Every finding on record at Coral Reef Subacute Care Center LLC

Based on record review, observation, and interview, the facility's staff failed to answer incoming calls after 8:00 PM. Six documented calls to the facility were not answered by the staff. This deficient practice had the potential to affect all 159 residents residing in the facility at the time of the survey. The findings include.Observational tour on 01/20/2026 at 3:35 PM, revealed the East Wing nursing station had three desk phones and one portable phone. The [NAME] Wing nursing station had three desk phones and one portable phone. The North Wing nursing station also had three desk phones and one portable phone on the counter. There were three nurses at each nursing station engaged in various tasks.On 12/29/2025 the surveyors made multiple attempts to contact the facility by phone at different times as follows:9:34 PM - The phone rang 10 times, but no one answered 9:42 PM - The phone rang 15 times, but no one answered.9:48 PM - The phone rang 15 times, but no one answered.10:01 PM - The phone rang 15 times, but no one answered.10:16 PM - The phone rang 17 times, but no one answered.10:28 PM - The phone rang 16 times, and no one answered.During an interview on 12/30/2025 at 10:35 AM, the Administrator explained that the facility's phone system routed calls to the receptionist between 8:00 AM and 8:00 PM, who then distributed calls to residents and the nursing station. After 8:00 PM, calls were directed straight to the nursing station, where nurses were responsible for answering. The Administrator stated that she did not understand why nurses failed to respond to the calls during the reported time frame.On 12/30/2025 at 11:20 AM, Staff A (Concierge) stated that she did not recognize Resident #2's name. Staff A stated that her role involved maintaining communication with residents and their families and also family members had her personal cell phone number to contact her directly in case of emergencies.On 01/20/2026 at 3:52 PM, Staff B Registered Nurse (RN), stated that when nurses received calls for the residents, the calls are transferred to the portable phone taken to the resident. Review of the facility's Policy and Procedures for Residents' Rights (published 10/20/2022) indicated: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and state laws guaranteed certain basic rights to all residents of this facility. These rights included the residents' right to communicate with and access people and services, both inside and outside the facility.

Based on observation, interview and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, clean homelike environment with a comfortable interior free of disrepair for 11 out of 32 resident rooms on the East Unit. (Photographic evidence available). There were 156 residents residing at the facility at the time of the survey. The findings included: On 06/02/25 starting at 06:30 AM during the initial tour and resident screenings on the facility's East Unit observation revealed: The chest of drawers in room numbers 4, 6, 9 ,11, 15,17, 18, 19, 20, 21, 25 and 26 noted with chipped paint, grime (dirt ingrained on the surface) and black marks covering the top. The floor in room# 25 bed A was littered with paper all around the bed. Observation in room [ROOM NUMBER]'s bathroom revealed the toilet tissue/paper dispenser was broken. Interview on 06/04/25 at 10:30 AM, Staff A, Registered Nurse (RN) East Unit Manager when showed the photos of the surveyor findings in the residents' rooms, stated: We have a program in our system where we go to report any maintenance concerns called [a building management platform], we enter the room number, location and the issue. Maintenance checks the system often throughout the day. Depending on the urgency of the issue, I checked the location where the issue occurred to see if it has been resolved. If the issue/issues are not resolved, I complete a new ticket in the system or talk to maintenance staff about the issue to find out when the issue will be resolved. I am not sure if the condition of the chest of drawers in the residents' rooms were addressed with maintenance prior to the survey. Interview on 06/04/25 at 11:32 AM, the Director of Maintenance when showed the photos of the surveyor findings in the residents' rooms, stated: I am aware of the disrepair of the furniture, we painted the furniture about six months ago, the issue is the chest of drawers are laminate and does not hold the paint well. Currently the facility is under renovation, and the goal is to replace the furniture within eight months during the renovation process. I have been maintaining the functionality of all the furniture (Changing handles, hinges and often the floor of the chest of drawers) . Review of the facility policy and procedure titled Homelike Environment dated 11/14/24 states: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment c. inviting colors and decor d. personalized furniture and room arrangements

Based on observation, interview and record review, the facility failed to ensure one (Resident #131) out of eight residents sampled was treated with respect and dignity during dining, as evidenced by Staff B, Certified Nursing Assistant observed standing while feeding Resident #131. This deficient practice has the potential to affect any residents residing in the facility requiring assistance from staff. The findings included: Observation on 06/02/25 at 12:42 PM, revealed Staff B, Certified Nursing Assistant (CNA) in Resident #131's room standing while feeding Resident #131. On 06/02/25 at 12:44 PM, the surveyor asked Staff B why he was standing while feeding Resident #131. Staff B revealed he prefers to stand and because he takes his time feeding the resident and makes sure the resident is safe. On 06/02/25 at 01:40 PM the Staff Educator (Staff C) acknowledged the identified concern related to dignity during dining and proper feeding practices. Review of the facility policy and procedure titled Dignity dated 11/14/24 states: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are always treated with dignity and respect. 2. The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with dignified dining experience. Review of the facility's undated document titled Dining Room Audits revealed: Policy Statement Our facility audits the food and nutrition services department regularly to ensure that residents' needs are met and that dining is a safe and pleasant experience for residents. Policy Interpretation and Implementation l. Sit next to the residents while assisting them to eat, rather than standing over them.

Based on observation, interview and record review, the facility failed to provide a safe environment that is free from potential hazards for one (Resident #54) out of eight vulnerable residents sampled. As evidenced by the electrical cord for an Intravenous (IV) infusion pump attached to a pole at the right side of the resident's bed observed extended across bed connected to an electrical outlet on the left side of the resident's bed. There were 156 residents residing in the facility at the time of the survey. The findings included: Observation on 06/03/25 at 08:40 AM, Resident #54 was asleep in bed, IV site present on the resident's left arm dated 05/29/25. There was an IV pole with infusion pump attached at the right side of the resident's bed; it was revealed that the IV pump's electrical cord hung from the IV pole on the right side of the resident's bed was positioned under the resident, extending across the bed to the left side of the bed was connected to an electrical socket on the wall behind the bed's left side. Interview on 06/03/25 at 08:44 AM Staff D, Registered Nurse (RN) stated: I am the assigned nurse for [Resident #54], I work 7:00 AM to 7:00 PM shift; I checked on the resident at the start of my shift, the resident was and is doing very well, he is currently on antibiotics for congestion and is tolerating his IV medications. Staff D revealed she is not sure who hung the electrical cord across the resident's bed in the manner observed and acknowledged the way the electrical cord is positioned is not safe for the resident, and she spoke to maintenance in the past about not having any electrical outlets on the right side of the bed. Interview on 06/04/25 at 10:35 AM, Staff A, Registered Nurse (RN) East Unit Manager stated: I was told by the nurse about the intravenous (IV) electrical cord issue with [Resident #54], when facing the resident in bed-we repositioned the IV pole from the right side of [Resident #54's] bed to the left side and educated the nurses on repositioning the resident on the right side, so the left arm with the IV site is close to the location of the IV pole for IV therapy administration. Review of the medical records for Resident #54 revealed the resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses include Breakdown (mechanical) of other cardiac electronic device, Chronic Obstructive Pulmonary Disease, Emphysema. Review of the Physician's Orders Sheet for June 2025 revealed Resident #54 had orders that included but not limited to: Piperacillin Sod-Tazobactam Solution Reconstituted 3-0.375 GM-Use 3.375 grams intravenously every 6 hours for Influenzas like symptoms until 06/03/2025 Record review of Resident # 54's Significant Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status Score (BIMS) 9 on a 0-15 scale, indicating the resident is cognitively moderately impaired. Record review of Resident # 54's Care Plans Dated 05/22/25 revealed: Resident #54 is on IV antibiotic medications and IV Fluids is using a mid-line on the left arm Date Initiated: 05/27/2025, Revision on: 05/27/2025. Resident #54 will not have any complications related to IV Therapy through the review date. Interventions include- Review of the facility policy and procedure titled Accidents and Incidents-Investigating and Reporting Dated 01/28/25 states: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on observation, interview and record review the facility failed to ensure medications and treatment ointments were stored in accordance with facility policy. As evidenced by ointments and medication were found in the residents' rooms unsecured. There were 156 residents residing in the facility at the time of the survey. The findings included: On 06/02/25 starting at 06:30 AM during the initial facility tour and resident screenings on the East Unit of the facility, the following were observed: rooms [ROOM NUMBERS] revealed Zinc Oxide ointment on the dresser in both rooms. room [ROOM NUMBER] had a half full 0.9% Sodium Chloride syringe on top of the dresser in the room. (Photographic evidence available) Interview on 06/04/25 at 10:48 AM, Staff A, Registered Nurse (RN) East Unit Manager when showed the photos of the findings in the residents' rooms, stated: The ointments and creams should be stored in the residents' personal drawers and the Sodium Chloride solutions must be stored on the medication cart or the medication room. Review of the facility policy and Procedure titled Medication labeling and Storage dated 01/27/25 states: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations, interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA) committee failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F641- Accuracy of assessment and F761- Label/Store drugs and biologicals. Facility's failure to accurately code the Minimum Data Set (MDS). Facility's failure to store medications appropriately. There were 156 residents residing in the facility at the time of the survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 01/19/ 2024, F641- Accuracy of assessment was cited for inaccurate coding of MDS section B for Corrective lenses. F761- Label/Store drugs and biologicals was cited due to facility's failure to ensure medications were securely stored. F867-Quality Assurance and Performance Improvement was cited due to the QAPI/QAA committee's failure to monitor previous problem areas identified with existing need for improvement based on the committee's continued evaluation of their performance improvement projects. Interview on 06/05/2025 at 01:00 PM, the Administrator revealed the QAPI committee meets on the third Tuesday of each month, the last meeting was held on May 20, 2025. The committee includes Medical Director, Administrator, Director of Nursing, Assistant director of nursing, Infection Preventionist, Director of Rehabilitation, MDS, Nurse Educator, Wound Nurse, Business Office, Human Resources, Director of Maintenance, Director of Housekeeping, Director of Food Services, Registered Dietitian, Social Worker, Activities Director, all unit managers, providers, Medical Records, Pharmacist consultant, Laboratory Diagnostic, Resident concierge, and others. Each department is assigned specific objectives or focus areas to monitor and report on monthly. The purpose of these meetings is to enhance the quality of care and services we provide by continually evaluating and improving our processes. It involves a thorough review of all aspects of care to ensure everything is working as intended, identifying any errors or areas of concern, and taking corrective action when needed. This process is not done in isolation; it requires the collaboration and input of the entire team. By working together, we can find solutions, implement improvements, and create a culture of accountability and excellence that benefits both staff and the individuals we serve.

Based on observations record reviews and interviews, the facility's staff failed to supervise and implement adequate measures to prevent the elopement for one (Resident #1) out of three residents sampled. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system were in place enabled Resident #1 who had risk factors that include visual impairment and seizure disorder, exited the facility undetected on 09/01/2024 shortly after lunchtime. Resident #1 who had displayed and voiced his intent to leave the day prior ambulated 3.2 miles from the facility in areas that has high traffic volume, intersections and cross streets; these factors increased the likelihood of an adverse outcomes, serious injury and serious harm or death. The facility's staff were not aware of Resident #1's absence until the resident's sister called the facility and reported a convenience store owner had called and said her brother was at the store. The Registered Nurse (Staff J) assigned to Resident #1 then left the facility at approximately 5:30 PM in her personal vehicle and picked up Resident #1 at the convenience store. Staff J did not document the incident and failed to inform administration of the incident. Review of the facility's policy titled: Wandering and Elopements Published: 05/19/2023 indicated: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner. c. instruct another staff member to inform the nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident is not authorized to leave, initiate a search of the building(s) and premises. and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries. b. contact the attending physician and report findings and conditions of the resident. c. notify the resident's legal representative (sponsor). d. notify search teams that the resident has been located. e. complete and file an incident report; and f. document relevant information in the resident's medical record. Review of the facility's Job duties and essential functions for the Registered Nurses Item 11 indicate: Conducts self in a professional manner in compliance with unit and facility policies. Communication: 1. Change of shift report is complete, accurate and concise. 2. Incident reports are completed accurately and in a timely manner Review of Resident #1's clinical records revealed the resident was admitted to the facility on [DATE], clinical diagnoses included Chronic obstructive pulmonary disease (COPD), history of transient Ischemic attack (TIA), and cerebral infarction without residual deficits, seizure disorder and visual impairment. Resident #1 was discharged on [DATE]. Review of Resident #1's Minimum Data Set (MDS) admission assessment dated [DATE] documented in Section B1200 for Corrective Lenses (contacts, eyeglasses or magnifying glass) used, indicated Yes. Review of Resident #1's Care Plans initiated 07/13/2024 indicated focus area the resident has highly impaired vision related to the disease process; as per resident only able to follow shadows. The resident is at risk for respiratory distress related to COPD. Has self-care deficit, seizure disorder and hypertensive heart disease. During an interview via telephone on 12/03/2024 at 12:28 PM, Resident #1's sister revealed: On 09/01/2024 at 5:04 PM, I received a call from a woman at a convenience store located at [address]. She told me that she had [Resident # 1] there with her and he had my name, address and phone number on a card that he gave to her. He asked her to call a cab for him. But she called me. instead. I told her that my brother was a patient at Coral Reef, and I would call the facility. When I called the facility they were not aware that my brother was missing. I spoke with the charge nurse and gave the phone number of the convenience store that had called me. Resident # 1's sister revealed the facility staff picked her brother up at the convenience at 5:43 PM and took him back to the facility. She further reported she had sent an email on 09/03/2024 to the Administrator about the incident and received no response. During an interview on 12/04/2024 at 6:33 AM, the Administrator (NHA) revealed she was not aware Resident #1 had left the faciity on [DATE]. The NHA reviewed the nursing notes and reported on 08/31/2024 during shift change at around 7:00 PM, Resident #1 was on the patio with his belongings in a bag and would not come inside. The NHA stated: From what I understand from the DON (Director of Nursing) it was the night nurse that encouraged him to come inside. The NHA was asked if she had received an email from the sister, the NHA reported she had not checked her emails. During an interview on 12/04/2024 at 7:11 AM; the DON stated: I checked the weekend 24 hour report and that is when I saw the note, the unit manager said on Saturday he (Resident #1) went outside with his belongings in the yard and the nurse told me she called the family but the patient did not want to come inside and the night shift nurse called the family and the family and she encouraged him to come in; she gave him food and she checked him all night and he did not go back outside anymore. On 12/04/2024 at 11:22 AM during an interview via telephone Staff I stated: I worked on the 3rd cart. I did not know he left the facility he always walked around in the facility. I remember something happened on the patio on August 31st because he went to the patio and the night supervisor, and I convinced him to come back inside. It was in the evening before my shift ended. That was the third time I worked with that patient. I documented that he was upset, and we called the sister. On 12/04/2024 at 11:42 AM the NHA was asked about the facility's video surveillance; the NHA revealed the facility does not have the footage of the resident on the patio because it automatically deletes after a month. On 12/04/2024 at 12:01 PM, during an interview via telephone, Resident #1 revealed he had some difficulty hearing but is able to hear somewhat. The resident was asked how he was able to leave and how he got out of the facility. Resident #1 stated: After I had lunch I walked through the side door and the gate to the sidewalk. The resident revealed he walked far and was a little tired. When asked about the weather that day, Resident #1 stated: It was wet and there were puddles. Resident #1 revealed two nurses picked him up and when he got back to the facility he was taken through the side door, and he had dinner when he returned to the facility. During a telephone interview on 12/04/2024 at 1:44 PM, Staff O, RN weekend supervisor reported he only worked weekends and was not aware of the incident on 09/01/2024. Staff O, RN revealed on 08/31/2024 Resident #1 was outside on the patio between the east and west wing with the nurse and wanted to leave. When the night supervisor [Staff A] came she convinced him to come inside at approximately 6:00 PM. I think he was ok on the first because I think he was in his room that day he was fine. [Staff A] was the supervisor for the night shift. I remember the nurse was checking the room. I know the nurses spoke with him and I think I spoke with the sister, and she said she was coming to pick him up the Monday. On 12/05/2024 at 11:50 AM the NHA reported she found the email that the sister sent to her on 09/03/ 2024, and she had not opened the email. On 12/06/2024 at 2:14 PM a telephone interview was conducted with Staff J in the presence of the NHA and DON. Staff J revealed on 09/01/2024 Resident #1's sister called the nurses' station to inform her that the Resident was in a store far from the facility. She (Staff J) immediately went to the resident's room to check if he was there, but he was not in his room. She immediately drove to the store to pick up the resident. As soon as she returned to the facility, she completed a full assessment of the resident. His vitals were within normal limits, and skin was intact. Staff J reported she called Resident #1's sister and informed her Resident #1 was ok and back in the facility. On that day she had last seen Resident #1 around noon and did not remember what time she picked him up but recalled it was not dark outside, and it had rained earlier. She revealed the incident was not reported and nothing documented because the resident was safe, and she was in shock. The facility's Corrective Actions included: Resident #1 no longer resides at the facility. He was discharged home. Two Elopement Drill and a head count was conducted on 12/5/24 as part of the elopement drill. Head count is conducted by daily resident census is printed out and it is utilized to validate residents in the building. Once a resident has been identified the resident is checked off from the daily census. Each charge nurse/designee will count/review the checked off daily census utilized to see which resident name is notified without a checked mark. A resident without a check mark net to their name is the one missing. The check mark next to the resident name will be added together on all three units and that will equal the total count. A head count was conducted during the elopement drill on 12/5/24 and all residents were 100% accounted for. Staff were able to locate the missing sample resident for the drill within 5 minutes of the announcement, the resident was observed sitting in the DON's office. Missing Resident Protocol followed. The DON was educated on 12/5/24 by the Regional Nurse on ensuring the facility policy on missing resident is being followed. The Administrator was educated on 12/5/24 by the Regional Nurse on ensuring the facility policy on missing resident is being followed, also on the importance of reviewing and responding to emails. A Quality Assurance and Performance Improvement AD HOC committee meeting was conducted on 12/5/24 and an Adverse Incident Reporting was completed on 12/5/24. Education was conducted for 189 out of 200 employees and 11 employees are still pending in-service. Identification of other residents with potential to be affected: All ambulatory residents are likely to be affected by this practice. An evaluation of resident's head count was conducted with 100% residents attendance on 12/5/24 An Elopement risk evaluation was conducted on all residents in house on 12/5/24 no new findings noted. Measures / Systematic changes made to ensure non-recurrence: The facility's policy titled Emergency Procedure - Missing Resident was reviewed by the DON and NHA with no changes indicated. The Administrator/DON/Facility Educator/Designee educated facility staff the facility policy titled Emergency Procedure - Missing Resident. The Administrator/DON/Staff Educator/Designee will educate staff on ensuring all incoming and outgoing residents sign in/sign out. Education includes the receptionist who will be responsible for ensuring no one leaves the facility before identification and signing out utilizing the electronic check in system. Nursing staff will monitor residents' attendance and provide adequate supervision to ensure any absence is reported in a timely manner. The education includes staff reporting to the nurse supervisor when resident expresses desire to leave, an elopement evaluation should be conducted. The doors that exit to the enclosed patios are now alarmed. The alarm can only be turned off, when it is manually turned off by a specific code. Based on the location of the doors, a staff member is required to always put in a code in order for the alarm system to be turned off. The residents who tend to wander near the door areas will be redirected by staff. Monthly elopement drills will be conducted on all shifts. Newly hired staff will be educated on elopement and participate in an elopement drill. The daily census will be printed and utilized for obtaining the head count. The Maintenance/Designee will conduct random audit to ensure the facility's gates are locked. The Maintenance/designee will check the gates to ensure they are in working order on a weekly basis and randomly. Monitoring of Corrective Action: The Administrator/Designee will conduct weekly audit x 4 then monthly x 3 to ensure incoming and outgoing residents sign in and out of the facility. The Administrator/Designee will conduct weekly audits x 4 then monthly x 3 to ensure no one leaves the facility without signing out. The DON/Designee will conduct weekly audits x 4 then monthly x 3 to ensure supervision is provided and any absence is reported in a timely manner. The DON/Designee will conduct weekly audits x 4 then monthly x 3 to ensure newly hired employees are educated on elopement and participate in elopement drill. The result of all audits will be presented to the QAPI committee for review and feedback. The frequency of audits may extend as per the QAPI committee's evaluation. On 12/06/2024 the facility's corrective actions were verified by the survey team through observations, records reviewed and interviews.

Based on observations record review and interviews, the facility's staff failed to ensure accuracy of controlled medication and failed to ensure drugs and biologicals used in the facility are stored and disposed in accordance with professional standards; as evidenced by three out of eight medication carts were observed unattended and unlocked, inaccurate narcotic accounting, medications observed in drawers at the north wing nurses' station and medications incorrectly disposed. On 12/02/2024 at 4:55 AM during the initial tour, the west wing's medication cart # 3 assigned to Staff N, RN was observed unlocked and unattended. On 12/02/2024 at 5:04 AM, Staff A, Registered Nurse (RN) observed tossing medications in the trash can attached to the medication cart. Staff A revealed the resident refused the medications, so she had to toss them. Staff A was asked if that was the process to discard medications. Staff A denied tossing the medications in the trash. The medications were retrieved from the trash and Staff A placed them in the sharps container. Staff A did not respond when was asked about the facility's policy for disposing medications. Observation on 12/02/2024 at 5:10 AM with Staff B, RN discontinued medications and the following unused medications: insulin, topical ointments and oral solutions were observed in the drawers at the north wing's nurses' station. Staff B, RN revealed the medications should not be in the drawer and should have been returned to the pharmacy. On 12/02/2024 at 5:15 AM during the north wing's cart #2 narcotics reconciliation review with Staff A, RN; Resident #16 Alprazolam (Xanax) bingo card had 5 tablets remaining and the narcotic disposition log documented by Staff A, RN noted 1 tablet was given on 12/02/2024 at 6:00 AM and 4 tablets remained on hand. Staff A, RN was asked to explain the discrepancies with the time and the amount of tablets left in the bingo card. Staff A, RN, reported the resident had refused the medication and it was an error. Staff A was asked if the resident had requested the as needed, Staff A did not respond. On 12/02/2024 at 5:22 AM narcotic reconciliation review with Staff A, RN for Resident # 17's Lorazepam (Ativan) ordered to be administered every 12 hours as needed, had 14 tablets in the bingo card and Staff A, documented on 12/2/02024 1 tablet was given at 9:00 PM and 13 tablets remained on hand. Staff A, RN explained she made an error with the date and had prepared the medications, but the resident had refused the medication. Staff A, RN revealed she usually signed the medications off first and that what she did was incorrect. The supervisor was in the vicinity and acknowledged the concerns. On 12/02/2024 at 7:45 AM, the night supervisor was informed of the concerns related to the medication carts left open, inaccurate narcotic counts, the medications observed in the drawer at the North Wing Nurses station and the nurse tossing pills in trash. The supervisor revealed the carts should not be left open when the nurse is not at the cart. The supervisor had no explanation regarding the medications in the drawer at the nurses station. Regarding discontinued medications, she stated: The regular medications are returned to the pharmacy after they are counted and placed in a gray bag with the label, and kept in the med room to be returned to the pharmacy. On the weekend the discontinued narcotics must be signed by two nurses; we fold the paper put an elastic band around it and put it in a plastic bag at the back of the narcotic box in the cart and on Mondays the unit Manager gives them to the DON. I am not sure because they do it during the week. I don't know how often they do it. The narcotic medications should be signed off immediately after they are removed and if the patient refuses two nurses are required to witness and dispose of the medication. On 12/02/2024 at 5:29 AM the west wing medication cart #1 was observed unlocked and unattended. During a second observation at 5:37 AM, the cart was still unlocked and unattended. The supervisor was shown the unlocked cart and asked which nurse was assigned to the cart. The supervisor revealed Staff D, RN, was assigned to Cart #1. At 5:42 AM Staff D was located. and acknowledged she had left the cart open. During narcotic count conducted with Staff D, the following discrepancies were noted; Resident #25's narcotic disposition log for Lorazepam (Ativan) 5 milligram (5 mg) as needed documented an on-hand amount of 28 but the bingo card had 27 tablets. Resident # 26's Pregabalin 50 mg capsule twice per day (9:00 PM and 9:00 PM) narcotic disposition log documented an on-hand amount of 38, the bingo card had 37 capsules. Resident # 27's Alprazolam (Xanax) as needed narcotic disposition log documented 9 tablets available, but the bingo card had 8 tablets. Staff D acknowledged the discrepancies and revealed the facility's policy is to sign out the narcotic and include the time and amount immediately after the medication is removed. On 12/02/2024 at 6:06 AM, during medication administration and narcotic review for the west wing's cart 2, Staff C, RN left the medication cart unlocked and unattended, entered Resident # 4's room. Staff C, RN reported the cart should not be left unattended and unlocked. On 12/02/2024 at 7:06 AM Staff N, RN was asked about the medication cart observed unattended and unlocked. Staff N revealed: when I am leaving the cart I usually lock it. On 12/04/2024 at 5:50 AM Resident # 15 was observed in bed asleep. At 6:04 AM a narcotic reconciliation for Resident # 15's Oxycodone 5 MG every 6 hours as needed. The bingo card had 2 tablets and the controlled drug disposition log documentation on 06/04/2024 at 6:45 AM Staff E, RN gave 2 tablets to Resident #15. Staff E, RN was asked to explain the discrepancy and explained she had actually given the medication at 5:45 AM not 6:45 AM. Review of the monitoring for the effectiveness of the medication showed no documentation in the Electronic Medication Records (EMAR), The nurse revealed she was not aware of that section in the EMAR. The Unit Manager acknowledge the discrepancy. On 12/02/2024 at 7:00 AM, the Director of Nursing (DON) was informed of the above concerns. When the nurse is giving a narcotic the nurse must check in the computer to make sure the order is right, when the medication is removed the nurse must immediately sign the amount on hand in the book. After the medication is given the nurse should sign the electronic health record; and in 30 minutes document if the medication was effective or not. Review of the facility's policy titled Controlled Substances published 09/26 2024 include but not limited to: Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage. b. Medication administration records.

Based on observations, record review and interview, the facility's staff failed to implement infection prevention control policies and procedures as evidenced by failure to handle soiled linen and garbage to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all residents residing in the facility. Observation on 12/02/2024 at 4:55 AM, several clear plastic bags containing trash and soiled linen were observed on the floor in the facility's hallways and resident's doorways. On 12/02/2024 at 4:57 AM during an observation on the east wing Certified Nursing Staff (CNA) Staff H was observed placing soiled linen in a bin and then returned few minutes later to remove clean linen from the clean linen cart that was noted beside two bins (a gray bin and a white bin). On 12/02/2024 at 7:11 AM, Staff H, CNA explained; the soiled linens and garbage should be placed in plastic bags and then in bins in the biohazard room. One bin is for the soiled linen and one for garbage. Staff H stated: Soiled items should never be on the floor in the bag for infection control. On 12/02/2024 at 4:57 AM Staff G, CNA was observed pulling two bags on the floor along the hallways from the west wing to the east wing; one bag had soiled linen, and one bag had trash. Staff G stated: I know the bags should not be on the floor. On 12/02/2024 at 4:58 AM on the west wing Staff S, CNA was observed with bags containing soiled linen and trash on the floor. Staff S exited a resident's room with soiled adult briefs in her gloved hands and placed them in a plastic bag on the floor close to the clean linen cart. On 12/02/2024 at 5:04 AM Staff Q, CNA was observed placing soiled linen and trash in plastic bags at residents' doorways Interview on 12/02/2024 at 7:53 AM, Staff G, CNA revealed she sets up two bags, one for dirty linens and one for the garbage. The bags are knotted and taken to the biohazard room and placed in its specific bin. Review of the facility's policy published 11/24/2024 titled: Laundry and Bedding, Soiled; Policy Statement- Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Policy Interpretation and Implementation. Handling: 1. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). a. Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). d. Staff handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons.

Based on observation, interview and record review, the facility failed to store food under sanitary condition as evidence by: 1) failure to ensure reach-in freezer and the reach-in refrigerators in the kitchen contained thermometers on the inside and 2) failure to ensure the resident's foods were labeled and dated. 3)The refrigerators were not working properly, and the refrigerator contained opened milk cartons in the snack/nourishment refrigerators on the resident's units. This has the potential to affect 163 out of 171 residents who eat orally residing in the facility at the time of the survey and potential to affect 55 out of 56 residents who eat orally residing on the East Wing. The findings included: 1) Observation of the initial kitchen tour on 1/16/24 at 8:34 AM with the Registered Dietitian (RD) and the Kitchen Supervisor revealed the following: 1) Reach-in freezer temperature outside was -4 degrees F and for the inside temperature, there was no thermometer noted. The reach-in freezer contained ice cream and desserts; 2) Reach-in Refrigerator #1 temperature outside was 40 degrees F and for the inside temperature, there was no thermometer noted. The reach-in refrigerator #1 contained sandwiches and juices and 3) Reach-in Refrigerator #2 temperature outside was 40 degrees F and for the inside temperature, there was no thermometer noted. The reach-in refrigerator #2 contained milk shakes, nectar juices and desserts. The facility was cited in November 2022 for failing to store, prepare, distribute, and serve food in a sanitary manner. Interview with the Kitchen Supervisor on 1/16/24 at 8:36 AM. She stated, There is no thermometer kept on the inside of the reach-in freezer and refrigerator. We only use the temperature on the outside of the reach-ins. Record review of the Refrigerators and Freezers Policy and Procedure (revision date November 2022); Policy Statement-The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation; Policy Interpretation and Implementation-1) Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees Fahrenheit (F) and freezers keep frozen foods frozen solid and 10) Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, excess condensation and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance and or cleaning schedules will be monitored for compliance. 2) Observation of the East Wing Nourishment Pantry on 1/17/24 at 10:40 AM revealed the refrigerator was 60 degrees F (Fahrenheit) and the freezer was 54 degrees F. The refrigerator had three plastic bags which contained resident's foods that were not dated and labeled. A pint carton of whole milk was opened and not dated. The Freezer was noted empty with condensation. Photographic evidence submitted. Observation and interview with Staff M, Registered Nurse (RN) North and East Unit Manager on 1/17/24 at 10:42 AM of the East Wing Nourishment Pantry Refrigerator. She stated, The resident's food should be dated and labeled, the opened container of milk should not be there, and the refrigerator temperature should be 41 degrees and the freezer should be 0 degrees F. Interview with the Registered Dietitian (RD) on 1/17/24 at 11:00 AM. She stated, The kitchen is responsible for the refrigerators in the nourishment pantries. She confirmed that the refrigerator temperature should be 40 or below and the freezer temperature should be 0 or below; the opened carton of milk should not have been in the refrigerator and the resident's food should be labeled and dated. Record review of the East Wing Nourishment Refrigerator and Freezer Temperature Log for January 2024 documented the following: 1/17/24 7:00 AM Refrigerator temperature was 39 degrees F, and the Freezer temperature was -2 degrees F.

Based on observations, interviews and record review the facility failed to ensure the refrigerator in the East Wing Nourishment Pantry used to store resident's food was working properly. This has the potential to affect 55 out of 56 residents who eat orally residing in the East Wing at the time of the survey. The findings included: Observation of the East Wing Nourishment Pantry on 1/17/24 at 10:40 AM revealed the refrigerator was 60 degrees F (Fahrenheit) and the freezer was 54 degrees F. Photographic evidence submitted. Observation and interview with Staff M, Registered Nurse (RN) North and East Unit Manager on 1/17/24 at 10:42 AM of the East Wing Nourishment Pantry Refrigerator. She stated, The refrigerator temperature should be 41 degrees and the freezer should be 0 degrees F. Record review of the East Wing Nourishment Refrigerator and Freezer Temperature Log for January 2024 documented the following: 1/17/24 7:00 AM Refrigerator temperature was 39 degrees F and the Freezer temperature was -2 degrees F. Interview with the Registered Dietitian (RD) on 1/17/24 at 11:00 AM. She stated, The kitchen is responsible for the refrigerators in the nourishment pantries. She confirmed that the refrigerator temperature should be 40 or below and the freezer temperature should be 0 or below. Record review of the Refrigerators and Freezers Policy and Procedure (revision date November 2022); Policy Statement-The facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation; Policy Interpretation and Implementation-1) Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees Fahrenheit (F) and freezers keep frozen foods frozen solid and 10) Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, excess condensation and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance and or cleaning schedules will be monitored for compliance.

Based on observation, record review and interview, the facility failed to treat residents with respect and dignity by the right to be free from any physical restraints for one (Resident number 27) out of two residents who triggered for physical restraints. The findings included: Initial observation of Resident number 27 on 1/16/24 at 10:10 AM revealed the resident lying in bed with the television on and her left hand contracted with a long sock covering up to the elbow. Second observation of Resident number 27 on 1/17/24 at 7:58 AM revealed the resident lying in bed with the television on and her left hand contracted with a long sock covering up to the elbow. Third observation of Resident number 27 on 1/17/24 at 8:22 AM with Staff A, Registered Nurse (RN) revealed the resident lying in bed with the television on and her left hand contracted long sock covering all the way up to the elbow. Staff A, RN removed the elbow long sock, and the left hand was contracted. Staff A stated, I don't know why the sock is on the left hand. Maybe the family wants it there for comfort. Review of the Demographic Face Sheet for Resident number 27 documented the resident was admitted on [DATE] with a diagnosis of atherosclerotic heart disease, dementia, diabetes mellitus, chronic kidney disease, heart failure, encephalopathy, and hypertension. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident number 27 documented the resident's Mental Status (BIMS) Summary Score was not scored, indicating severed cognitive impairment and she required dependent assistance for ADL (activities daily living), and no restraints were used. Record review of the Use of Restraints Policy and Procedure (revised 8/2023) documented: Policy Statement: Restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls; Policy Interpretation and Implementation: 1) Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body and 4) Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. Interview with the Director of Nursing (DON) on 1/17/24 at 10:28 AM. She stated, I was informed about the resident having a sock over her left hand. I spoke to the CNA, and she said she didn't want the resident to be cold and she put the sock on. I immediately educated her that we could get gloves to make her hands warm and if the resident takes off the blanket, we just put it back on. Our policy is not to use the sock because that is considered a restraint. I will be providing one to one education with her now. Interview with Staff B, Certified Nursing Assistant (CNA) on 1/17/24 at 10:30 AM via a Spanish translator. Staff B revealed she placed the sock on the left hand of the resident. She thought she was making her comfortable because her hands were cold. She now knows she is not to do that. She received education on not putting a sock on the resident's hand. Review of One-to-One Education In-Service form dated 1/17/2024 documented Staff B, CNA received education about physical restraints.

Based on record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) for hospice for one Resident (#307) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The Findings Included: On 01/17/24 at 02:49 PM, review of Resident #307's MDS revealed no Significant Change MDS was completed for the resident's status change to hospice effective 12/11/23. Review of the Physician's Orders Sheet for January 2024 revealed Resident #307 had orders that included but not limited to: admitted to Hospice effective (12/11/23) for diagnoses late effect Cerebral Vascular accident (CVA). Prognosis is for a life expectancy of 6 months or less if terminal illness runs its normal course, and Start continuous care 1/15/24 due to uncontrollable vomiting/ Intravenous hydration. Further review of the medical records for Resident #307 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting the right dominant side. Interview on 01/18/24 at 08:39 AM, the Minimum Data Set (MDS) Coordinator, (Staff E) stated: I am aware that when a resident goes on hospice we have to do a significant change report, I see here in the medical records there is no significant change report, I will have to open a significant change MDS to capture the change in the resident to hospice. Staff E then opened a Significant Change MDS for Resident #307 on 1/18/23 during the interview with the surveyor. Review of the facility's policy titled MDS Completion and Submission Timeframes revision date July 2017 indicated: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The assessment coordinator or designee is responsible for ensuring that the 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 . based on the current requirements in the Resident Assessment Instrumental Manual.

Based on observations, interview, and record review the facility failed to accurately code the Minimum Data Set (MDS) for one Resident (#100) out of 34 sampled residents. As evidenced by inaccurate coding of MDS section B for Corrective lenses. There were 171 residents residing in the facility at the time of the survey. The Findings included: During observation on 01/16/24 at 09:21 AM Resident #100 was in bed eating breakfast with dark glasses on. On 01/17/24 at 09:07 AM Resident #100 was observed in bed asleep with dark glasses on, call light on the bed and no distress noted. On 01/18/24 at 09:15 AM Resident #100 had a room change and was observed in bed in new room with dark glasses on. Record review of Resident #100's Quarterly Minimum Data Set (MDS) dated [DATE], Section B for Vision and Hearing in subsection B 1200 documented the resident has no corrective lenses. Review of the Physician's Orders Sheet for January 2024 revealed Resident #100 had orders that included but not limited to: May use treat in place protocols and activity level as tolerated. Further review of the medical records for Resident #100 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified glaucoma, low vision right eye category 2, and blindness left eye category 4. Record review of Resident #100 's Care Plans Reference Date 01/09/24 documented Resident has impaired vision and is at risk for falls and complications related to the aging process secondary to glaucoma, blindness left eye. Wears glasses. Interventions Include- Arrange consultation with eye care practitioner as required. Cleanse eyes with care daily and follow up with doctor for any concerns. Explain care and services before providing them. Keep resident in supervised area when out of bed. Inform doctor if sign/symptoms of pain, discomfort, or infection. Observe and report changes in vision status to doctor. Provide resident in an environment with adequate lighting and clutter free. Adapt environment to resident's needs. During an interview on 01/18/24 at 08:36 AM the MDS Coordinator (Staff E) stated that Social Services completed section B of the MDS, maybe at the time of the evaluation Social Services did not see the resident with the glasses on; I will go and personally look at the resident and make the modification to the MDS as soon as possible. Review of the facility's policy titled MDS Completion and Submission Timeframes revision date July 2017 states: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The assessment coordinator or designee is responsible for ensuring that the 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 Instrumental Manual.

Based on record review and interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was revised following admission for one resident (#107) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The findings Included: During observation on 01/16/24 at 09:57 AM, Resident #107 was in bed well-groomed and had a cell phone in her hand. On 01/19/24 at 08:45 AM, Resident #107 was observed on a medical stretcher and leaving the facility, accompanied by two attendants. Record review of Resident #107's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: MI or suspected MI (check all that apply) - no mental Disorders checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related Neurocognitive disorder - no. Section III Not a provisional admission. Section IV No diagnosis or suspicion of SMI or ID indicated. Level II PASRR evaluation not required. PASRR Level I completed by and Registered Nurse (RN) at a local hospital dated 11/6/2023. Record review of Resident #107's Psychiatrist Evaluation dated 11/13/2023 revealed a mental status examination was performed that showed Resident 107 was pleasant, cooperative, very tearful, overwhelmed, clear, coherent, reliable historian, admits to seeing people not there that hurt her, superficial, slowed. Diagnoses: Major Depression recurrent with psychotic features moderate anxiety, follow up in one month. Medications- Psychoactive Medications: Quetiapine 50 mg (milligrams) every night, Sertraline 100 mg each morning. Start Hydroxyzine 10 mg every day. Review of the medical records revealed Resident #107 was originally admitted to the facility on [DATE], readmitted on [DATE] and discharged from the facility on 1/19/2024. Resident # 107's clinical diagnoses included but not limited to: Major Depressive Disorder, Anxiety Disorder and Psychosis. Review of the current Physician's Orders revealed Resident #107 had orders that included but not limited to: Sertraline HCl 100 MG Tablet give one tablet by mouth one time a day for Depression dated 11/8/2023. Record review of Resident # 107's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section A for Identification Information revealed resident is not currently considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and or intellectual disability or a related condition. Section C for Cognitive Patterns documented Brief Interview for Mental Status score (BIMS), 15 on a 0-15 scale indicated the resident was cognitively intact. Section I for Active Diagnosis documented Psychotic Disorder. Section O for Special Treatments, Procedures and Programs revealed occupational and physical therapy were received while a resident. Record review of Resident #107 's Care Plans initiated date 06/16/2022 and revised date 11/9/2023 revealed: uses anti-anxiety medications related anxiety disorder. Interventions included: Consult with pharmacy, Medical Doctor (MD) to consider dosage reduction when clinically appropriate. Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Monitor/record occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Antianxiety side effects: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. Paradoxical side effects: Mania, Hostility, and rage, Aggressive or impulsive behavior, Hallucinations. Resident 107 is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips, and legs. Monitor for safety. Resident #107 uses antidepressant medication related to Depression. Interventions included: Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to MD as needed (PRN) and ongoing for signs and symptoms (s/s) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Offer nonpharmacological interventions such as conversation, hand massage, diversional activities, music therapy, redirection, reassurance, education on deep breathing and relaxation techniques, or assist to a quieter environment. During an interview on 01/18/24 at 12:00 PM, the Director of Nursing (DON) when asked about the PASRR process at the facility the DON reported that all residents' most current PASRRs are in the electronic medical record and residents' physical charts. Registered Nurse (Staff G) is responsible for checking PASRRs and updating when a resident is admitted to facility. On 01/19/24 at 12:01 PM when asked about the PASRR process at the facility Staff G stated she is responsible for updating PASRR and Resident 107's most updated PASRR is located on the electronic medical record and the residents' physical charts. On 01/19/24 at 1:02 PM. The surveyor was approached by Staff G and given a PASSR for Resident #107, dated 1/18/2024 with appropriate diagnosis checked, and signed by Staff G. On 01/19/24 at 8:23 AM DON stated the PASRR process at the facility is that all new admissions from the hospital come to facility with a PASRR included in the admissions packet. The admissions office brings the PASSR to the morning meeting the next day and it is reviewed and updated by the interdisciplinary team. The interdisciplinary team includes social services, admissions, rehabilitation team, administrator, and unit managers. The DON further stated that each PASRR is reviewed to ensure the diagnosis matches the patient's hospital record, medications and an initial psych evaluation is scheduled. The DON informed that Resident #107 level I PASRR did not have any diagnosis checked. The DON stated that she does not know how the diagnosis for Resident #107 was omitted from the PASRR and that she plans to add additional personnel to assist with updating PASRR to ensure accuracy. On 01/19/24 at 08:46 AM Staff G stated the PASRR for newly admitted residents are reviewed during the morning meetings to ensure all diagnosis are updated and information matches from hospital records and medications. Residents' PASRR are updated on an ongoing basis whenever there is a change, she reviews physician orders daily and psychiatric evaluations to update PASRR. When the surveyor discussed with Staff G that Resident #107's level I PASRR was incomplete. Staff G stated the diagnosis for Resident #107 was omitted from the PASRR dated 11/6/2023 by mistake due to the Resident #07's frequent hospitalization s. On 01/19/24 at 08:50 AM the admissions director stated that when a resident is readmitted from the hospital, a new PASRR is not received from the hospital; during morning meetings all readmissions' PASRR are reviewed. Review of the facility's PASRR Policy and procedure published 4/21/2022 general statement of Policy: It is the policy of the facility that all residents have the required pre-admission screen prior to admission to the facility and any time that there is a significant change that has bearing on the resident's specialized service needs. The facility will protect the rights of the individuals by reviewing resident needs prior to admission to determine if specialized and services can be met by the facility. The facility will also protect the rights of facility residents by ensuring that identified specialized developmental and mental health services can be appropriately provided at the facility. Procedure: a. Prior to a resident's admission, the Admissions department/ designee will obtain: 1. A Screen and Level I Referral since the resident was referred to facility for rehabilitation. 2. A Level II if the Level I Referral indicates that the resident is known to be affected by serious mental illness and or mental retardation/ developmental disability per the guidelines. b. Upon admission the Screen will be incorporated into the resident's clinical record.

Based on record review and interview, the facility failed to develop and implement a hospice care plan in a timely manner for one resident (#307) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The Findings Included: Review of the care plans with reference date 9/29/23 for Resident #307 revealed the hospice care plans created, were completed on 1/16/24, the first day of initial observation of the resident by the surveyor. The care Plans documented: Resident is at end of life, diagnosis of terminal illness and have chosen Hospice care. Date Initiated: 01/16/2024, Revision on: 01/16/2024. Interventions include-Administer medications per physician orders, Assess and treat Pain, assess emotional and spiritual needs of resident/family/caregiver, and meet same when possible and provide comfort measures and honor preferences when possible. Review of the Physician's Orders Sheet for January 2024 revealed Resident #307 had orders that included but not limited to: admitted to Hospice effective (12/11/23) for diagnoses late effect Cerebral Vascular Accident (CVA). Prognosis is for a life expectancy of 6 months or less if terminal illness runs its normal course and start continuous care 1/15/24 due to uncontrollable vomiting/ Intravenous hydration. Further review of the medical records for Resident #307 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting the right dominant side. During an interview on 01/18/24 at 08:39 AM, the Minimum Data Set (MDS) Coordinator, (Staff E) stated: I am aware that when a resident goes on hospice we have to do a significant change report, I see here in the medical records there is no significant change report, I will have to open a significant change MDS to capture the change in the resident to hospice. Staff E then opened a Significant Change MDS for Resident #307 on 1/18/23. Staff E stated the hospice care plans were created on 1/16/23 either by review of the medical chart or the resident's orders. We have three (3) MDS staff and any one of us could create the care plans. Interview on 01/18/24 at 08:47 AM, the MDS Coordinator, (Staff F) stated: I saw that the resident had an update in his orders for hospice on 1/16/23, so I added a care plan for hospice for this resident. Sometimes I create the care plans by looking at the updated orders, we get a printout daily for all residents with updated orders, if needed we update the care plans with the new orders, and if the resident's MDS is currently open we update the MDS also at that time. Review of the facility's policy titled Care Plans, Comprehensive Person Centered revision date March 2022 states: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Interpretation and Implementation 2. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observations, interviews, and record review the facility failed to ensure oxygen therapy was administered accurately as ordered for one out of two sampled residents (Resident #105) who were investigated for oxygen administration. This deficient practice has the potential to affect all residents who are on oxygen therapy. The findings included: Observation on 01/16/2024 at 08:22 AM showed Resident #105 was lying down on her bed while receiving oxygen (O2) via nasal cannula. Further observation showed the oxygen was running at 1 liter per minute (LPM). (Photographic evidence obtained) Observation on 01/18/2024 at 08:19 AM showed Resident #105 was lying on her bed while receiving oxygen (O2) via nasal Cannula. Observed a third-party staff from a hospice care service was at Resident #105's bedside. Further observation showed the oxygen was running at 1 liter per minute (Photographic evidence obtained). Review of Resident #105's face sheet revealed an initial admitted [DATE] and a re-entry date of 10/25/2023. Review of the physician's orders revealed an active order created on 01/10/2024 noting Consult to Respiratory Therapist for Incentive Spirometry. Also, an order placed on 01/13/2024 noting O2 at 3 liters per minutes via nasal cannula - every shift for O2 Supplement. Review of Resident #105 quarterly MD'S (Minimum data set) assessment dated [DATE] revealed in Section C: Cognitive Patterns BIMS (Brief Interview for Mental Status) score of 00 out of 15 that suggests severe cognitive impairment and Section J: Health Conditions showed shortness of breath or trouble breathing when lying flat. Review of Resident #105's clinical diagnoses included, but were not limited to, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hyperlipidemia (unspecified), chronic ischemic heart disease (unspecified), unspecified systolic congestive) heart failure, pulmonary hypertension (unspecified), acute kidney failure (unspecified), major depressive disorder (single episode, unspecified), hypothyroidism (unspecified), osteomyelitis (unspecified), essential (primary) hypertension, unspecified dementia, Alzheimer's disease (unspecified), anemia (unspecified), gastro esophageal reflux disease without esophagitis. During an interview with Staff I, Licensed Practical Nurse (LPN), on 01/19/2024 at 11:39 AM regarding the oxygen level for Resident #105, Staff I stated, According to the doctor's orders, the oxygen level is supposed to be 3 liters per minute, and it is continuous. I check it when I'm coming in between 07:15 AM to 07:30 AM. Basically, when I do the round, I check them. In my experience, the only way it can move down or up if someone moves it. It has a button to control it. Yesterday I wasn't here, Tuesday I wasn't here. My shift, I always check, I don't know if the other nurses check. Staff I then stated that Staff D, Registered Nurse (RN), worked On Thursday January 18, and Staff K, RN, worked Tuesday January 16. On 01/19/2024 at 12:17 PM, The Director of Nursing stated that the nurses suppose are supposed to check the physician's orders and monitor the oxygen level for the residents. She then stated that if the resident is receiving hospice, the hospice nurse is supposed to monitor the oxygen level, and she has a respiratory therapist who is supposed to monitor the oxygen level as well. She further stated that she did not know what might cause the oxygen level to be at LPM. She then stated, Sometimes, when they clean the machine, they wipe it, that could be a possibility of the reason it was so low. Review of the facility's policy and procedures relating to Oxygen Administration revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. Steps in the Procedure: 7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 8. Turn on the oxygen. unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, record review and interviews. The facility failed to ensure medications were securely stored as evidenced by four broken and three loose pills found on two out of four carts checked. There were 71 residents residing in the facility at the time of the survey. The findings included: On 01/17/24 at 02:18 PM, in an observation and interview with Registered Nurse (RN) Staff A on the North Wing's medication cart one, showed inside the cart two (2) broken pieces and three (3) white pills (stamped:C-128, F/91, T/07) were found. When asked about the facility's policy regarding loose pills found on medication carts and the cleaning of medication carts. Staff A, RN stated, Every day I clean my cart. When I receive my cart, I check the resident's insulins, check for expired medications, and refill medications. I check my cart in the morning and in the middle of the day to clean it. Every shift is to clean medication carts. I'm going to place the loose pills in the drug buster. On 01/17/24 at 03:16 PM; in an observation and interview with Staff L, RN on North Wing's medication cart two revealed two (2) half pills were found in the cart. When asked about the facility's policy regarding loose pills found and cleaning of medication carts. Staff L, RN stated, I clean my medication cart every morning. I count narcotics and check my medications for expiration dates. I will throw these medications away in the drug busters. On 01/19/24 at 11:00 AM, the Director of Nursing was asked about the facility's policy for loose pills found in medication cart. The Director of Nursing stated, I work with the nurses to ensure their medication carts are cleaned. The nurses clean them every day during their shifts. We have two shifts that work per day. Review of the facility's policy titled Medication Labeling and Storage. Published 5/19/2023. The Policy statement stated the facility stores all medication and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. In the section titled Policy Interpretation and Implementation, Medication Storage, 1) Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. 2) The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review, the facility failed to ensure that menus are developed and prepared to meet residents' choices including their cultural and ethnic needs for one (Resident number 207) out of three residents who triggered for food. The findings included: Initial observation and interview with Resident number 207 on 1/16/24 at 9:47 AM revealed the resident sitting up in bed, watching television and eating breakfast which her daughter brought in. The resident stated, They have been giving me Cuban food and I don't eat that. I have told them that I don't like it. My daughter has to bring me food every day to eat. Record review of the Demographic Face Sheet for Resident number 207 documented the resident was initially admitted on [DATE] with a diagnosis that include but not limited to anemia, diabetes mellitus, neuropathy, gastro esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease, osteoarthritis, depression, insomnia, anxiety disorder, major depressive disorder, and gastrointestinal hemorrhage. Review of the Minimum Data Service (MDS) Admission assessment dated [DATE] for Resident number 207 documented the resident's Mental Status (BIMS) Summary Score was 13, indicating no cognitive impairment and able to make her needs known and she required independent to supervision assistance for ADL (activities daily living) and eating. Review of the Physician's Order Sheets (POS) dated December 2023 and January 2024 for Resident number 207 documented the resident was on a CCD (Carbohydrate Control Diet), NAS (No Added Salt) diet, Regular texture, and Thin liquids consistency. Review of the Nutrition care plan (written 1/01/2024) for Resident number 207 documented the following: Focus: Resident is at high nutrition risk due to multiple chronic and acute health complications such as GI (gastrointestinal) bleeding, Dehydration, HTN (hypertension), Hyperlipidemia, DM (diabetes mellitus), GERD (gastroesophageal reflux disease); Goal: Resident will maintain weight plus/minus 2-3% (percent) thru NRD (next review date) with no further loss by 5% in 30 days; 7.5% in 90 days; 10% in 180 days; Interventions: Diet: CCD, NAS, Regular, Thin liquids; Honor resident's food/fluid preferences. No cream cheese, no sour cream. No Cuban food, only American foods. Second observation of Resident number 207 on 1/18/24 at 12:35 PM revealed the resident sitting up in bed watching television and waiting for lunch to be served. Her lunch arrived at 12:38 PM and her lunch consisted of Pork Chunk, [NAME] Rice, Capri Blend Vegetables, Pinto Bean Soup and Tropical Fruit. The meal ticket documented Dislikes: No Cuban food and Preferences: Likes American food. The resident refused to eat the lunch. Photographic evidence submitted. Interview with the Registered Dietitian (RD) on 1/18/24 at 12:42 PM. She reviewed the meal ticket. She stated, She should not have Cuban food, only American food. She offered the resident an alternative meal. Interview with the Kitchen Supervisor on 1/19/24 at 9:46 AM. She stated, The dietitian goes to her room every day to write down what she wants for breakfast, lunch and dinner. We go by what she has told the dietitian. Interview with the RD on 1/19/24 at 9:49 AM. She stated, We will document her likes of foods she wants to eat and her dislikes of foods. We will try to accommodate her.

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F645 PASRR (Preadmission Screening and Resident Review) for Individuals with a serious mental illness (SMI), intellectual disability(ID), F695 Respiratory/Tracheotomy Care and Suctioning, and F812 Food Procurement, Store/Prepare/Serve-Sanitary. This deficiency has the potential to affect 171 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 11/17/2022, F645 PASRR (Preadmission Screening and Resident Review) for Individuals with a serious mental illness, intellectual disability, F695 Respiratory/Tracheotomy Care and Suctioning, and F812 Food Procurement, Store/Prepare/Serve-Sanitary were cited. Interview with Administrator and the Director of Nursing on 01/19/2024 at 12:15 PM. The Administrator stated that the QAPI (Quality Assurance and Performance Improvement) meetings are held on the third Tuesday of each month. Record review of the facility's policy and procedure revealed. Vision: Our vision is to become the preferred pos-acute care and long-term care provider in our community we serve. We commit to improving the lives of the people entrusted to our care through clinical excellence and extraordinary service offered in an atmosphere of compassion, hospitality, and respect for the dignity of each person. Mission: Our mission is to foster and provide unprecedent level of genuine care and customer service for our communities' rehabilitation and nursing needs, in a soothing, tranquil, and state-of-the-art environment. Performance Improvement Projects (PIPs): The QAA committee will review data input on a monthly basis to look for potential topics for PIPs. We will monitor and analyze data, and review feedback and input from residents, staff, families, volunteers, providers, and stakeholders. We will look at issues, concerns, and areas that need improvement as well as areas that will improve the quality of life and quality of care and services for the residents living and staying in our facility. Factors we will consider high risk, high volume, or problem prone areas that affect health outcomes, quality of care and services, and areas that affect staff. Systematic Analysis: Our uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, any change that is made and has the potential to have a broader impact than intended. The impact of all changes to specific system or processes are reviewed and assessed for both intended and unintended consequences/outcomes. The QAPI committee monitors progress to ensure that intervention or actions are implemented and effective in making and sustaining improvements by choosing indicators that tie directly to the new action and continue ongoing periodic measurements. Scope: Our facility provides services across the full spectrum that have an impact on the clinical care and quality of life for our residents. All departments and services will be involved in QAPI activities and the facility efforts to continuously improve services and overall resident outcomes. On an annual basis, and as needed, a Facility Assessment will be conducted to include an overview of the services and care areas that are provided. Any new service areas or changes in population or services to our residents will be included in our QAPI Plan.

Based on interviews, observations and records reviewed, the facility failed to provide care, services, and supervision to prevent suicide for one resident (Resident #1) out of 10 residents sampled. The facility failed to effectively monitor behaviors related to Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . While unsupervised in his room, Resident #1 suffocated himself by placing a trash bag over his head, resulting in death by suicide. On [DATE], it was determined the findings of the survey posed immediate jeopardy to the health and safety of all residents admitted to the facility. The Findings Included: Record review of the Facility's abuse policy {Review dated [DATE]} revealed; It is the policy of the facility to protect all residents from physical or mental abuse, involuntary seclusion, neglect or misappropriation of personal property .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Preventive measures included: The assessment, care planning, and monitoring of residents with needs and behavior which might lead to conflict or neglect . Record review of the facility's policies and procedures revealed the {undated} policy Name: [CONDITION(S)] Medication. The General Statement of Policy noted; [CONDITION(S)] medications include any drug that affects brain activities associated with process and behavior, including anti-anxiety/hypnotic, anti psychotic and antidepressant classes of drugs. Physicians and physician -extenders (Ex. Physician Assistant, Nurse Practitioner) will use [CONDITION(S)] medications appropriately, working with the interdisciplinary team nurse to ensure appropriate use, evaluation, and monitoring. Standards included: C. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . G. Psychopharmacological medications will be used to enhance the quality of life for the resident and will never be used for the purpose of discipline or convenience. Procedures followed by the Primary Care Physician, PA[Physician's Assistant], or NP [Nurse Practitioner] noted: 2. Documents rationale and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Evaluates with the interdisciplinary team, effects, and side effects of psychoactive medications within 14 days of initiating, increasing, or decreasing dose and during routine visits thereafter. Procedures Followed by the Psychiatrist / mental health included: item 1 indicated- May assist the facility in establishing appropriate guidelines for use, dosage and monitoring of [CONDITION(S)] medications. Item number 5 indicated- Help develop behavior management plans. Procedures Followed by Nursing: 1. Monitors [CONDITION(S)] drug use daily, noting any adverse effects such as increased somnolence or functional decline. 2. Will monitor for the presence of target behaviors on a daily basis. Behaviors will be documented as warranted. 3. Reviews the use of the medication with the physician and the interdisciplinary team on a quarterly basis to determine the continued presence of target behavior and or the presence of any adverse effects of the medication use. 4. AIMS [Abnormal Involuntary Movement Scale] will be performed on any resident on anti psychotic on a quarterly basis changes and will be reported to the physician. 5. May develop behavioral care plans that include individualized non-pharmacological interventions. Social Services: Coordinates the interdisciplinary team resident reviews of psychoactive medications. Record review of Resident # 1's face sheet revealed, he was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration and Treatment Record for Resident #1 revealed, medication included: [MEDICATION(S)] 1 mg (milligram) tablet ordered 1 tablet to be given by mouth at bedtime for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 50 mg tablet ordered 1 tablet to be given by mouth every day at bedtime for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 5 milligram tablet, ordered 2 tablets to be given by mouth twice a day for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the Comprehensive Minimum Data Set (MDS) and interview with the MDS coordinator, Staff H on [DATE], at 9:48 AM revealed, Resident #1 was readmitted to the facility on [DATE]. In his most recent comprehensive MDS, dated [DATE]. He had a score of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was able to verbalize his needs and was not cognitively impaired. Further review of the MDS revealed that Resident #1 had a clear speech pattern and was able to understand others as well as make self-understood. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plans for Resident #1 revealed a care plan dated [DATE]; Resident #1 exhibited behaviors of anxiety/agitation. Goals: Resident #1 will be able to display appropriate response to situations by next review date. Approaches included, Determine cause of anxiety, Observe for changes in mental status, mood and behavior, Notify MD [Medical Doctor] of changes as needed. Further review of the care plans showed that Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches included, observe for changes in mood, encourage verbalization of feelings, administer antidepressants as ordered. There were no care plans for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Behavior Monitoring Sheets for the months of July, August, September and [DATE], indicated that Resident # 1 was monitored for the behaviors afraid/panic. Related to the use of [MEDICATION(S)] 1 mg 1 tablet. There was no record to indicate that Resident #1 was monitored for any other behavior such as mood changes or danger to self. Review of Resident #1's behavior monitoring records showed no records to indicate that he was monitored for his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Behavior Monitoring Sheets showed the resident had multiple episodes documented as Afraid/Panic: During the Month of [DATE] ( Initiated on [DATE]) Resident #1 had a total of 9 episodes of Afraid/Panic. Five out of nine different episodes occurred between the hours of 7:00 AM to 7:00 PM, on [DATE], 17, 20, and 25. Four different episodes of Afraid/Panic occurred between 7:00 PM to 7:00 AM, on [DATE], 27 and 28. Interventions for each episode noted Routine, indicating that the facility's only intervention was the administration of his routine medication; [MEDICATION(S)] 1 mg tablet by mouth at bedtime. For diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of the Nurses Progress Notes from [DATE] to [DATE], showed no recorded documentation that addressed any of the episodes of anxiety exhibited by Resident #1. Review of behavior monitoring sheet for [DATE] (Initiated on [DATE]) showed no record and was left blank for [DATE], [DATE], and during the day shift (7:00 AM to 7:00 PM). The behavior sheet for [DATE]th, 2021, Indicated documented behavior Afraid/Panic was not monitored during that time. Further review of the behavior monitoring records for [DATE], revealed Resident #1 had 15 different episodes of Afraid/Panic during the evening shift (7:00 PM to 7:00 AM). The Afraid/Panic behaviors occurred on [DATE],10,11,13, 15, 16,17,18,19, 22, 23, 24, 25 and 29. Review of Nurses Progress Notes for [DATE] showed no record that addressed any of the episodes of afraid/panic exhibited by Resident #1. Review of behavior monitoring sheets for [DATE] for Resident #1 showed the resident continued to be monitored for episodes of Afraid / Panic. Resident #1 had a total of 17 different episodes during the month of September. Four out 17 different episodes of Afraid/Panic occurred between 7:00 AM to 7 :00 PM: on [DATE],4,and 5. The intervention noted Routine QHS (every night at bedtime) indicating that the facility's only intervention was the administration of his routine medication; [MEDICATION(S)] 1 mg tablet 1 tablet by mouth at bedtime. Further review of September's behavior monitoring record showed that Resident #1 had 13 out of 17 different episodes of Afraid/Panic during the evening shift (7:00 PM to 7:00 AM) that occurred on [DATE], 12, 13, 14, 17, 19, 20, 21, 24, 26,27 and 28. The intervention noted Refer to Nurses Notes . Review of the Nurses Progress Notes for [DATE] showed no record that addressed any of the episodes of afraid/panic exhibited by Resident #1. Review of the behavior monitoring sheet for [DATE], showed that Resident#1 had a total of three episodes of Afraid/Panic. Two episodes of Afraid/Panic occurred during the day shift (7:00 AM to 7:00 PM) on [DATE]st and on the day of his death, [DATE]nd. Resident #1 also had one episode of Afraid/Panic between 7:00 PM to 7:00 AM on [DATE]st, 2021. The interventions for each episode noted Routine QHS. indicating that the facility's only intervention was the administration of his routine medication; [MEDICATION(S)] 1 mg tablet by mouth at bedtime. Review of the progress notes for [DATE] showed no record that addressed the afraid/panic episodes exhibited by Resident #1. Further review the nurses progress notes dated [DATE] with time noted as 11:00 PM documented by LPN, Staff C revealed: Resident assigned CNA [Certified Nursing Assistant] was observed running over to me while I was doing my med pass as he verbalized code blue, I immediately assigned a staff member to call 911 as I grabbed the defibrillator machine. I assigned another staff member to get the crash cart. I ran to his room. The residents skin color was noted as pale whitish color, no pulse was noted resident was transferred from wheelchair to the bed, board was placed under the patient and CPR [Cardiopulmonary Resuscitation] was initiated. 911 arrived and EMT[Emergency Medical Technicians] pronounced his death. No obvious injuries were noted at the time of death. CNA assigned to this resident verbalized that he was unable to enter his room. The CNA stated he had to push very hard to open the door. CNA stated resident wheelchair was pushed against the door with patient sitting in the wheelchair. Trash bag was noted over his head. CNA stated he removed the trash bag to see if patient was not breathing. Patient was not breathing per CNA statement. CNA then verbalized to me and to the police how he found the patient. Family was notified by police. Police officer spoke to [Emergency Contact]. The medical examiner arrived and transferred residents' body out of the facility. Review of the investigative report and interview with the Clinical Regional Nurse on [DATE] at approximately 2:30 PM revealed, the regional nurse reviewed the facility's video recording as she investigated the event. She documented her observations of the video. The Clinical Regional Nurse reported that she reviewed the video recording on Tuesday or Thursday last week. The investigative report noted that on Saturday [DATE] at 2:54 PM Resident #1's Certified Nursing Assistant (CNA) (Staff A) went into the residents' room [room #] at 4:18 PM. Nurse (Staff B), Registered Nurse (RN)was passing meds, you can see her going in and out of rooms. At 4:30 PM the friend (Resident #4) leaves Resident #1's room. The video showed that at 4:52 PM meal was delivered to Resident #1's room. His Door remained open the whole time. At 5:21 PM the Nurse (Staff B) went into Resident #1's room. At 5:43 PM the CNA [Staff A] picked up the tray. Noted that he ate 100%. At 6:25 PM it appears the door is shut from inside the room. No one checked on the resident or attempted to enter the room from approximately 6:25 PM to 8:15 PM (Staff C, LPN) was scheduled to start her shift at 7:00 PM, no indication that she checked on Resident #1 until the CNA called her at around 8:15 PM. At 8:15 PM the CNA tried to get into the room and noted that the door was closed. The CNA tried to open the door, but it was blocked. (Staff A ) was in the room for a few second, leaves the area gets the nurse and the crash cart . The Regional nurse explained that the CNA had to push the door open and when he entered, he noted Resident #1 seated in his wheelchair, unresponsive with a bag over his head. The CNA stated that he pulled the bag off Resident #1 head and ran to get help. A code was called as well as 911, staff responded to this resident's room where they transferred him to the bed, a backboard placed, and CPR initiated. Law enforcement and EMT responded shortly thereafter and pronounced this Resident. The Residents body was transferred to the Medical Examiner's office. Interview on [DATE] at 3:53 PM with Staff A, Certified Nursing Assistant (CNA) revealed, he worked in the facility for about one year and floated on different units every week. He took care of Resident #1 on Friday, ([DATE]) and Saturday ([DATE]), when he died . Staff A, CNA explained that Resident # 1 was assigned to the Bed B at the window and Bed A by the door was empty. Staff A,CNA reported that Resident #1 was alert and liked to stay in his room alone with the door closed. He required assistance to go to the bathroom and remained in his room on isolation precautions. Staff A,CNA revealed his schedule for that weekend was on Friday, [DATE] he worked a double shift from 7:00 AM -3:00 PM and from 3:00 PM to 11:30 PM. He continued on Saturday [DATE] to again work from 7:30 AM to 11:30 PM. Staff A explained, on the day of the incident, ([DATE]) I came back from my break which is from 8:00 PM to 8:30 PM, when I came back and was doing my rounds and noticed that the door would not open. I spoke to one of the CNAs. He recommended; I pushed the door. I thought he might have blocked the door with something. When I finally opened the door, I noticed the resident was sitting in his chair with a plastic bag over his head. The wheelchair was locked. He normally had two trash containers, one on each side of his bed, with plastic bag inside of it. Once I opened the door, I notice the plastic bag on his head. I took the plastic bag; I threw it on the floor and cried for help. The floor nurse was on the hallway. We went to get the crash cart, She called code blue. The nurse and I transferred the resident from the wheelchair, they initiated the CPR. They all continued until the ambulance arrived. The police arrived they interviewed me. I could not leave the facility until after the detective interviewed me. Staff A, CNA explained that sometimes Resident #1 was aggressive and had behaviors like refusing care such as he refused a haircut and refused to shave and Staff A convinced Resident #1 and allowed Staff A to shave him. Staff A added not that long ago, maybe two weeks, [Resident #1] would sometimes get angry and yell at staff; like one time, he took off his gown and threw at me, I told the nurse on the floor about the behavior and asked her to come to the room and help me translate. I explained to [Resident #1] that I was here to take care of him, and that there was no need to be aggressive toward me, [Resident#1] understood and even apologized. On [DATE] at 12:15 PM, during an interview with the Director of Nursing ( DON) and the Clinical Regional Nurse, the DON explained; The nurses on the floor usually complete the behavior monitoring sheets. The nurses are the ones that monitor and document the behaviors, the CNA would report each behavior to the nurses. Behaviors that are reported and documented are behaviors that are unusual for the patient and any behavior that might put the patient in distress, such as anxiety. The plan of care for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . For activities, it is whatever the residents are interested in. Encourage them to talk about their feelings. Encourage socialization. Provide feedback to reinforce positive behaviors. Notify MD ( Medical Doctor) of changes as needed. Psych consult as needed and Administer antidepressants as ordered. During the interview, record review of Resident #1's clinical record showed, Resident # 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and Clinical Regional Nurse was asked about Resident #1's clinical record that showed no plan of care that specifically addressed his use of [CONDITION(S)] or his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The use of [MEDICATION(S)] requires we monitor for suicidal ideation. We monitor depending on the resident. We have residents that are verbally able to report, we look for verbalization, we also look at signs or symptoms. We document behaviors on the behavior sheet, the specific behavior that occurs and on the daily skill nurses' notes. When it comes to the [MEDICATION(S)] we would monitor for side effects which could include sleepiness, fatigue, abnormal coordination, depression. During the interview and continued record review of Resident #1's clinical record, the DON explained; We have behavior monitoring sheets for the use of [MEDICATION(S)], it shows that we monitor for behaviors Fear/Panic, anxiety kind of stuff. According to the nurse's documentation on the Behavior Monitoring Sheets Resident #1 had panic/anxiety episodes. The DON explained: The nurses and general staff reported that the resident was showing frustration over his health. He did not like the catheter. He did talk about it sometimes. He had anxiety on [DATE]st and 2nd. The only intervention was the medication as documented on the Behavior Monitoring Sheets .We do not have a behavior monitoring record for the use of antidepressants. The DON and Clinical Regional Nurse both agreed to review the residents record for any notes that addressed Resident #1's behaviors, and acknowledged there were no actual written notes that addressed any of the resident's behaviors or mood. Both the DON and the Clinical Nurse Manager agreed such documentation was necessary. On [DATE] at 12:05 PM, during an interview the Psychiatrist explained that Resident #1 gave no indication that he was depressed, and that the facility staff was usually very good at letting us know when there is any indication, not only present, but also past history, or any indication of clinical depression. They usually call me for an evaluation. I see most of the patients that are taking antidepressants, they usually generate a consult for me. If the patient had shown any signs or symptoms, indicating they had clinical depression or suicidal ideation, the staff would have notified me. The Psychiatrist acknowledged that he saw Resident #1 once, on [DATE] and that his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1's clinical record. The Psychiatrist explained that he met with facility staff and discussed residents behaviors and if any adjustments are needed. The Psychiatrist was asked about Resident #1's behaviors. The Psychiatrist reported he was not aware that Resident # 1 had any behaviors. Upon discussion of multiple documented episodes of afraid/panic noted on Resident #1's clinical records the psychiatrist reported he was not aware of any of the documented behaviors and stated that the nurses did not communicate said behaviors to him. The psychiatrist stated that the facility staff should have communicated any anxiety, afraid/panic episodes and other behavior exhibited by Resident #1 to him. If they tell me I would definitely do something. The nurses usually call me. They did not tell me about those episodes. Had I known, I would have definitely done something, would have gone to see him, maybe change the medication. On [DATE] at 2:51 PM, review of Social Services assessment dated [DATE] and interview with the facility's Social Services Staff; Social Services Director (SSD) and Social Services Assistant (SSA), Staff F, it was revealed that social services is responsible for assessing the residents upon admission, quarterly, and annually. The SSD revealed social services saw the residents often around the facility, assess for BIMS (Brief Interview of Mental Status) score, moods, and behaviors. The SSD stated he went to the resident's room to complete the initial assessment on [DATE]. Review of the social services note dated [DATE] indicated social services will be available to Resident #1 and family for support if needed . The Psychosocial and mood assessment indicated the resident had little interest or pleasure in doing things, frequency, 2 to 6 days. Feeling down depressed or hopeless, frequency, 2 to 6 days. Feeling tired or having little energy, frequency 7 to 11 days. Poor appetite or overeating, frequency 7 to 11 days. The Social Services Director explained they followed the questionnaire on the form Patient Health Questionnaire (PHQ-9) which asks about interest / pleasure in doing things, feeling down, depressed, or hopeless, trouble falling /staying asleep or sleeping too much, if tired, feeling little energy, feeling bad about yourself. [Resident #1's] assessment showed the score result for his mood was a six which indicated that the resident had a symptom of feeling tired having low energy, he had poor appetite, little interests in doing stuff and was feeling down. He was upset about the news. The SSD reported he did not address Resident #1's report that he was feeling down, Once I learned the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was already on antidepressant. I saw that he was already care planned. He was a patient that we saw in the hallway often, very social, attended therapy. I did not do anything, I asked the resident why he was depressed, he said it was about politics, there was not much I could do about that. I was not aware of panic attacks. The Social Services Director reported they usually learned about residents concerning behaviors during morning meetings and never knew that he had any behaviors. When asked why there was only one social services assessment and progress note in Resident #1's clinical record, the SSD responded, There must have been other progress notes, I don't know what happened to them. Interview on [DATE], at 10:01 AM with Staff B Registered Nurse(RN) reported working in the facility since January this year and normally worked with (Resident #1) three days a week, from 7:00 AM to 7:00 PM. The resident was alert and oriented times three. He communicated his needs well. He normally slept until about 9:00 AM/10:00 AM. He liked to participate in therapy and activities. He liked to come out of the room. On the day of the incident (Resident #1) was on isolation precautions due to a [CONDITION(S)] (Urinary Tract Infection). Staff B, RN stated, I worked from Thursday, [DATE]th, to Saturday [DATE]nd . I monitored for behaviors related to his use of [MEDICATION(S)], we monitored for panic attack, fear, or anxiety. I don't remember him having any behavior. He sometimes would get a little upset with the CNAs, asked that we closed the door, close the window, or yell, don't touch me! Generally, I document if the patient's behavior is constant. Normally, he was easily re-directed. Staff B, RN reported not being present when Resident #1 had the aggressive behavior of throwing his gown at Staff A, CNA. I did complete the behavior monitoring sheet for the resident on the days that I worked. I filled it out on [DATE]st and [DATE]nd, the day that he passed away. What I documented was that he had one behavior of anxiety. Staff B, RN explained, he was asking a lot about why he remained with the treatment, about the IV (Intravenous). He kept asking about it, although I had already spoken to him about it. The intervention, during the anxiety episode was teaching about the reason for the treatment, what was the reason, and why he remained in isolation. What I documented on the behavior monitoring sheets about afraid/panic episode was related to the antibiotic treatment, that he received the treatment and that it was effective. I did not document on the nurses notes that the resident was having an episode of anxiety because I did my action, I did not see him to be desperate, he allowed me to administer his IV treatment. Sometimes with the elderly, they usually ask a lot about their treatment. The episode of anxiety noted on him, was normal, expected. The purpose of the Behavior Monitoring Sheet is to follow for a prescribed antianxiety medication, and document the episodes related to the behavior, for which the resident is taking the medication. The intervention was 12 - Refer to nurses' notes. Staff B upon review of the records agreed there was no record to explain anything about the resident's mood or behavior. Staff B stated that: It's established that a patient can have at least three small episodes of anxiety, we take action if they have a big one. Big ones we would document on the nurses' notes. The purpose of the behavior monitoring sheet is to see if the medication seems effective throughout the month. What the behavior monitoring sheet shows is that the medication is effective. I documented that he had anxiety on [DATE]nd, 3rd, and 4th. The one episode could have been something like, I don't want to shower. I don't know the behavior. Staff B agreed that the documentation does not reflect the exact nature, or details of the behavior, she did not know, could not recall. Staff B added, I also documented no behavior on [DATE]th 10th, 11th, 16th, 17th, 24th, 25th, 26th. When I noticed the behavior, I did not report to anyone. I did not think that I needed to communicate it to the Psychiatrist. We did not monitor him for depression. I did not know he had any antidepressant or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On that day he seemed well, he did not seem depressed, he did not reject care, or complain of pain. Upon discussion of Resident #1's Diagnoses, Staff B, RN reported, I am surprised that he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Regional Nurse and discussion of surveillance video showed that staff B last saw the resident at approximately 5:21 PM. Record review revealed Resident #1 was under the care of Staff C Licensed Practical Nurse (LPN) one of the two times it was documented that Resident #1 called the police because he was in so much pain ([DATE]) and on the night that he committed suicide ([DATE]). On [DATE] attempted to conduct a telephone interview with Staff C, LPN on [DATE] at 12:13 PM and a voice message was left. On [DATE] at 5:04 PM telephone call was made again to interview Staff C. Staff C was interviewed by phone and was asked that we call back in 15 minutes. On [DATE] at 5:08 PM an incoming call was received from Staff C, she reported she misdialed and requested we call her back in 15 minutes. On [DATE] at 5:24 PM, during a telephone interview Staff C, LPN reported that Resident #1 never had any complaints and he never had any anxiety or depression when ask to clarify her notes that the resident had pain the call was disconnected. During a follow up telephone interview on [DATE] at 7:20 AM, Staff C was asked whether or not the resident ever expressed pain or showed any signs or symptoms of anxiety or depression while under her care, Staff C again reported, no, when asked about her handwritten nurses' notes dated [DATE], 12:00PM Staff C, stated: oh yeah, one time, I had to call the police because he was complaining of so much pain. Staff C was asked to clarify if she had called the police or if Resident #1 had called the police, staff C stated that Resident #1 was the one who called the police. Staff C stated: He did call the police! Staff C LPN explained; the police was called to help Resident #1 calm down while she helped him transfer to the hospital. Cross References F656 J, F694 D, and F742 J

Based on interviews, policy and records reviewed, the facility failed to implement, develop an effective care plan for the quality of care and treatments required by one (Resident #1) out of 10 sampled residents reviewed during this complaint investigation. The facility failed to develop a care plan to address Resident #1's pain and did not develop a care plan that addressed the Resident's use of [CONDITION(S)] medications [MEDICATION(S)] and [MEDICATION(S)]. The facility also failed to implement the Resident's care plan for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of these deficient practices, Resident #1 suffocated himself by placing a plastic trash bag over his head, resulting in his death by suicide. The Findings Included: Record review of the Facility's policies and procedures revised December 2016 titled; Care Plans, Comprehensive Person - Centered revealed the policy statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation noted: 1. The interdisciplinary team in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person -centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of the care plans for Resident #1 revealed, a care plan dated 08/10/2021; Resident #1 exhibited behaviors of anxiety/agitation. Goals: Resident #1 will be able to display appropriate response to situations by next review date. Approaches included, determine cause of anxiety, observe for changes in mental status, mood, and behavior, notify MD (Medical Doctor) of changes as needed . Further review of the care plans showed that Resident #1 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches included, observe for changes in mood, encourage verbalization of feelings, administer antidepressants as ordered. There were no care plans in Resident #1's clinical records for the use of psychotropics, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's behavior monitoring sheets for the months of July, August, September and October 2021, indicated that Resident # 1 was monitored for the behaviors afraid/panic related to the use of [MEDICATION(S)] 1 mg tablet. There was no recorded documentation to indicate that Resident #1 was monitored for any other behavior such as depression, mood changes or danger to self. Further review of behavior monitoring sheets revealed that Resident#1 had multiple episodes documented as Afraid/Panic: During the Month of July 2021 ( initiated on 7/15/2021) Resident #1 had a total of 9 episodes of Afraid/Panic. Five out of nine different episodes occurred between the hours of 7:00 AM to 7:00 PM, on July 15, 16, 17, 20, and 25. Four different episodes of Afraid/Panic occurred between 7:00 PM to 7:00 AM, on July 25, 26, 27 and 28. Interventions for each episode noted Routine, indicating that the facility's only intervention was the administration of ordered routine medication; [MEDICATION(S)] 1 mg tablet by mouth at bedtime that was ordered for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During the Month of August 2021, the behavior monitoring sheet showed no documentation (left blank) for August 6, August 7, and during the day shift (7:00 AM to 7:00 PM) of August 8th, indicating that the behavior Afraid/Panic was not monitored during that time. Further review of August's Behavior Monitoring record for Resident #1, showed that he had 15 different episodes of Afraid/Panic during the evening shift (7:00 PM to 7:00 AM) that occurred on August 8, 9, 10, 11, 13, 15, 16, 17, 18, 19, 22, 23, 24, 25 and 29, 2021. Review of nurses progress notes for the month of August 2021 (From 08/06 to 08/31/2021), showed no record that addressed any of the episodes of afraid/panic exhibited by Resident #1. For the Month of September 2021 (Initiated on 09/01/2021) Resident #1's behavior monitoring sheet showed the resident had a total of 17 different episodes during the month of September. Four out 17 different episodes of Afraid/Panic occurred between 7:00 AM to 7:00 PM: on September 2, 3, 4,and 5, 2021, the intervention noted Routine QHS (every bedtime). indicating that the facility's only intervention was the administration of his routine medication; [MEDICATION(S)] 1 mg tablet by mouth at bedtime. Further review of September's behavior monitoring record showed that Resident #1 had 17 episodes of Afraid/Panic. Resident #1 had 13 out of 17 different episodes of Afraid/Panic during the 7:00 PM to 7:00 AM shift on September 6, 7, 12, 13, 14, 17, 19, 20, 21, 24, 26, 27 and 28, 2021. The intervention noted Refer to Nurses Notes. Review of nurses progress notes for September 2021, showed no record that addressed any of the episodes of afraid/panic exhibited by Resident #1. The Behavior Monitoring Sheet dated October 2021, showed that Resident#1 had a total of three episodes. Two episodes of Afraid/Panic occurred during the day shift (7:00 AM to 7:00 PM) on October 1st and on October 2nd (the day of his death). He also had one episode of Afraid/Panic between 7:00 PM to 7:00 AM shift on October 1st, 2021. Interventions for each episode noted Routine QHS. indicating that the facility's only intervention was the administration of his routine medication; [MEDICATION(S)] 1 mg tablet, one tablet by mouth at bedtime. Review of the progress notes for October, showed no record that addressed the afraid/panic episodes exhibited by Resident #1. On 10/19/2021 at 12:15 P, during an interview and record review with the Director of Nursing (DON), and the Clinical Regional Nurse. The DON explained; the nurses on the floor usually complete the behavior monitoring sheets. The nurses are the ones that monitor and document the behaviors, the CNA would report each behavior to the nurses. Behaviors that are reported and documented are behaviors that are unusual for the patient and any behavior that might put the patient in distress, such as anxiety. The clinical records were discussed related to the Plan of care the DON explained diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Activities, whatever they are interested in encouraging them to talk about their feelings. Encourage socialization, provide feedback to reinforce positive behaviors. Notify MD of changes as needed. Psych consult as needed and Administer antidepressants as ordered. The DON and the Clinical Regional Nurse acknowledged Resident # 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and the Clinical Regional Nurse were apprised that Resident #1's clinical record showed no plan of care that specifically addressed his use of psychotropics or his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The use of [MEDICATION(S)] requires we monitor for suicidal ideation. We monitor depending on the resident. We have residents that are verbally able to report, we look for verbalization, we also look at signs or symptoms. We document behaviors on the behavior sheet and documentation for the specific behavior that occurs is also on the daily skill nurses' notes. When it comes to the [MEDICATION(S)] ([MEDICATION(S)]) we would monitor for side effects which could include sleepiness, fatigue, abnormal coordination, depression . The DON explained; We have behavior monitoring sheets for the use of [MEDICATION(S)], it shows that we monitor for behaviors Fear/Panic, anxiety kind of stuff. According to the nurse's documentation on the behavior monitoring sheets, Resident #1 had panic/anxiety episodes . The DON explained, the nurses and general staff reported that the resident was showing frustration over his health. He did not like the catheter. He did talk about it sometimes. He had anxiety on October 1st and 2nd. The only intervention was the medication as documented on the behavior monitoring sheets .We do not have a behavior monitoring record for the use of antidepressants. The DON and Clinical Regional Nurse both agreed to review the residents record for any notes that addressed Resident #1's behaviors, We did not notice any actual written notes that addressed any of the resident's behaviors or mood Both the DON and the Clinical Nurse Manager agreed such documentation was necessary. Interview on 10/20/2021 at 12:05 PM, the Psychiatrist explained that Resident #1 gave no indication that he was depressed, and that facility staff was usually very good at letting us know when there is any indication, not only present, but also past history, or any indication of clinical depression. They usually call me for an evaluation . I see most of the patients that are taking antidepressants, they usually generate a consult for me. If the patient had shown any signs or symptoms, indicating they had clinical depression or suicidal ideation, the staff would have notified me. The Psychiatrist acknowledged that he saw Resident #1 once, on 08/31/2021 and that his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He explained that he met with the facility staff and discussed the residents' behavior and if any adjustments are needed. When asked, the Psychiatrist reported he was not aware that Resident # 1 had any behaviors. Upon discussion of multiple documented episodes of afraid/panic noted on Resident #1's clinical record, The Psychiatrist reported he was not aware of any of the above-mentioned behaviors. The nurses did not communicate said behaviors to him. The Psychiatrist explained that the facility staff should have communicated any anxiety, afraid/panic episodes and other behavior exhibited by Resident#1. If they tell me I would definitely do something. The nurses usually call me. They did not tell me about those episodes. Had I known, I would have definitely done something, would have gone to see him, maybe change the medication . On October 21, 2021 at 10:01 AM, Staff B Registered Nurse(RN) revealed; she normally worked with Resident #1 three days a week from 7:00 AM to 7:00 PM. The resident was alert and oriented times three and communicated his needs well and normally slept until about 9:00 AM to 10:00 AM, participated in therapy and activities and liked to come out of the room. Staff B explained that on the day of the incident Resident #1 was on isolation precautions due to a Urinary Tract Infection ([CONDITION(S)]). Staff B, RN stated: I worked from Thursday, September 30th to Saturday October 2nd . I monitored for behaviors related to his use of [MEDICATION(S)], we monitored for panic attack, fear, or anxiety, I don't remember him having any behavior. He sometimes would get a little upset with the CNAs, asked that we closed the door, close the window, or yell, don't touch me! Generally, I document if the patient's behavior is constant. Normally, he was easily re-directed .I did complete the behavior monitoring sheet for the resident on the days that I worked. I filled it out on October 1st and October 2nd, the day that he passed away. What I documented was that he had one behavior of anxiety. Staff B, RN explained that Resident #1 kept asking about the IV (Intravenous) treatment. The intervention, during the anxiety episode was teaching about the reason for the treatment, what was the reason, and why he remained in isolation. Staff B stated that her documentation on the behavior monitoring sheets about the afraid/panic episode was related to the antibiotic treatment, that Resident #1 received the treatment and that it was effective. Staff B stated: I did not document in the nurses notes that the resident was having episode of anxiety, because I did my action, I did not see him to be desperate, he allowed me to administer his IV treatment. Staff B reported that the purpose of the behavior monitoring sheet is to follow for a prescribed anti anxiety medication, and document the episodes related to the behavior, for which the resident is taking the medication. The intervention was to refer to nurses' notes. Staff B agreed there was no record to explain anything about the resident's mood or behavior. Staff B stated: It's established that a patient can have at least three small episodes of anxiety, we take action if they have a big one. Big ones we would document on the nurses' notes. The purpose of the behavior monitoring sheet is to see if the medication seems effective throughout the month .what the behavior monitoring sheet shows is that the medication is effective. I documented that he had anxiety on September 2nd, 3rd, and 4th. The one episode could have been something like, I don't want to shower, I don't know the behavior. Staff B then agreed that the documentation does not reflect the exact nature, or details of the behavior, she did not know and could not recall the behavior. Staff B stated: I also documented no behavior on September 9th 10th, 11th, 16th, 17th, 24th, 25th, 26th. When I noticed the behavior, I did not report to anyone. I did not think that I needed to communicate it to the psychiatrist. We did not monitor him for depression. I did not know he had any antidepressant or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On that day he seemed well, he did not seem depressed. He did not reject care, or complaint of pain. Upon discussion of Resident #1's Diagnoses, Staff B reported: I am surprised that he had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I went in to see him at approximately 7:10 PM he was in his room, he asked we close the door. (Investigative report and interview with The Clinical Regional Nurse on 10/19/2021 at approximately 2:30 PM showed that per surveillance video, staff B last saw the resident in his room at approximately 5:21 PM). Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's clinical record showed no documentation to indicate that Resident #1 received said pain consult. Resident #1 returned from the hospital on 8/21/2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . for five days for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Cross References F600 J, F684 D, and F742 J

Based on records reviewed and interviews, the facility failed to ensure adequate behavior monitoring and supervision was provided for one resident (Resident #1) out of 10 sampled residents of the 17 Residents that received Anti anxiety medications and 47 residents that received antidepressant medications. The facility failed to effectively monitor behaviors related to Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 while unsupervised in his room, placed a plastic trash bag over his head and suffocated himself resulting in death by suicide. The Findings Included: Record review of the Federal 1 day report revealed, on [DATE] at 9:00 PM, Resident #1 was admitted to the facility on [DATE]. Resident #1 was an alert and oriented vulnerable resident with physical limitations, used a wheelchair and is able to transfer to the wheelchair on his own and able to go to the bathroom on his own and was independent but would ask for assistance if he needed it was found by Certified Nursing Assistant (CNA) Staff A with a plastic bag over his head. The facility's staff immediately called the code and initiated Cardiopulmonary Resuscitation (CPR) and called 911 and the resident expired. Record review of the facility's policy and procedures titled, Safety and Supervision of Residents. Revised in [DATE], revealed the policy statement: Our facility strives to make the environment as free from accident hazards as possible. Residents' safety and supervision and assistance to prevent accidents are facility wide commitment to safety at all levels of the organization. Facility oriented approach to safety included: Employees shall be trained on potential hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Individualized, resident-centered approach to safety included: 1.Our individualized, resident centered approach to safety addresses safety and accident hazards for individual residents. 2.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accidents hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Systems approach to safety noted: 2. Resident supervision is a core of the systems approach to safety. Review of the care plans for Resident #1 revealed, care plan dated [DATE]; Resident # 1 exhibited behaviors of anxiety/agitation. Goals: Resident #1 will be able to display appropriate response to situations by next review date. Approaches included, determine cause of anxiety, observe for changes in mental status, mood, and behavior, notify MD (Medical Doctor) of changes as needed. Further review of the care plans showed that Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches included, observe for changes in mood, encourage verbalization of feelings, administer antidepressants as ordered. Record review of Resident #1's behavior monitoring sheets for July, August, September and [DATE], indicated that Resident # 1 was monitored for the behaviors afraid/panic. Related to the use of [MEDICATION(S)] 1 milligram (mg) tablet. There was no record to indicate that Resident #1 was monitored for any other behavior such as mood changes or danger to self. There was no behavior record to indicate that he was monitored for his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the behavior monitoring sheets showed that Resident #1 had multiple episodes documented as Afraid/Panic. The behavior monitoring sheet initiated on [DATE] indicated Resident #1 had a total of 9 episodes of Afraid/Panic. Five out of nine different episodes occurred during the hours of 7:00 AM to 7:00 PM on [DATE], 17, 20, and 25. Four different episodes of Afraid/Panic occurred between the hours of 7:00 PM to 7:00 AM, on [DATE], 27 and 28. The documented interventions for each episode noted Routine. Review of the nurses' progress notes for [DATE], showed no record that addressed any of the episodes of anxiety exhibited by Resident #1. Review of the behavior sheets for [DATE] documented an initiated date of [DATE], but the behavior monitoring sheet showed no record (left blank) for [DATE], [DATE], and during the day shift (7:00 AM to 7:00 PM) on [DATE]th, indicating that Resident #1's behavior Afraid/Panic was not monitored during that time. Further review of the behavior monitoring records for [DATE] showed that Resident #1 had 15 different episodes of Afraid/Panic during the 7:00 PM to 7:00 AM shift. The Afraid/Panic behaviors noted to have occurred on [DATE], 10, 11, 13, 15, 16, 17, 18, 19, 22, 23, 24, 25 and 29. Review of the nurses' progress notes for [DATE], showed no recorded documentation that addressed any of the afraid/panic episodes exhibited by Resident #1. Review of Resident # 1's behavior sheets for [DATE] (initiated on [DATE]) showed Resident #1 had a total of 17 different episodes of Afraid / Panic during the month of September. Four out 17 different episodes of Afraid/Panic occurred between 7:00 AM to 7:00 PM on [DATE], 4,and 5. The intervention documented noted Routine QHS [nightly at bedtime]. Further review of September's behavior monitoring record showed that Resident #1 had 13 out of 17 different episodes of Afraid/Panic during the evening shift (7:00 PM to 7:00 AM) on [DATE], 12, 13, 14, 17, 19, 20, 21, 24, 26, 27 and 28. The documented intervention noted, Refer to Nurses Notes. Review of Nurses Notes for [DATE] showed no recorded documentation that addressed the episodes of afraid/panic exhibited by Resident #1. Review of the behavior monitoring sheet dated [DATE], showed that Resident#1 had a total of three Afraid/Panic episodes. Resident #1 had one episode of Afraid/Panic between 7:00 PM to 7:00 AM on [DATE]st, 2021. Resident #1 had two episodes of the Afraid/Panic that occurred during the day shift (7:00 AM to 7:00 PM) on [DATE]st and on the day of his death, [DATE]nd, 2021. Interventions for each episode noted Routine QHS[Every hour of sleep]. Review of the progress notes for [DATE], showed no recorded documentation that addressed any of the episodes exhibited by Resident #1. Review of the nurses progress notes dated [DATE] at 11:00 PM documented by Licensed Practical Nurse (LPN) Staff C revealed: Resident assigned CNA [Certified Nursing Assistant] was observed running over to me while I was doing my med pass as he verbalized code blue, I immediately assigned a staff member to call 911 as I grabbed the defibrillator machine. I assigned another staff member to get the crash cart. I ran to his room. The residents skin color was noted as pale whitish color, no pulse was noted resident was transferred from wheelchair to the bed. Board was placed under the patient and CPR [Cardiopulmonary Resuscitation] was initiated. 911 arrived and EMT[ Emergency Medical Technicians] pronounced his death. No obvious injuries were noted at the time of death. CNA assigned to this resident verbalized that he was unable to enter his room. The CNA stated he had to push very hard to open the door. CNA stated resident wheelchair was pushed against the door with patient sitting in the wheelchair. Trash bag was noted over his head. CNA stated he removed the trash bag to see if patient was not breathing. Patient was not breathing per CNA statement. CNA then verbalized to me and to the police how he found the patient. Family was notified by police. Police officer spoke to [ Emergency Contact]. The medical examiner arrived and transferred residents' body out of the facility. Review of the investigative report and interview with the Clinical Regional Nurse on [DATE] at approximately 2:30 PM revealed, the Clinical regional nurse had reviewed the facility's video recording as she investigated the event. The Clinical Regional Nurse documented her observation of the video and reported that she reviewed the video recording on Tuesday or Thursday last week. The report noted that on Saturday [DATE] at 2:54 PM Resident #1's CNA, (Staff A) went into the residents' room [room #] at 4:18 PM. Nurse (Staff B) was passing meds. The Clinical Regional Nurse stated: You can see her going in and out of rooms. At 4:30 PM the friend (Resident #4) leaves Resident # 1's room. The video showed that at 4:52 PM meal was delivered to Resident #1's room. His door remained open the whole time. At 5:21 PM the Nurse [Staff B] went into Resident #1's room. At 5:43 PM the CNA (Staff A) picked up the tray, (Noted that he ate 100%). At 6:25 PM it appears the door is shut from inside the room. No one checked on the resident or attempted to enter the room from approximately 6:25 PM to 8:15 PM (Staff C) LPN was scheduled to start her shift at 7:00 PM, no indication that she checked on Resident #1 from the time her shift started until the CNA called her at around 8:15 PM. At 8:15 PM, the CNA tried to get into the room and noted that the door was closed. The CNA tried to open the door, but it was blocked. Staff A was in the room for a few second, leaves the area gets the nurse and the crash cart . The Regional nurse explained that the CNA had to push the door open and when he entered, the room he noted Resident #1 seated in his wheelchair, unresponsive with a bag over his head. The CNA stated that he pulled the bag off Resident #1's head and ran to get help. A code was called as well as 911, staff responded to this resident's room where they transferred him to the bed, a backboard was placed, and CPR initiated. Law enforcement and EMTs responded shortly thereafter and pronounced this Resident. The Residents body was transferred to the Medical Examiner's office. During an interview on [DATE] at 10:56 AM the Psychiatrist reported he did not review the above mentioned behavior monitoring sheets in Resident #1's clinical record. The Psychiatrist explained that he met with the facility's staff and discussed residents' behaviors and if any adjustments are needed. When asked about Resident #1, the Psychiatrist reported he was not aware that Resident # 1 had any behaviors. Upon discussion of the multiple documented episodes of afraid/panic noted on Resident #1's clinical record, the Psychiatrist reported he was not aware and that the nurses had not communicated the behaviors to him. The Psychiatrist explained that the facility staff should have communicated anxiety, afraid/panic episodes and any other behavior exhibited by Resident#1 to him. If they tell me I would definitely do something. The nurses usually call me. They did not tell me about those episodes. Had I known, I would have definitely done something, I would have gone to see him, maybe change the medication . Crowss References F600 J, F656 J, and F684 D

Based on observation, interview, and record review the facility failed to ensure infection control procedures were followed as evidenced by 1) failure to appropriately disinfect the multiple patient use glucometer for two out of two residents observed (Resident #112 and Resident # 21), and inappropriately discard used lancet, used blood glucose test strips and used alcohol pads visibly soiled with blood during blood sugar check on the north wing increasing the risk for cross contamination and likelihood of being infected with blood-borne pathogens. 2) Failed to ensure hand hygiene was followed after removal of gloves as per facility's policy during pressure/wound care observation for one (Resident#121) out of one resident observed for wound care. 3) Failed to ensure appropriate use of Personal Protective Equipment (PPE) for one out of nine residents on transmission based- droplet precautions for COVID-19 on a non COVID-19 unit( Resident #118 ). 4) Failed to ensure proper use of disposable gloves and implement appropriate hand hygiene and increase risk for cross contamination due to staff having artificial nails that were more than one quarter inch long during perineal care observation for one out of one resident observed for perineal care (Resident #65). These deficient practices have the potential to have an adverse effect on any of the 123 residents residing in the facility at the time of the survey. It was determined Immediate Jeopardy existed related to infection control and prevention based on the facility's failure to appropriately disinfect the blood glucose monitoring device/glucometer that was being used for multiple residents. The likelihood existed for cross contamination, increased risk for exposure and being infected with blood [MEDICAL CONDITION] through contaminated blood glucose monitoring equipment and supplies. This also increased the likelihood of serious harm that could create life-threatening diseases and complications/conditions to any of the 48 residents residing in the facility with physician's orders [REDACTED]. On November 18, 2020 at 5:44 PM. the facility's administration was notified that ongoing Immediate Jeopardy existed for infection control. The findings included: Review of the facility's policy titled Cleaning glucometer review date 09/25/20 documented clean the glucometer machine between each use with disinfectant wipes approved by the facility and wait until dry by manufacture recommendation. Review of the facility's Facility Policy titled Blood Sugar Check with review date 08/24/2020 indicated the purpose is to guide safe handling of capillary blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Item 6 of the document indicated : Discard lancet into sharps container. Review of the Center of Disease and Control Prevention (CDC) website (www.cdc.gov) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration indicated for Blood Glucose Meters : Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions, to prevent carry-over of blood and infectious agents . 1) On 11/16/20 at 4:24 PM, observation of a blood sugar monitoring check for Resident #112 performed by Staff A, a Registered Nurse (RN) was conducted. Observation revealed Staff A wheeled the resident to her room then returned to the medication cart, retrieved a blood glucose monitor from the cart drawer, a bottle of test strips, a disposable lancet, an alcohol pads and placed the supplies on a white foam tray. Staff A entered the residents' room, placed the white tray on top of the resident's table. Staff A performed hand hygiene donned gloves and performed blood glucose check. Staff A then removed the blood soiled test strip from the glucose monitor and placed the soiled strip, the used lancet and the monitor on top of the foam tray. Observation revealed Staff A cleaning the blood glucose monitor with alcohol pads, then cleaned the bottle of test strips with alcohol pads. Staff A exited the resident's room and placed the glucose monitor and the bottle of test strips on top of the medication cart. On 11/16/20 at 4:40 PM, observation of a blood sugar monitoring check for Resident #21 performed by Staff A, a Registered Nurse was conducted. Observation revealed Staff A placed the same glucose monitor used with Resident #112, the bottle of test strips a new disposable lancet and alcohol pads on a white foam tray. Staff A entered the resident's room, placed tray with gathered supplies on top of the table, after performing hand washing Staff A donned gloves, inserted a test strip into the monitor, wiped the resident's finger with an alcohol pad fast dried then pricked the finger and dropped a drop of blood onto the test strip. Observation revealed Staff A placed the blood soiled test strip on the white foam tray next to the glucose monitor. Staff A stated the monitor was off and that she had to do it all over again. Staff A then wiped the finger with an alcohol pad again and placed it on the white foam tray with supplies (blood was noted on the alcohol pad), waved the residents finger with her hand. Staff A with her soiled gloved hand, open the test strip bottle inserted her gloved finger into the bottle and retrieved a test strip and placed it in the glucose monitor and completed glucose check. Staff A placed the glucose monitor next to the bloody alcohol pad on the foam tray. Staff A removed her gloves, did not perform hand hygiene and donned another pair of gloves and proceeded to clean the monitor with alcohol pads. The State surveyor intervened and asked staff A about the disinfecting of the glucose monitor and other concerns identified. On 11/16/20 at 4:48 PM, in response to the identified concerns, Staff A stated that she usually cleaned the glucose monitor with alcohol pads. She stated that is how she was educated by the facility to clean the monitor. Staff A stated it is her standard of practice to clean the glucose monitor with alcohol pads. Staff A added that she cleaned the bottle of test strips with alcohol when she is done and then let it dry. Staff A then donned one glove, proceeded to the medication cart and disposed the used disposable lancet, soiled test strips and the soiled alcohol pads, including the alcohol pad visibly soiled with blood into regular trash can attached to the medication cart. Observations revealed the glucose monitor and the test strips bottle were left in the room on top of the residents table. Staff A then returned to the resident's room, performed hand washing donned gloves and again cleaned the glucose monitor and the bottle of test strips with alcohol pads. She stated that normally she does not bring the test strip bottle into the resident's room. Staff A then returned to the medication cart and without disinfecting the glucose monitor, she placed the monitor and the test strips bottle in the first top drawer of the medication cart. Staff A stated Resident #21 blood sugar results and indicated insulin coverage was required. On 11/16/20 at 4:58 PM, observation revealed Staff A donned gloves, retrieved two insulin syringes, removed gloves and donned new gloves without performing hand hygiene. Staff A wiped the insulin bottles rubber top and drew [MEDICATION NAME] two (2) units, then drew [MEDICATION NAME] 17 units, removed her gloves and did not perform hand hygiene, entered the resident room and because the paper towel holder in the room was jammed she had to go to another resident's room to wash her hands. Review clinical records for the 43 residents residing in the facility at the time of the survey with a physician's orders [REDACTED].#36) out of the 10 residents assigned to RN, Staff A indicated clinical a [DIAGNOSES REDACTED]. On 11/16/20 at 6:05 PM, during an interview Staff B, a RN supervisor, stated that the nurses are to disinfect the glucose monitor with Super Sani Cloth wipes which is an approved wipe. On 11/17/20 at 2:40 PM, the Director of Nursing (DON), stated during an interview that the blood glucose monitor disinfection was mentioned during their general Infection Control education conducted during the facility assessment and polices review on 10/27/20. The DON was asked to provide a copy of the last monitored in-service provided to the staff. The DON stated that the nurses are supposed to clean the glucose monitor before and after each use with the approved wipes. The DON added the facility has two types of wipes and they are to follow manufacturer instructions. The DON added that for the purple bottle wipes, they have to wipe the monitor and wait two minutes to kill the bacteria and let it dry. Review of the facility's records documented a certificate dated 11/04/20 for Staff A from Occupational Safety and Health Administration (OSHA): Occupational Exposure to blood borne pathogens for two (2) contact hours from an outside provider. The DON stated that the OSHA training included blood-borne infections and how it is transmitted Review of a document provided by the Administrator titled Hand Hygiene with no facility's name, no effective or revision date, documented .when to wash hands or use an alcohol-based hand rub: before applying and after removing gloves .after contact with body fluids .non-intact skin and wound dressings . moving from a contaminated body site to a clean body site during patient care .after contact with inanimate objects in the immediate vicinity of the patient .rub hands vigorously for at least 20 seconds .turn off water faucet with clean paper towel . 3) On 11/20/20 at 8:25 AM, observation of pressure ulcer/wound care performed by Staff W, a Registered Nurse (RN) for Resident #121 assisted by Staff X, a Certified Nursing Assistant. Staff W gathered wound care supplies placed them on a white foam tray. At 8:28 AM, observation revealed Staff W entered Resident #121's room, placed the white foam tray over the residents table and unto a barrier. Staff W then placed the wound care unopened supplies packages over the barrier. Staff W proceeded to performed hand hygiene, donned exam gloves, removed the resident sacrum pressure ulcer/wound dressing after Staff W removed her exam gloves,without performing hand hygiene, reached the clean field, donned exam gloves, then removed the left buttock dressing, removed her exam gloves and without hand hygiene, donned exam gloves and removed residents right buttock dressing, removed her exam gloves and without hand hygiene, she reached to the clean field, donned exam gloves. Staff W proceeded with performing the wound care dressing without performing hand hygiene between change of gloves. Observation revealed Staff X with gloved hands repositioning the resident's brief. Further observations revealed the brief was touching the undressed right buttock ulcer/wound. Staff X was observed holding Resident #121 back and legs with gloved hands and repositioned residents as requested by Staff W. Further observation revealed Staff X, with the same exam gloves, pressing on place the clean gauze dressings that Staff W placed over the resident's ulcers/wounds. Staff X was told to removed the resident's catheter bag and tubing that was lying on the floor from the privacy bag by Staff W. Observation revealed Staff X donned exam gloves without performing hand hygiene and then removed the catheter bag as requested. On 11/20/20 at 3:54 PM, during an interview, Staff W and was asked why she did not perform hand hygiene between gloves changes during Resident #121 wound care observation. Staff W stated she was educated to do hand hygiene before and after entering a resident's room or after touching any surfaces. Staff W was apprised that she removed the resident sacrum pressure ulcer/wound soiled dressing, removed her gloves and donned gloves again without performing hand hygiene. Staff W stated that if it is the same resident and the same place/ulcer location, she does not have to do hand hygiene after the removal of gloves. Staff W added that if she is moving from one part of the body to another like changing from the sacrum to the foot, then she would perform hand hygiene in between gloves changes. Staff W stated what changes is the location of the wound and that is when she would be required to remove her gloves and perform hand hygiene. Staff W again stated that she was not educated to do hand hygiene between gloves changes. Staff W was apprised that she did an up and down stroke with the same gauze while cleaning Resident #121 right buttock pressure ulcer and denied doing so. Staff W was also apprised that Staff X, a Certified Nursing Assistant, her assistant during pressure ulcer/wound care for Resident #121, removed gloves and donned gloves without performing hand hygiene. Staff W confirmed that Staff X did not do hand hygiene between gloves changes neither. On 11/21/20 at 12:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that Staff W informed her that she did not change the gloves during wound care. The DON stated, she did not do it right. Review of a document provided by the Administrator titled Glove use Policy and Procedure with no facility's name, no effective or revision date, documented .applying and removing gloves, perform hand hygiene before applying non-sterile gloves .wash hands after you have removed the gloves. 4) On 11/20/20 at 8:55 AM, a random observation revealed Staff T, a Licensed Practical Nurse (LPN), exiting Resident # 118's room. wearing a gown, a mask, goggles, and gloves. Resident # 118 was on transmission based droplet precautions on the north wing. Further observation revealed Staff T parked the medication cart across from the Resident's room and with the room door open, she opened the Medication Administration Record [REDACTED]. At 9:02 AM, during an interview Staff T stated that she did the residents blood pressure check and was ready to prepare his medications. Staff T stated she changed the gloves but kept the same gown and did not disinfect the goggles before she came out of the room. Observation revealed Staff T continued to pour the random resident's medications and did not attempt to change her gown or to close the resident's room door. On 11/20/20 at 9:05 AM, Staff N, RN north wing supervisor was called to observe Staff T. The supervisor (Staff N) stated that the room door is supposed to be closed. At 9:10 AM, a joint interview with Staff N and Staff T was conducted while Staff T continues at the resident in droplet precautions open door. Staff T again stated that she went into the resident's room to check his blood pressure and came out, kept the same gown she used to go in the room. Staff T then added, how am I supposed to check his medications? Staff N then stated that the LPN (Staff T) should have changed her gown and closed the door. 4) On 11/20/20 at 9:15 AM, observation of perineal care performed by Staff M, a Certified Nursing Assistant, for Resident #65 was conducted. Observation revealed Staff M with approximately one inch long acrylic/artificial nails performing hand hygiene. Staff M pulled a piece of a paper towel, then with a bare hand touched the paper holder to retrieve another piece of paper towel. Staff M failed to performed hand hygiene after touching a potentially contaminated paper towel holder. Staff M donned gloves, pulled the resident's privacy curtains, repositioned the bed by using the bed's remote control, also a potentially contaminated frequently touched object. Staff M, while wearing the same pair of gloves, placed a barrier over the bed table, walked to the bathroom with a basin and with gloved hand open the water faucet and filled the basin with water. Staff M continued wearing the same pair of gloves, closed the water faucet, carried the water basin and placed it on top of the table. Staff M opened the resident's nightstand drawer and retrieved toiletries including a soap container, pulled the privacy curtains open, retrieved a plastic bag from across the resident's roommate's area. Staff M moved the trash can closer to the bed, placed a plastic bag at the bottom of the resident's bed. Staff M removed the resident's cover sheet, pillows, call bell, opened the nightstand drawer and closed it, pulled the privacy curtains, and retrieved a hand towel from the plastic bag. Staff M then attempted to wash Resident #65's face and the resident refused. Staff M then pulled the curtains open and closed them, returned to the resident's bedside removed the resident's brief and performed perineal care. Staff M did not change gloves during the entire perineal care process. After Staff M completed perineal care she removed her gloves, held the soiled water basin with bare hands and discarded the water, performed hand hygiene, then retrieved a piece of paper towel by touching the paper holder with a bare hand and again failed to perform hand hygiene after touching a potentially contaminated surface. On 11/20/10 at 10:01 AM, during an interview Staff M was apprised regarding using one pair of gloves throughout the entire procedure, touching resident drawer, cabinet and privacy curtains with gloves on and after performing the perineal care with the same pair of gloves. Staff M stated she did the perineal care procedure wrong. Staff M was asked about her acrylic nails and the facility's policy, Staff M stated she did not know the policy. On 11/20/20 at 4:48 PM, Staff N, the north wing nursing supervisor was apprised of concerns identified during perineal care observation for Resident #65. Staff N was informed that Staff M used one pair of gloves throughout the entire procedure and wiped the residents back with one towel, wiped the groin area with an up and down stroke several times with the same side of the towel. Staff N stated that Staff M should have changed the gloves in between dirty and clean. On 11/21/20 at 12:49 PM, the Director of Nursing (DON) stated that the staff providing direct care should have short nails, no acrylic nails. She was apprised of Staff M with long acrylic nails and stated that the staff are required to trim their nails and keep them clean. The DON stated, a neat nail length may be a quarter inch. Review of the Center of Disease and Control Prevention (CDC) website guidelines for hand hygiene in Healthcare settings https//www.cdc.gov/mmwr documents HCWs (healthcare workers) who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails . The facility's immediate jeopardy removal plan included: Corrective action: The nurse in question was provided an in-service by DON on cleaning techniques as per policy for the glucometer. Individual counseling on policy and procedures for glucometer cleaning was provided by DON. The nurse in question was able to perform return competency demonstration of disinfecting glucometer as per policy. Identification of other residents with potential to be affected: All patients receiving glucometer tests have the potential to be affected by this practice. Measures/Systematic changes made to ensure non-reoccurrence: Inservice return competency demonstration of disinfecting glucometer. An in-service with all nurses was conducted as to the was provided by the DON immediately on 11/18/2020 with all onsite nurses as to the policy and procedures of disinfecting glucometers. An in-service with all nurses was conducted as to the policy and procedures of disinfecting the glucometer. All employed nurses will receive in-service by the end of today. The policy and procedure for disinfecting the glucometer will be included in the nurses' employee handbook along with a return competency during orientation. All findings will be reported during the quality assurance for the next two quarters.

Based on observation, interview, and record review, the facility failed to complete an accurate assessment to develop a plan of care related to pain for 1 of 2 residents (#113) reviewed for pain management. The facility had 39 residents on a pain management program at the time of the survey. The deficient practice of the facility failing to accurately assess resident #113's pain and dental status caused actual harm to the resident in that she experienced significant pain which affected her ability to chew her food. Cross reference to F309 and F412. Findings include: Interview with resident #113 on 10/21/14 at 10:08 am revealed she had pain in her teeth. The pain was especially prevalent when she chewed. She could not chew food on the right side of her mouth because of the pain. She said, she told the social worker in order to try to get an appointment with the dentist but the social worker had not gotten back to her. She also indicated that she told her son about it because she felt facility staff was likely ignoring her. Observation on 10/22/14 at 8:51 am revealed resident #113 was seated in her wheelchair and had her breakfast tray in front of her. She had 2 slices of toast, a hard boiled egg, and hash. She also had coffee and juice. She drank the coffee with a straw and then dipped the toast in the coffee. She put the toast in the left side of her mouth. As she chewed she had a pained facial expression. She said she had pain in her mouth right now. She turned down her lip and showed a mouth sore on the inside of her bottom lip on the right side. Interview with resident #113 on 10/23/14 at 9:06 am revealed she said she ate her breakfast this morning. She said she has pain in her mouth and pointed to the lower right side of her mouth. She turned her lip down and there was a visible mouth sore on the inside of her bottom lip. Interview with the resident's son on 10/23/14 at 11:29 am revealed his mother had been in pain for a little over a year. He said it was not severe pain. He told one of the caretakers that she was in pain but he could not recall the name of the person and that person no longer works there. Review of resident #113's dental consultation dated 1/8/14 revealed the resident was seen for a complete evaluation. The consultation found that the resident's lower teeth were hopeless (teeth with severe attachment loss) and recommended multiple extractions with alveoplasty (surgical shaping of the dental alveoli and alveolar processes especially after extraction of several teeth or in preparation for dentures). It indicated medical clearance was needed from the primary physician in order to perform the procedure. Antibiotics were recommended starting the day before the extractions. Review of the medical clearance form dated 1/8/14 revealed resident #113 was Diabetic, Hypertensive, and taking an anti-coagulant. The clearance form included a request for the physician to provide considerations before the dental treatment. It indicated the resident needed multiple extractions with alveoplasty. The rest of the form was blank. It included sections regarding whether there were any contraindications, whether the resident needed pre-medications, whether there were local anesthetic restrictions, whether there was a need to stop any medications, and whether there were any other precautions needed. It also included a signature line for the physician. Record review of nurses' notes dated 1/8/14 at 2:30 pm revealed, the resident returned from a dental appointment in stable condition with an order for [REDACTED]. Record review of a nurses' note dated 1/13/14 at 8:00 pm revealed the 7am-7pm nurse gave a report that the resident's tooth extractions would be re-scheduled. The patient's family wanted the tooth extractions scheduled with the facility's dentist and the date was unknown at the time. Staff notified the physician, who discontinued the previous orders and indicated that new orders would be given when the date of the extraction was known. Record review of a nurses' note dated 1/21/14 at 1:30 pm revealed the nurse spoke to a Social Services staff member in regards to the dental appointment being re-scheduled. The Social Services staff member said there was insurance verification pending with a new appointment. There was no other nurses note regarding the resident's planned extractions or re-scheduling of the appointment up through 10/22/14. Review of resident #113's annual Minimum Data Set (MDS) assessment dated [DATE] revealed, there was nothing checked for the resident's oral/dental status indicating there were problems, such as the resident experiencing any pain. Interview with the MDS staff LPN on 10/23/14 at 9:12 am revealed, on the day the assessment was completed, resident (#113) didn't complain of pain, didn't have any mouth sores and she didn't have any broken natural teeth. Review of resident #113's care plans revealed there was no care plan specific to the resident being at risk for experiencing pain. Review of resident #113's Medication Administration Records (MARs) from January 2014 through October 2014 revealed they included a pain rating scale for each shift, every day. They also included orders for PRN (as needed) [MEDICATION NAME] 325 milligrams (mg) 2 tablets by mouth every 4 hours for pain and PRN [MEDICATION NAME] 500 mg 1 tablet by mouth every 4 hours for mild pain less than or equal to 4 out of 10. Review of resident #113's January 2014 MAR indicated [REDACTED]. Resident #113 was given a dose of the [MEDICATION NAME] 325 mg 2 tablets by mouth on 1/11/14 on the 7am to 7pm shift. Review of a 1/11/14 physician's progress note revealed resident #113 had a toothache and would be scheduled for multiple dental extractions. It also noted the resident had chronic pain in both shoulders due to a dislocation. Review of resident #113's 1/13/14 psychologist's progress note revealed the resident stated she was not feeling well because of bone pain. Review of resident #113's February 2014 MAR indicated [REDACTED]. According to the reverse side of the MAR (where nurses document the reason for the administration of the PRN pain medication, the location of the pain, and the effectiveness of the medication after administration), the resident had pain at a level 5/10 on 2/01/14, 2/03/14, and 2/04/14 and pain at a level 4/10 on 2/10/14. There was no indication for the reason the medication was administered or the resident's pain level on 2/02/14, 2/05/14, 2/07/14, and 2/10/14. Further review of resident #113's 2014 MARs revealed the next administered dose of PRN [MEDICATION NAME] for pain was on 6/25/14 when the resident was given the 500 mg dose for pain at a level 6/10. Review of a 10/18/14 communication form revealed Licensed Practical Nurse (LPN) E indicated that resident #113 complained of mouth pain almost daily. Review of a 10/20/14 psychologist's progress note indicated resident #113 complained of bone pain, mouth pain, and left eye pain. Further review of resident #113's 2014 MARs revealed the next administered dose of PRN pain medication was on 10/23/14 when she was given [MEDICATION NAME] 325 mg 2 tablets by mouth for mouth pain at a level 7/10.

Based on observation, interview, and record review the facility failed to coordinate care between disciplines, related to 1) fluid restriction in 2 (Resident #378, #379) out of 6 residents with fluid restrictions and 2) pain management for 2 residents (Resident #113 and Resident #380) out of 2 residents sampled for pain management. The facility did not monitor the residents on fluid restriction for fluid amounts in excess of the physician order. The facility did not adequately assess pain for Residents #113 and #380 and did not implement interventions to alleviate the pain . The facility had 39 residents on a pain management program. This deficient practice of the facility failing to manage resident #113 ' s pain caused actual harm to the resident, in that she experienced significant pain which affected her ability to chew food. Cross reference to F278 and F412. The findings include: 1) Review of resident #113's care plans revealed there was no care plan specific to the resident being at risk for experiencing pain. The resident did, however, have a care plan dated 8/21/14 related to the resident being at risk for dental/oral problems related to missing teeth. The goal was for the resident to be free of oral problems by the next review date (11/21/14). The approaches were as follows: 1) Speech therapy screen for chewing problems as needed (PRN), 2) Dental consult as needed, 3) Observe for signs and symptoms (s/s) of complications, i.e. pain, redness, swelling, drainage, 4) Notify the Medical Doctor (MD) of changes, 5) Daily oral care, 6) Denture care. Review of resident #113's dental consultation dated 1/8/14 revealed the resident was seen for a complete evaluation. The consultation found that the resident's tower teeth were hopeless (teeth with severe attachment loss) and recommended multiple extractions with alveoplasty (surgical shaping of the dental alveoli and alveolar processes especially after extraction of several teeth or in preparation for dentures). It indicated medical clearance was needed from the primary physician in order to perform the procedure. Antibiotics were recommended starting the day before the extractions. Review of the medical clearance form dated 1/8/14 revealed resident #113 was Diabetic, Hypertensive, and taking an anti-coagulant. The clearance form included a request for the physician to provide considerations before the dental treatment. It indicated the resident needed multiple extractions with alveoplasty. The rest of the form was blank. It included sections regarding whether there were any contraindications, whether the resident needed pre-medications, whether there were local anesthetic restrictions, whether there was a need to stop any medications, and whether there were any other precautions needed. It also included a signature line for the physician. Record review of resident #113's nurses' notes 1/08/14 at 2:30 pm revealed the resident returned from a dental appointment in stable condition with an order for [REDACTED]. There was an additional order to hold all anticoagulants 3 days before and 3 days after the extractions. Record review of a nurses' note dated 1/13/14 at 8:00 pm for resident #113 revealed the 7am-7pm nurse gave a report that the resident's tooth extractions would be re-scheduled. The patient's family wanted the tooth extraction scheduled with the facility dentist and the date was unknown at the time. Staff notified the physician, who discontinued the previous orders and indicated that new orders would be given when the date of the extraction was known. Record review of a nurses' note dated 1/21/14 at 1:30 pm for resident #113 revealed the nurse spoke to a Social Services staff member in regards to the dental appointment being re-scheduled. The Social Services staff member said there was insurance verification pending with a new appointment. There was no other nurses note regarding the resident's planned extractions or re-scheduling of the appointment up through 10/22/14. There was no indication in the rest of resident #113's record from January 2014 to October 2014 that she ever got the extractions. Review of resident #113's Medication Administration Records (MARs) from January 2014 through October 2014 revealed they included a pain rating scale for each shift, every day. They also included orders for PRN (as needed) [MEDICATION NAME] 325 milligrams (mg) 2 tablets by mouth every 4 hours for pain and PRN [MEDICATION NAME] 500 mg 1 tablet by mouth every 4 hours for mild pain less than or equal to 4 out of 10. Review of resident #113's January 2014 MAR revealed the resident was noted with pain at a level 3 on 1/1 during the 7am to 7 pm shift and pain at a level 2 on the 7pm to 7am shift. The resident was not given pain medication on 1/1/14. Resident #113 was given a dose of the [MEDICATION NAME] 325 mg 2 tablets by mouth on 1/11/14 on the 7am to 7pm shift, however, there was no noted pain on the pain monitoring scale for that date. Additionally, the reverse side of the MAR did not note the location of the pain. Review of a 1/11/14 physician's progress note revealed resident #113 had a toothache and would be scheduled for multiple dental extractions. It also noted the resident with chronic in both shoulders due to dislocation. Review of a 1/13/14 psychologist's progress note revealed resident #113 stated she was not feeling well because of bone pain. Review of resident #113's February 2014 MAR revealed she was given [MEDICATION NAME] 325 mg 2 tablets by mouth on 2/1, 2/2, 2/3, 2/4, 2/5, 2/7, and 2/10. According to the reverse side of the MAR (where nurses document the reason for the administration of the PRN pain medication, the location of the pain, and the effectiveness of the medication after administration), the resident had pain at a level 5/10 on 2/1, 2/3, and 2/4 and pain at a level 4/10 on 2/10. There was no indication for the reason the medication was administered or the resident's pain level on 2/2, 2/5, 2/7, and 2/10. There was no indication of the location of the pain for any of the administered pain medication doses. Further review of resident #113's 2014 MARs revealed the next administered dose of PRN [MEDICATION NAME] for pain was on 6/25/14 when the resident was given the 500 mg dose for pain at a level 6/10, despite the physician order [REDACTED]. The reverse side of the MAR did not indicate the location of the pain. Review of a 10/18/14 communication form revealed staff A indicated that resident #113 complained of mouth pain almost daily. Review of a 10/20/14 psychologist's progress note indicated resident #113 complained of bone pain, mouth pain, and left eye pain. Further review of resident #113's 2014 MARs revealed the next administered dose of PRN pain medication was on 10/23/14 when she was given [MEDICATION NAME] 325 mg 2 tablets by mouth for mouth pain at a level 7/10. Review of resident #113's MAR for October 2014 revealed it included a pain rating scale (from 1 to 10 with 1 being mild pain and 10 being the worst pain) daily for each shift. There were only 2 instances where the resident was noted with pain which was not consistent with LPN E's communication note or the observations of and interviews with the resident. The resident had pain at level 4 on the 7pm to 7 am shift on 10/1/14. The resident had pain at a level 4 on the 7pm to 7am shift on 10/3/14, however, there was no indication the resident was given pain medication. Interview with resident #113 on 10/21/14 at 10:08 am revealed she had pain in her teeth. The pain was especially prevalent when she chewed. She could not chew food on the right side of her mouth because of the pain. She said she told the social worker in order to try to get an appointment with the dentist but the social worker had not gotten back to her. She also indicated that she told her son about it because she felt facility staff was likely ignoring her. Observation on 10/22/14 at 8:51 am revealed resident #113 was seated in her wheelchair and had her breakfast tray in front of her. She had 2 slices of toast, a hard boiled egg, and hash. She also had coffee and juice. She drank the coffee with a straw and then dipped the toast in the coffee. She put the toast in the left side of her mouth. As she chewed she had a pained facial expression. She said she had pain in her mouth right now. She turned down her lip and showed a mouth sore on the inside of her bottom lip on the right side. Interview with resident #113 on 10/23/14 at 9:06 am revealed she said she ate her breakfast this morning. She said she has pain in her mouth and pointed to the lower right side of her mouth. She turned her lip down and there was a visible mouth sore on the inside of her bottom lip. Interview with the facility's Social Services Director (SSD) on 10/23/14 at 9:20 am revealed the Social Services department was responsible for dental consultations. She said there is an appointment setter that works for Social Services who makes all the dental appointments. Interview with the facility's appointment setter on 10/23/14 at 9:24 am revealed she said she usually gets a communication form from the nurse with a telephone order from the doctor regarding dental consultations. The facility works with two dental companies (dental company A and dental company B). She explained the process for scheduling dental consultations with both companies. First, she contacts the company and lets them know the resident's specific dental issue and tells them that the resident needs to be seen urgently. Then, she faxes them the demographics and the physician's telephone order. Next, the dental office calls her and lets her know when the dentist is going to come see the resident or whether the resident has to go out to the dental office. The appointment setter said resident #113's son came to her and let her know that he didn't want to use dental company A so she moved the resident to dental company B. Dental company B's dentist visited the facility on 10/10/14 but the resident was not in her room. The dentist did not see the resident that day. The appointment setter explained that resident #113's son let her know that resident #113 had mouth pain. She explained that the dentist would have to do x-rays to see what is actually going on. She explained that the resident's mouth pain had been ongoing for about a week. She found out the resident had mouth pain first when the son spoke to her. She provided a communication form from nursing dated 10/18/14. She said the dentist is coming either today or tomorrow. She called dental company A who told her that they had no records for resident #113 from January 2014 but on April 8, 2014 they evaluated the resident. They called the facility to coordinate an extraction but the resident had been disenrolled from the program. She then contacted the resident's son and he denied disenrolling the resident from dental company A and was not aware of the orders for extraction in January 2014. The appointment setter could not explain who had disenrolled resident #113 from dental company A. Interview with the facility Social Services Director on 10/23/14 at 9:45 am, revealed she said she was not aware of the January 2014 scheduled extraction that did not take place. She was unable to explained why the dentist came to the facility on [DATE] but left without seeing resident #113 aside from saying that the resident was not in her room and may have been on the patio with her son. She could not explain whether any staff member attempted to find the resident in order for her to see the dentist or whether any staff member spoke to the dentist regarding the resident's whereabouts. Interview with the resident's son on 10/23/14 at 11:29 am revealed his mother had been in pain for a little over a year. He said it was not severe pain. He told one of the caretakers that she was in pain but he could not recall the name of the person and that person no longer works there. He re-iterated that resident #113 is not in severe pain and that it is more like discomfort. Interview with LPN F on 10/23/14 at 3:49 pm revealed she said that when staff gives a resident a PRN medication, they should document the pain level, the location of the pain, and the effectiveness of the medication. She confirmed that there were multiple instances where the resident was given PRN pain medication but that staff did not indicated the location of the pain. She said early in the morning, the resident denied having pain but later in the morning, the resident complained of mouth pain and was given Tylenol. Interview with LPN G on 10/23 at 4:01 pm revealed she gave the PRN Tylenol in February because most of the time the resident complained of shoulder pain or generalized pain. She denied the resident ever reported to her that she had mouth pain. 2) Record review revealed Resident #378 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 10/22/14 at 8:23 am revealed that Resident #378 was sitting in a wheelchair, in his room, and had just finished eating breakfast. Inside of the resident's room there was no signage observed alerting the staff that this resident is on a fluid restriction. Record review for Resident #378 revealed that there was a physician telephone order dated 10/07/14 which read: Diet clarification 1200ml/day fluid restriction. The breakdown for the fluid restriction: (Nursing: 480ml/day and Dietary: 720ml/day). Review of the fluid restriction worksheet dated 10/07/14 for Resident #378 revealed that the breakdown included the following: daily fluid restriction-1200ml/day with Nursing Department: 480ml/cc of fluid per day (7:00pm-7:00am shift 240ml, 7:00am-7:00pm shift 240ml) and Dietary Department: 720ml/cc of fluid per day (Breakfast-240cc, Lunch-240cc, Dinner-240cc). Review of Care Plans for Resident #378 related to fluid restriction (a total of 2) revealed the following: Resident is at risk for complications related to nutrition/hydration (dated 10/07/14) for [DIAGNOSES REDACTED]. Resident is at risk for [MEDICAL CONDITION] (dated 10/14/14) related to fluid restriction; Goal: resident will be free from complications of fluid excess through next review; Approaches: 1) Provide treatments/meds as ordered. Interview with the Assistant Director of Nursing (ADON) on 10/22/14 at 9:33 am revealed that the fluid intakes for residents on fluid restrictions are documented on the Medication Administration Record (MAR) and the Certified Nursing Assistant (CNA) documents the percentage of fluid a resident consumes at a mealtime in the CNA book. The ADON confirmed, that the nurses do not report the total amount of fluid that a resident consumes in a day. Interview with Resident #378 CNA on 10/22/14 at 2:40 pm revealed that the CNA documents the percentage of fluid a resident consumes at a mealtime in the CNA book. Interview with the Registered Diet Technician (DTR) on 10/23/14 at 12:37 pm revealed when asked how does the facility know the amount of total fluid a resident has consumed in a day, she replied by the amount given to the resident via dietary and nursing. Review of facility documentation revealed that there is currently no documentation for a nurse to indicate that a resident has not gone over the allotted fluid restriction. 3) Record review revealed Resident #379 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 10/22/14 at 8:13 am revealed that Resident #379 was sitting in a wheelchair, in his room, eating breakfast and neatly groomed. Also, a pitcher with ice and water and a cup filled with water was on the bedside table. Furthermore, a 16.9 oz. bottle of water was on bedside table. Inside of the resident s room there was no signage observed alerting the staff that this resident is on a fluid restriction. Record review for Resident #379 revealed that there was a physician telephone order dated 10/13/14 which read: Diet recommendation-Fluid restriction 1500ml/day. The breakdown for the fluid restriction: (Nursing: 6000ml/day and Dietary: 900ml/day). Review of the fluid restriction worksheet dated 10/13/14 for Resident #379 revealed that the breakdown included the following: daily fluid restriction-1500ml/day with Nursing Department: Nursing Department: 600ml/cc of fluid per day (7:00pm-7:00am shift 180ml, 7:00am-7:00pm shift 420ml) and Dietary Department: 900ml/cc of fluid per day (Breakfast-420cc, Lunch-240cc, Dinner-240cc). Review of Care Plans for Resident #379 related to fluid restriction (a total of 2) revealed the following: Resident is at risk for complications related to nutrition/hydration (dated 10/13/14) for [DIAGNOSES REDACTED]. Resident is at risk for [MEDICAL CONDITION] (dated 10/10/14) related to end stage [MEDICAL CONDITIONS]; Goal: resident will have no complications from [MEDICAL CONDITION] with close monitoring daily through next review; Approaches: 1) Observe for signs & symptoms of complications; 2) Report to MD abnormal findings and 3) Monitor site for [MEDICAL CONDITION] and report abnormal findings. Interview with Resident #379 LPN Nurse on 10/22/14 at 11:49 am revealed that the fluid restriction is monitored on the MAR. 4) Record review revealed Resident #380 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and Interview with Resident #380 on 10/23/14 at 8:21 am revealed that the resident was sitting up in bed, eating a pureed breakfast. Also, the resident was grimacing with pain. He revealed that he has pain with his teeth. Record review of the physician's orders [REDACTED].#380 revealed the following: 1) Pain Rating Scale: 0=None; 1-2=Mild; 3-4-5=Moderate; 6-7-8=Severe; 9-10=Worst; 2) [MEDICATION NAME] 5/325mg give 1 tablet by mouth every 4 hours as needed for mild pain and 3) [MEDICATION NAME] 5/325mg give 2 tablets by mouth every 4 hours as needed for mild-severe pain. Review for Resident #380 revealed that there was a physician telephone order dated 10/20/14 which read: Change diet to Puree diet and [MEDICATION NAME] apply to tooth as needed maximum 4 times a day for toothache. Review of Resident #380 October 2014 MAR revealed 1) No pain noted for 10/10/14-10/21/14; 2) [MEDICATION NAME] 5/325 1 tablet by mouth every 4 hours as needed for mild pain was given on 10/15/14, 10/17/14 and 10/20/14 and 3) No [MEDICATION NAME] was given to the resident, since the order was written on 10/20/14. Review of Resident #380 Nurses' Notes dated 10/20/14-10/22/14 revealed no pain noted by the resident. Review of Resident #380 Alterations in Comfort Care Plan dated 10/10/14 revealed the following: The resident is at risk for alterations in comfort secondary to impaired mobility; Goal: Will maintain comfort and have efficient pain management thru next review date; Approaches: [MEDICATION NAME] as ordered PRN; Observe effectiveness of meds; 10/20/14 [MEDICATION NAME] PRN as Rx for toothache. Interview with the ADON on 10/23/14 at 11:51 am revealed that the pain scale is completed at the end of the shift and pain medications that are given should be documented on the MAR.

Based on observation, interview, and record review, the facility failed to provide dental services for 1 of 1 resident (#113) sampled for a dental review. The deficient practice of the facility failing to address resident #113's dental problems caused actual harm to the resident, in that she experienced significant pain which affected her ability to chew her food. Cross reference to F309 and F412. Findings include: Review of the facility's undated Dental Policy and Procedure revealed the facility would assist residents in obtaining routine and 24 hour emergency dental care. The procedure was, when a resident needed dental care, he/she would be referred to the appointment setter either by nursing, by the resident, by the physician, through the care plan meeting, or by the family. The appointment setter would then fax the face sheet to the dentist's office. A copy of the list would be placed in the dental book in the social services office. The appointment setter would then follow-up with residents who were able to make their own decisions because they may or may not refuse the services. If the dental recommendations were not covered by Medicare/Medicaid, the appointment setter would advise the resident and/or family and abide by their decision to proceed or not proceed. The appointment setter would then assist the resident/family in making the dental transportation arrangements. Review of resident #113's dental consultation dated 1/8/14 revealed the resident was seen for a complete evaluation. The consultation found that the resident's lower teeth were hopeless (teeth with severe attachment loss) and recommended multiple extractions with alveoplasty (surgical shaping of the dental alveoli and alveolar processes especially after extraction of several teeth or in preparation for dentures). It indicated medical clearance was needed from the primary physician in order to perform the procedure. Antibiotics were recommended starting the day before the extractions. Review of the medical clearance form dated 1/8/14 revealed resident #113 was Diabetic, Hypertensive, and taking an anti-coagulant. The clearance form included a request for the physician to provide considerations before the dental treatment. It indicated the resident needed multiple extractions with alveoplasty. The rest of the form was blank. It included sections regarding whether there were any contraindications, whether the resident needed pre-medications, whether there were local anesthetic restrictions, whether there was a need to stop any medications, and whether there were any other precautions needed. It also included a signature line for the physician. Record review of nurses' notes dated 1/8/14 at 2:30 pm revealed, the resident returned from a dental appointment in stable condition with an order for [REDACTED]. Record review of a nurses' note dated 1/13/14 at 8:00 pm revealed the 7am-7pm nurse gave a report that the resident's tooth extractions would be re-scheduled. The patient's family wanted the tooth extractions scheduled with the facility's dentist and the date was unknown at the time. Staff notified the physician, who discontinued the previous orders and indicated that new orders would be given when the date of the extraction was known. Record review of a nurses' note dated 1/21/14 at 1:30 pm revealed the nurse spoke to a Social Services staff member in regards to the dental appointment being re-scheduled. The Social Services staff member said there was insurance verification pending with a new appointment. There was no other nurses note regarding the resident's planned extractions or re-scheduling of the appointment up through 10/22/14. There was no indication in the rest of the resident's record from January 2014 to October 2014 that she ever got the extractions. Record review of a psychologist's progress note dated 10/20/14 revealed resident #113 complained of mouth pain and stated that she had to go to the dentist. The psychologist noted an intervention to encourage the resident to talk to her son to make an appointment with the dentist. Interview with resident #113 on 10/21/14 at 10:08 am revealed she had pain in her teeth. The pain was especially prevalent when she chewed. She could not chew food on the right side of her mouth because of the pain. She said she told the social worker in order to try to get an appointment with the dentist but the social worker had not gotten back to her. She also indicated that she told her son about it because she felt facility staff was likely ignoring her. Observation on 10/22/14 at 8:51 am revealed resident #113 was seated in her wheelchair and had her breakfast tray in front of her. She had 2 slices of toast, a hard boiled egg, and hash. She also had coffee and juice. She drank the coffee with a straw and then dipped the toast in the coffee. She put the toast in the left side of her mouth. As she chewed she had a pained facial expression. She said she had pain in her mouth right now. She turned down her lip and showed a mouth sore on the inside of her bottom lip on the right side. Interview with resident #113 on 10/23/14 at 9:06 am revealed she said she ate her breakfast this morning. She said she has pain in her mouth and pointed to the lower right side of her mouth. She turned her lip down and there was a visible mouth sore on the inside of her bottom lip. Interview with the facility's Social Services Director (SSD) on 10/23/14 at 9:20 am revealed the Social Services department is responsible for dental consultations. She said there is an appointment setter that works for Social Services who makes all the dental appointments. Interview with the facility's appointment setter on 10/23/14 at 9:24 am revealed she said she usually gets a communication form from the nurse with a telephone order from the doctor regarding dental consultations. The facility works with two dental companies (dental company A and dental company B). She explained the process for scheduling dental consultations with both companies. First, she contacts the company and lets them know the resident's specific dental issue and tells them that the resident needs to be seen urgently. Then, she faxes them the demographics and the physician's telephone order. Next, the dental office calls her and lets her know when the dentist is going to come see the resident or whether the resident has to go out to the dental office. The appointment setter said resident #113's son came to her and let her know that he didn't want to use dental company A so she moved the resident to dental company B. Dental company B's dentist visited the facility on 10/10/14, but the resident was not in her room. The dentist did not see the resident that day. The appointment setter explained that resident #113's son let her know that resident #113 had mouth pain. She explained that the dentist would have to do x-rays to see what is actually going on. She explained that the resident's mouth pain had been ongoing for about a week. She found out the resident had mouth pain first when the son spoke to her. She provided a communication form from nursing dated 10/18/14. She said the dentist is coming either today or tomorrow. She called dental company A who told her that they had no records for resident #113 from January 2014 but on April 8, 2014 they evaluated the resident. They called the facility to coordinate an extraction but the resident had been disenrolled from the program. She then contacted the resident's son and he denied disenrolling the resident from dental company A and was not aware of the orders for extraction in January 2014. The appointment setter could not explain who had disenrolled resident #113 from dental company A. Review of the communication form dated 10/18/14 revealed it was completed by a night nurse, staff A. The form indicated that the resident may be in need of a dental consult because she complained of mouth pain almost daily. Interview with the facility Social Services Director on 10/23/14 at 9:45 am, revealed she said she was not aware of the January 2014 scheduled extraction that did not take place. She was unable to explained why the dentist came to the facility on [DATE] but left without seeing resident #113 aside from saying that the resident was not in her room and may have been on the patio with her son. She could not explain whether any staff member attempted to find the resident in order for her to see the dentist or whether any staff member spoke to the dentist regarding the resident's whereabouts.