is having weakness and still having left sided pain and a little nausea and not eating or drinking. Family Member A called and wanted Doctors to see resident and assess resident. Family Member A wants doctor to call her while doctor is here. Encouraged resident to eat and drink. Family Member A voices that she always had a hard time getting doctor to call her and may have to change to another doctor out of facility. 11:15 (am) Resident c/o pain under left breast. Nurse took Tylenol to resident for pain then resident refused. Tylenol and voices she was not having any pain. Care provider encouraged resident to take Tylenol. resident took medication at 14:15 (2:15pm) Physician C here and assessed resident, resident denied pain voicing she is not having pain and has not had any pain. 01/10/24 at 9:14 PM Author Nurse Manager M Resident has green/yellow bruising to left lower back. notified Physician team about pain to residents back and Family Member A wanting x-rays done. Physician team ordered rib series of the left side. x-rays returned and sent to physician team. 01/12/24 at 10:05 PM Author: Nurse Manager M Skin on 1/10/24 at 1249 (12:49pm). Nurse was notified that resident had large bruise to her side/back. Resident could not recall any fall or injury to that area. Notified Family Member A. Root Cause: fall 01/19/24 at 6:30 AM Author: RN Z LATE ENTRY Note Text: At 06:30 CNA F came to inform this nurse that while she was assisting resident to change the brief, she has notice resident's forehead is redden. And resident has old, scabbed wound and old bruised on the left wrist. Resident does not seem to be in pain. Asked resident what happened to her forehead, did you fall? Resident answered NO. Last night, all night, resident was sleeping in her bed, making frequent routine rounds did not hear any falls or noises. Resident is stable, went back to sleep. At 0635, called and spoke with Family Member A, informed her about the redness on her forehead and old healed bruised on left wrist. At 06:36, texted Physician B pager, no answer. At 06:40, paged again, still no answered. At 06:54, texted to inform the Physician Team on call phone. 1/19/2024 07:10, The Physician Team texted back in response. Physician B himself called back and spoke with this nurse that he will make round to see resident today and will address the issues with Family Member A. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #1 bruise incident (bruise) 1/10/24 Resident #1 Skin incident (redness) 1/19/24 Record review of Resident #2's face sheet, 01/26/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include joint subsequent encounter (active treatment to an injury or injury that is in the recovery phase), displaced fracture of second cervical vertebra, cognitive communication deficit, unsteadiness on feet, weakness, muscle weakness. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately intact. Section J1700. Fall History Did the resident have a fall anytime in the last month prior to admission/entry or reentry: Yes. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry: Yes. J2100. Recent Surgery requiring SNF Care Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay: Yes. Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #2 Care plan revealed the following: Initiated 01/04/24 revised 01/16/24. Focus: Resident #2 is at risk for impaired skin integrity due to recent fall with fracture. admitted with wound to the right knew. Goal: Resident # 2 will have intact skin, free of redness, blisters, or discoloration through review date. Initiated 01/04/24. Focus: Resident #2 is at risk for falls due to recent history of falls. Goal: Resident #2 will be free of falls through the review date. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #2 was not on the incident accident report. Record Review of Resident #2 Progress notes revealed the following: 1/17/2024 at 7:06 PM Author: LVN AA hospitalized Evidence of pain: yes, to right knee Injury assessment: right knee laceration with copious amount of blood Signs/symptoms relevant to injury: pain to right knee Modes of transportation: ambulance Nursing Comments: CNA called nurse to inform of call patient on floor patient did not hit head, she fell forward on knee from toilet in an attempt to clean self. CNA was outside door. patient was on floor laying under sink. EMS called and transported to the Hospital. Record review of hospital records dated 01/17/24 and discharge date of [DATE] revealed the following: History of present illness: Resident #2 had a right distal femoral replacement (total knee replacement) on 12/27/24. Resident #2 family member claimed resident fell in the shower. Skin Horizontal laceration with clotted blood below vertical surgical wound to the right knee. Record review of Resident #3's face sheet, 01/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include dementia, difficulty walking, mood disorder, muscle weakness, cognitive communication deficit, unsteadiness on feet, and repeated falls. Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately intact. J1700. Fall History: No data in this section. J1800. Falls since admission. Has the resident had any falls since admission/entry or reentry or prior assessment: Yes. J1900 Number of Falls since Admission or Reentry or Prior assessment No Injury Section V: Care Area Assessment Falls were triggered and care planned. Record review of Resident #3 Care plan revealed the following: Initiated 06/23/23 Revised o on 01/06/23. Focus: Resident #3 is at risk for falls. Gait/balance problems. Ensure resident has walker when ambulating. 1/04/24: Resident is noted to have a fall- Redness noted to back. Goal: [NAME] will be free of falls through the review date. Initiated 07/21/23 Revised 07/21/23. Focus: Resident #3 has impaired cognitive status- has impaired decision making, poor safety awareness Goal: Resident #3 will maintain current level of cognitive function through the review date. Interventions: Communicate with the resident /family/ caregivers regarding residents' capabilities and needs. No care plan at the time of record review regarding his interactions with Resident #6. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Unwitnessed fall 01/04/24 Unwitnessed fall 01/08/24 Record review of Resident #3 progress notes revealed the following: 01/04/24 at 2:49 PM Author: LVN BB Staff heard a thud and noted resident on floor in resident's wife's room. Resident assisted to walker x2 assist. V/S and neuro checks initiated. Noted no reaction to light to both eyes. Skin assessment completed. Noted redness to middle of back. Notified family and doctor. No new orders at this time. 1/05/24 at 2:36 PM Author: Nurse Manager X IDT unwitnessed fall on 1/4/24. Skin assessment completed and no new orders. There was no progress note for the fall that occurred on 01/08/24. The following are notes post fall on 01/08/24: 1/09/24 at 2:36 PM Author: Nurse Manager X CNA reported patient was having a lot of pain to his left lower back from his fall on 1/8/2024. I notified physician's team and doctor came and did an exam on the area and in his assessment, patient did not have any bony tenderness there. He said continue Tylenol PRN if patient has pain. No x-ray ordered at this time. 1/12/24 at 1:45 PM Author Nurse Manager X IDT unwitnessed fall on 1/8 Resident was seen on the floor by the window in a sitting position. I was sitting at the nurse's station on the computer. Resident #3 was sitting on the floor near the window in his bedroom. Assessed resident, got some help and using safety technique we helped the resident transfer back into his recliner. Resident stated he had gotten up from recliner to walk over to get his walker when suddenly he lost his balance and fell near the window and scraped his back with the wooden bench. Doctor and family notified of fall. No recent falls, infections, or wounds. No supplements needed. Root cause: [NAME] not within reach/resident lost balance. Implementation: Make sure walker is within reach. No progress notes regarding allegation that someone pushed Resident #1 and no progress note reflecting the resident-to-resident altercation. Record review of Resident #4's face sheet, 01/26/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (memory deficit) and mood disorder. Record review of Resident #4's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section A Acute Onset Mental Status Change: No evidence of an acute change in mental status. Section E: Behavior: No potential indicator of psychosis E0200. Behavioral Symptom Physical, verbal, and other behavioral symptoms: 1. Behavior of this type occurred 1-3 days. E0300. Overall Presence of behavioral Symptoms: Yes E0800. Rejection of Care: 1. Behavior of this type occurred 1 to 3 days. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Resident #4 Skin Tear incident (bruise) 1/25/24 Record review of Resident #4 progress notes revealed the following: 01/25/24 at 10:43 AM Author: LVN N Staff reported while changing resident clothing that skin tear to the L arm near the antecubital region, with some bruising. No pain or discomfort. Doctor notified with no new orders. Record review of Resident #5's face sheet, 01/26/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia. Record review of Resident #5's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section E Behavior No potential indicators of psychosis. Section V: Care Area Assessment Behavior was not triggered, or care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: Bruise incident (Bruise) 1/25/24 Record review of Resident #5 progress notes revealed: 1/25/24 Resident received scheduled shower; CNA notified this nurse of a bruise to right upper inner arm. No pain or discomfort. Record review of Resident #6's face sheet, 01/27/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (memory deficit), cognitive communication deficit, psychotic disorder with delusions, and dementia. Record review of Resident #06's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section E-Behavior E0100. Potential Indicators of psychosis: No data entered. E0200. Behavioral Symptoms Other behavioral symptoms not directed towards others: 1 Behavior of this type occurred 1 to 3 days. E1100. Change in behavior or other symptoms. How does residents' current behavior status, care rejection, or wandering compared to prior assessment: 2. Worse. Section V: Care Area Assessment Behaviors were triggered and care planned. Record review of incident accident report dated 11/19/23-01/25/24 revealed the following: No pertinent information regarding Resident #6 on this report Record review of progress notes did not reveal any information about Resident #6 having any physical altercation with anyone. During an interview on 01/25/24 at 1:07 PM, Care Giver E stated that she could not remember when she discovered the bruise. She stated she took a picture of the bruise and sent it to Family member A. She Said after looking at her phone that the date of her picture on her phone was 01/10/24. She said that she discovered the bruise because Resident #1 had a bowel movement, and she had her seated on the toilet. She said that when Resident #1 leaned over to grab toilet paper, she noticed a bruise on the left side of her back. She said she grabbed the phone, took a picture, and sent it to Family member A. She stated she then reported it to the nurse's station. She stated Family Member A must have called everyone. She stated that before the bruise, she had been unaware of any falls. She said that CNA J told her that Resident #1 had been complaining of pain for weeks. The Care Giver stated that she was unaware of any pain Resident #1 may have had as she did not complain. She stated she worked Monday through Friday and did a split shift. She said her hours were 8:00 AM to 2:00 PM and then 4:00 PM to 8:00 PM. She stated she was notified that Resident #1 had three fractured ribs. She stated that Resident #1 had another incident. She stated when she came to work Monday, 01/22/24, she had a black eye, scratch, and small bruise on her left arm and a red spot on her forehead. She said she did not know where those injuries came from. She said that she did not remember seeing those injuries when she worked on Friday, 01/19/24. She said Resident #1 did not have a roommate. She said Family Member A placed a camera in Resident #1 room. She said she did not report the second set of injuries to anyone because Family Member A was present, and the doctor said the injuries seemed to be consistent with a fall. The Caregiver stated she was not questioned about the first bruise, fractured ribs, or the second set of injuries on Resident #1. During an interview on 01/25/24 at 1:33 PM, Family Member A stated that although she received a picture of the bruise, it was not the first issue. She stated the first issue was Resident #1 complaining of pain. She said she thought it was abdominal pain based on the way the previous caregiver described it. She said Resident #1 hurt when she moved. She said on 01/04/24, Care Giver E was not present, but there was a different one. She said she reported the pain to RN I. She said it was her understanding that there was a member of the physician team on the memory unit, but her mother was not seen. She said RN I went into the room and asked Resident #1 about pain, and Resident #1 stated she did not have pain. Family member A stated this was when she was mad because they reported the pain for Resident #1. She said the next day, Friday, 01/05/24, was when she was on the phone with Resident #1. She said the staff were attempting to get Resident #1 up, and this was when she heard Resident #1 holler out because she was in pain. She said this concerned her greatly because Resident #1 had a high pain tolerance, and for her to holler out, it must have been bad. She said she was so shocked that she called the nurse to try and get the doctor to see her. She said she believed she reached out to RN I. She said she was told that the doctor did not see Resident #1 because they thought it was a UTI and they were just going to take a UA from Resident #1. She also said the physician team thought it was musculoskeletal (pain associated with arthritis). She stated that she attempted to follow up on the UA sample on Saturday (01/06/24) but could not contact anyone. She said she attempted to contact the nurse 20 or 30 times with no luck. She said she was originally told that the doctors do not come out on the weekend but was then told by another staff that the doctor had seen her mother. She said she found out from a couple of sources that when the doctor came the previous week, the doctor spoke with the facility nurse but did not examine Resident #1. She said she was told that they took the UA on 01/06/24. She said she had requested to the nurse RN I that blood be taken but was told that blood could not be taken over the weekend. She said she attempted to get the results the weekend of 01/6/24 and 01/07/24 and was told that the UA had been mislabeled and would have to try to get another sample. She said the staff on 01/07/24 was finally able to get a UA. She said she was told by the staff on 01/07/24 that they could draw blood on the weekends but that RN I did not write this request down. She said it was Monday (1/08/24) when they received the results of the UA. She said she tested positive for a UTI and was started on an antibiotic. She stated she was told on Tuesday that the physician would be at the facility to see Resident #1. She stated she arranged for her cousin to be at the facility. She stated her cousin was present when the doctor came. According to her cousin, the physician did not lift Resident #1 shirt or undress her to examine her. She stated she was told that the physician patted around on her a few times. She said that on 01/07/24, she was told by the nurse on duty that Resident #1 had pain under her rib. She said on Monday she wanted Resident #1 to have x-rays done on 01/08/24 but was told that Resident #1 would have to go to the hospital. She later found out that x-rays could be taken on the memory unit. She said although Resident #1 said she did not have pain, she started asking her in diverse ways to determine if she had pain. She said she would have to ask Resident #1 if it hurt when she moved; that was how she determined Resident #1 was experiencing pain. She said she does not believe Resident #1 received any pain medication. She said she was unaware of Resident #1 receiving any medication until Wednesday (01/10/24) or Thursday (01/11/24). She said after receiving a copy of the MAR, she became aware that Resident #1 had standing orders for Tylenol. She stated she was not made aware of this medication order. She said no one knows what happened to Resident #1 but that, according to the physicians, their best guess was a fall, especially after the second injury. The physician team and facility staff feel certain that Resident #1 could get off the floor if she fell . She said she was unsure if Resident #1 could get up off the floor if she fell . She said she asked Resident #1 if she had fallen, and she was told, No, not that I know of. Family Member A said on Friday, 01/19/24, she had planned to drive to the facility to see Resident #1, and around 6:30 AM, she received a call from LVN G. She said LVN G told her that Resident #1 had a hurt wrist and red marks on her forehead. She said LVN G may have used the term bruising. She said LVN G told her that the previous night, Resident #1 had been checked on, and she was unaware of any falls or issues from the previous night. She stated LVN G wondered if Resident #1 had fallen. She said if a fall had occurred, it would have occurred on Thursday (01/18/24) because she had not heard from the caregiver. She said that they had a meeting on 01/22/24, and Physician B stated that no further evaluation needed to be done. She said it was Monday when she paid attention to the blackness on Resident #1 eye. It was concluded that Resident #1 may have had her glasses on when she fell . Family Member A stated this did not make sense to her because if she had fallen at night, she would not have had her glasses on. She said no one had confirmed what happened to Resident #1. She said she was unaware of any additional interventions since the fracture. She said she was informed that she could put cameras in the room if she wanted to. She said the meeting on 01/22/24 was when they first suggested a fall mat. She said that some items also went missing that was reported. She said Care Giver E air pods and watch went missing. She said Resident #1 Apple watch also went missing simultaneously. She said this occurred around the time of the discovery of the fractured ribs. She stated that she thought about Resident #1's purse when this happened. She stated she did not want to alert anyone to the purse because it could also get stolen. She stated she was told by staff that a police report could be filed. She stated she was told that the staff would keep an eye out for the missing items. Resident #1 purse and wallet were confirmed missing on 01/13/24. She said she had not witnessed a fall since the cameras had been placed in Resident #1 room. During an interview on 01/25/24 at 2:45 PM, CNA H stated she came in to work one day (unsure of the date), and staff stated that Resident #3 had fallen. She stated she saw the bruises on his back. She stated this was a couple of weeks ago from the interview. She stated it was an unwitnessed fall, and Resident #3 was not with it, meaning he could not tell you what happened. During an interview on 01/25/24 at 3:15 PM, RN I stated she did not know much about Resident #1. She stated she may be susceptible to falling. She stated if she fell or was in pain, she would not say anything because Resident #1 does not like people fussing over her. She stated she believed that Resident #1 was capable of getting back up if she were to fall on the floor. She stated Family Member A had had some concerns, but she would not consider them complaints. She stated the last thing she remembered was Resident #1 not eating breakfast, and Family Member A wanted to ensure a tray was saved. She said the only time Resident #1 complained about the pain was when an x-ray was conducted, the doctor came out, and this was when Resident #1 had fractured ribs. She said Family Member A was concerned about Resident #1 receiving a UA, but she was able to provide a sample, and it turned out she had a UTI. She said she could not say an actual timeline because she had worked a lot with many residents. She said it was believed that the fractured ribs came from a fall. She said the last time she was on the memory unit; she observed the abrasion on her forehead and her bruised wrist. She stated it was speculated that it was from a fall, but they did not know what caused the second care of injuries. She stated she received a report from the overnight nurse but could not remember when or which nurse gave her report. She said she was told that all notifications were made to management staff and the doctor. She said she observed Resident #1 having a full range of motion in both wrists. She stated she was unsure if any checks were done to her head. She said she was not sure why no x-rays were conducted. She stated she had been questioned about Resident #1 but not Resident #4 or Resident #5. During an interview on 01/25/24 at 3:40 PM, CNA J stated she did not know what was happening with Resident #1. She stated it was her understanding that the overnight shift does not bother the residents as much. They check their briefs and try not to wake them. She stated on 01/05/24, she went to the room to get Resident #1 up, and she did not want to get up. She said Resident #1 was acting cranky the morning of 01/05/24. She said she was concerned. She said Resident #1 was on the phone with her daughter. She stated she went to get CNA K for assistance. She said it took her and CNA K to get Resident #1 to the restroom. She said at this time, Resident #1 was extensive, and normally, she was limited. She said Resident #1 normally does not require much assistance as she did on 01/05/24. She said when she got to the restroom, she lifted her shirt but did not see anything. She said Resident #1 was in pain the entire weekend. She stated that they had to baby Resident #1 all weekend. She stated that she did not know if Resident #1 received any pain medication. She stated they were very concerned about her condition. She said they reported it to RN I on Friday (01/05/24) and Saturday (01/06/24). She stated on Sunday that the nurse was LVN L, but she was unsure. She reported to the nurse each time Resident #1 was in pain. She stated she never knew where the fractures came from. She said there was no furniture out of place when she walked into the room. She stated that resident #1 was not always steady. She said she was unsure if Resident #1 could get off the floor if she fell . She stated that the bruise on her wrist occurred the previous week. She stated that 01/19/24 Resident #1 had a bruise on her wrist. She stated that she noticed that there was blood on the bed. She stated she notified RN I. She said she could not remember what RN I responded. She said she did not see resident #1 forehead until Sunday (01/21/24). She said she did not notice her forehead. She said she noticed Resident #1 eye on 01/24/24. She said she was unsure if management knew about the second set of injuries. She said RN I and Nurse Manager M knew and did not know where those injuries came from. She stated there were no interventions put in place from the fracture, but as of 01/24/24, a format was placed in Resident #1 room. She stated Resident #1 was a proud woman, and she did sometimes get up on her own. She stated there were times when she would place her clothes next to her and walk out, and by the time she got back, Resident #1 would have already dressed. She stated that nurse manager M had spoken to her about resident #1's injuries. It is believed that she may be getting up at night. CNA J provided no information about Residents #4 and #5. During an interview on 01/25/24 at 3:56 PM, CNA K stated that regarding Resident #1, she had no idea how she got the fractures. She stated she did write a statement and gave it to nurse manager M. She stated the first set of fractures or injuries had occurred a few weeks ago. She stated that Resident #1 was complaining of side pain. She stated that she may be a little off on the date but was sure she told RN I. She stated on 01/05/24, she helped Resident #1's shower. She stated she assessed her body as they showered, and there were no bruises. She stated Resident #1 was in a lot of pain. She stated this was also reported to RN I. She stated Resident #1 and continued to complain of pain on her left side. She said the bruise did not show up during the time of the shower. She said it was the following Wednesday (01/10/24) when they noticed bruising. RN I look[TRUNCATED]

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for two of two residents (Residents #1, #2,) and 2 of 2 CNAs (CNA A, B) reviewed for incontinent care. CNA A and CNA B failed to wash their hands or use hand sanitizer before, during, or after performing incontinent care on Resident #1 and #2. CNA A placed on a clean pair of gloves without using hand sanitizer or performing hand washing techniques and then touched Resident #1's bed railing before performing incontinent care. CNA A and CNA B failed to perform the correct techniques while performing incontinent care for Resident #1 and #2. CNA A and B used one wipe to consistently wipe in one spot instead of using one swipe method. CAN A failed to perform the correct cleaning technique for catheter care for Resident #2 These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #1 Record review of admission record for Resident #1 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include acute respiratory failure with hypoxia (absence of enough oxygen), pneumonia, anemia (lack of red blood cells in the body), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), vitamin deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, pressure ulcer of buttock stage 2. Record review of Resident #1's Annual assessment dated [DATE] revealed Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section H - Bladder and Bowel: HO300 Urinary continence was coded 3, 3 - Always incontinent (no episodes of continent voiding). H0400 Bowel Continence was coded 3, 3 - Always incontinent (no episodes of continent bowel movements). Resident #2 Record review of admission record for Resident #2 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of surgical amputation, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), type 2 diabetes, vitamin deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypokalemia (low potassium), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure, low blood pressure, chronic obstructive pulmonary disease, overactive bladder, benign prostatic hyperplasia (age related prostate enlargement), with lower urinary tract symptoms. Record review of Resident #2 Annual assessment dated [DATE], revealed Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section H - Bladder and Bowel: HO300 Urinary continence was coded 9, 9 - not rated, resident had a catheter (indwelling condom, urinary ostomy, or no urine output for the entire 7 days) H0400 Bowel Continence was coded 2, 2 - frequently incontinent (2 or more episodes of continent bowel incontinence, but at least one continent bowel movement). During an observation of incontinent care on 05/08/2023 at 10:17 am with CNA A and CNA B, performed incontinent care on Resident #1. CNA A and CNA B did not perform hand hygiene prior to gathering incontinent care supplies or prior to putting on gloves to provide care. CNA A and CNA B did not perform hand hygiene after providing incontinent care for Resident #1. Upon entering Resident #1's room, Resident #1 stated, I am soaked in urine. Observed CNA A and CNA B place on clean gloves without washing hands. CNA A proceeded in removing Resident #1's pants and removed Resident #1's urine-soaked brief. CNA A used one wipe and proceeded in cleaning one area with continuously wiping instead of using the one swipe per wipe method. CNA A used the wipe and started in the center groin area, wiping from the top groin area towards the shaft of the penis with several wipes and not changing to a clean wipe. CNA B removed gloves and left Resident #1's room to go get a clean brief for the resident. CNA A and CNA B failed to gather supplies prior to care. CNA B came back into resident's room with a clean brief and failed to wash hands. CNA A used a total of 2 wipes for the entire front groin area. CNA A turned Resident #1 over to the right side to clean his back area. Observed a bandage that was covering his top wound, halfway off and had been exposed in the urine-soaked brief. CNA A continued to use a clean wipe to clean the back side, starting at the center of the buttocks. CNA A discarded the wipe. CNA A used a total of 2 wipes for the backside area. CNA A did not fold the wipe to gain a clean side on either wipe. CNA A proceeded in putting the urine-soaked bandage back on the resident's wound and then stated, I am not certified to clean the wound, I will have to get a nurse. CNA A and CNA B did not wash hands for the entire incontinent care process, nor did they change gloves. CNA A and CNA B disposed of gloves at the end of providing care for Resident #1. During an observation of incontinent care on 05/08/2023 at 10:36 am with CNA A. CNA A notified Resident #2 that she would be performing catheter care. CNA A failed to wash her hands between providing incontinent care for Resident #1 and Resident #2. Observed CNA A failed to wash hands prior to providing incontinent care. CNA A placed on a new pair of gloves and was touching on the side of Resident #2's bed and bedside table prior to providing catheter care for Resident #2. CNA A got a basin full of warm water and asked Resident #2 to verify that it was not too warm. CNA A proceeded in taking off Resident #2's pants and brief to provide catheter care. CNA A dampened the clean washcloth and proceeded in wiping the catheter from the insertion site downward and then back up on the tubing toward the insertion area without using a different clean area of the washcloth. CNA A cleaned the tubing up and down a couple of times with the same washcloth. CNA A proceeded in using the washcloth and rinsing it out in the basin and cleaning Resident #2's groin area. CNA A replaced with clean brief and helped Resident #2 place back on his pants. During an interview with CNA A on 05/08/2023 at 10:52 am, CNA A stated that she had not been trained in infection control practices. CNA A stated that the form of training for other things is usually in-services, but she has not been trained in infection control practices. CNA A stated that she is not sure who is in charge of making sure that training is completed. CNA A stated that she did understand the errors of failing to wash hands before, during, and after resident care, incorrect cleaning technique for incontinent care and catheter care that was found while observations of providing incontinent care. CNA A stated that she would normally wash hands before, during, and after care. CNA A stated that she is not sure why she did not do this. CNA A stated, I guess I was a little nervous. CNA A stated that she did realize that her techniques were incorrect after she had already completed care for the resident. CNA A stated, I was just really nervous. CNA A stated that the negative potential outcome for not washing hands before, during, or after incontinent care means that she could have spread germs to other residents. CNA A stated that the only thing she could think of to do with Resident #1s open bandage being soaked in urine was to place it back on because she is not certified to clean wounds. CNA A stated that by placing the bandage back on the wound with it being soaked with urine could make the wound worse. CNA A stated that she wasn't thinking about that at the time she did that. During an interview with CNA B on 05/08/2023 at 11:13 am, CNA B stated that she has not been trained in infection control practices. CNA B stated that she did have a hand washing check off but it's been a while back (fall of 2022). CNA B stated she is not aware of who is responsible of making sure that training is completed. CNA B stated, Maybe the administrator. CNA B said that she understands the errors of failing to wash hands before, during, or after resident care, that were found during the observation of incontinent care. CNA B stated that they are supposed to wash hands before and after providing care. CNA B stated that she thought since she had gloves it would be okay to not wash hands. CNA B stated that if gloves were to break then she would have possibly exposed the resident or other residents to the spread of germs and infections. CNA B stated that she is aware that it is not hygienic practice to not wash your hands before and after providing care to residents. During an interview with the DON and the Administrator at same time on 05/09/2023 at 3:18 pm, the DON stated she trains staff to ensure they have proper techniques for incontinent care. Stated on hire there is a check off and annual skills fair. Stated they work with the agency themselves to make sure their staff has the correct credentials and then when they come to the facility, they get an orientation to the floor when they start to show where supplies are located. The DON stated she did incontinent care in-service and hand washing. The DON stated that by not washing hands you could spread germs. Administrator stated she would not expect staff to put the soiled bandage back on the wound but get the nurse and put a clean dressing on the wound. Potential outcome Infection and worsening wound. Administrator stated that she will start working on an in-service for infection control practices and hand washing. Record Review of facility provided policy, labeled, Infection Control, date not provided, revealed: Purpose: To provide guidelines for general infection control while caring for residents. General Guideline: 1). Standard precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard precautions apply to blood, body, non-intact skin, and/or mucous membranes. 3). Wash hands thoroughly with soap and water. A). Before any procedure, B0. Before resuming any procedure after an interruption, C). Anytime they become soiled with blood or body fluids, D). After changing or removing gloves or any personal protective equipment (PPE), E). Whenever in doubt, F). After completing a task or procedure. 4). Follow guidelines for the use of alcohol-based hand rubs. 5). Wear PPE as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Record Review of facility provided policy, labeled, Hand Washing, date updated on 01/27/2016, revealed: Purpose: To prevent the spreading of germs to our residents and employees. When to Wash: 1). Before eating, 2). Before, during, and after handling or preparing food. 3). After contact with blood or body fluids (i.e. nasal secretions, saliva, urine, etc). 4). After changing a diaper/brief. 5). After touching something that culd be contaminated. 6). Before dressing a wound or giving medicine. 7). After using the restroom. Steps in Procedure: 1). Wet your hands and apply soap. 2). Rub hands together vigorously to make lather and scrub all surfaces. 3). Continue for at least 20 seconds. 4). Rinse hands well under warm running water. 5). Dry your hands using a paper towel. 6). Use your paper towel to turn off the faucet. Record Review of facility provided policy, labeled, Incontinent Care, date not provided, revealed: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps: 1. Gather equipment needed. Arrange supplies for easy access. 2. Wash and dry your hands 3. Fold the bedspread or blanket toward the foot of the bed. 4. Fold the sheet down to the lower part of the body, Cover the upper torso with a sheet. 5. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 6. Put on gloves. 7. Instruct the resident to bend his or her knees and put his or her feet flat on the bed/mattress. Assist as necessary. 10. For Male resident: A). Wash perineal area starting with urethra and working outward. 1). Retract foreskin of the uncircumcised male. 2). Wash and rinse urethral area using a circular motion. 3). Continue to was the perineal area including the penis, scrotum and inner thighs. 4). Do not use the same wipe to clean the urethra. B). Gently dry perineum following same sequences. C). Reposition foreskin of uncircumcised males. D). Instruct or assist the resident to turn on his side with the upper leg slight bent, if able. E). Wipe the rectal area thoroughly, including the area under the scrotum, the anus, and the buttock. F). Dry area thoroughly. 11. Discard disposition items into designated containers. 12. Remove gloves and discard into designated container, wash and dry your hands. 13. Reposition the bed covers, make the resident comfortable. 14. Place the call light within easy reach of the resident. 15. Clean wash basin and return to designated storage. 16. Clean the bedside table. 17. Wash and dry your hands. 18. If the resident desire, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Record Review of wound tracking log dated week ending of 04/14/2023 revealed: Resident #2 dated 04/12/2023 showed resident had 6 new wounds: coccyx stage 3 treated with calcium alginate and cover, left proximal dorsal foot (surgical) treated with calcium alginate and cover, left distal dorsal foot (surgical) treated with calcium alginate and cover, left lateral foot (surgical) treated with calcium alginate and cover, right 3rd toe (diabetic) treated with betadine. On 04/21/2023 shows that the wounds have not changed. On 04/28/2023 shows that 4 of the wounds have improved on the left lateral foot wound shows to have deteriorated, the right 3rd toe shows to have no change. Record Review of wound tracking log dated week ending of 04/21/2023 revealed: Resident #1 showed resident has 4 new wounds: right ischium treated with cover with allevyn, coccyx treated with venelex, left ischium treated with venelex, left glute treated with venelex. On 04/28/2023 shows that wound on left ishium is healed, on the left glute and coccyx shows to be improved on the right ischium shows that wound has deteriorated. Record Review of CDC guidelines for hand hygiene, https://www.cdc.gov/handwashing/index.html, date not provided, revealed: Hand hygiene protects you and those receiving the care you provide. The simple act of cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics. Keeping the skin on your hands healthy and clean is a challenge that requires all healthcare personnel to be knowledgeable about how to care for their hands and when hands should be cleaned. Regular hand washing is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others.