Every finding on record at Creekside Village

Based on record review and interview, the facility failed to ensure that the resident representative was promptly notified of a significant change in the resident's condition for 1 of 7 Residents (Resident #1) reviewed for notification. Specifically, the facility did not notify Resident #1's RP following an unwitnessed fall that occurred on 3/19/2026. This failure has the potential to delay the representative's involvement in the resident's care and decision making. The findings included: Record review of Resident #1's face sheet dated 4/09/2026 revealed a [AGE] year-old male admitted to the facility on [DATE], readmitted on [DATE] and discharged on 04/03/2026 with diagnoses that included traumatic subdural hemorrhage(injury causing bleeding under the outer covering of the brain), Peripheral vascular disease (poor blood flow in the vessels outside of the heart and brain), dementia (a decline in memory and thinking that makes it hard to do everyday activities), legal blindness, and repeated falls. Record review of Resident #1's MDS 5-day reentry assessment dated [DATE] revealed the resident has a severely impaired vision and BIMS was zero, which indicated severely impaired cognition and resident needs maximal assistance with activities of daily living. Record review of Resident #1's care plan dated 4/09/2026 revealed Resident #1 was High risk for falls r/t Vision/ problems, weakness. Resident #1 had falls on 1/18/26 unwitnessed no injury, 1/19/26 fall from wheelchair reaching to get shoes no injury, 02/09/2026 - fall during staff assistance, and 3/19/2026 - unwitnessed no injury and c/o pain to right hip, X-ray ordered- no fracture. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Educate CNAs, when getting resident up in the morning CNAs need to make sure residents are fully dressed. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Record review of the facility's incident log dated 4/09/2026 revealed that Resident #1 sustained an unwitnessed fall on 3/19/2026. Further review of the incident documentation dated 3/19/2026, indicated that the DON and the physician were notified. However, there was no documentation to indicate that Resident #1's RP was notified of the incident. During an interview with Resident #1's RP on 4/9/2026 at 9:35 a.m., she stated that her father (Resident #1) had a fall on 3/19/2026 and no one from the facility notified her of the fall. During an interview with RN F on 4/9/2026 at 1:19 p.m., she stated that Resident #1 was identified as a fall- risk resident and sustained an unwitnessed fall on 3/19/2026, during the night shift. She stated that the incident occurred during the night shift and she was unaware of the reason the assigned nurse did not notify the RP. She indicated that notification should have occurred either during the night shift or been communicated to the day shift for follow - up. She further stated that she was unaware the RP had not been notified, as this information was not communicated to her during shift report. She stated failure to notify the RP compromises effective communication and advocacy for the resident and limits the family's awareness of the resident's condition and care needs. During an interview with DON on 4/9/2026 at 2:15 p.m., she stated that Resident #1 was identified as a fall-risk resident and had fall interventions in place. The DON stated upon review of the report, the DON noted that the nurse documented notification of the physician and the administrator; however, there was no documentation that the RP had been notified. She stated that, based on information obtained from the nurse, the nurse chose not to notify the family during the night shift to avoid disturbing them. The DON further stated that she did not know why the information was not communicated during shift report so the day shift nurse could follow up with the notification. The DON stated that the facility expectation was that any fall, whether witnessed or unwitnessed and with or without injury, was considered a change in condition and must be reported through the appropriate channels, including notification of the RP. The DON stated that failure to notify the RP could prevent the family from being aware of the resident's condition, delay decision-making, and limit their ability to participate in the resident's care and welfare. During an interview with Administrator on 4/10/2026 at 11:55 a.m., she stated she was aware that Resident #1 sustained a fall on 3/19/2026; however, she was not aware that the RP had not been notified. She stated that facility's expectation was that any fall, whether witnessed or unwitnessed, was considered a change in condition and must be reported, including notification of the resident's RP. Upon review of the incident report for that date, there was no documentation indicating that the RP was notified. The Administrator stated that although the incident occurred after midnight, the nurse could have communicated the information to the day shift for follow-up; however, she was unable to explain why this did not occur or why the RP was not notified.The Administrator stated that failure to notify the RP may result in delayed communication, lack of timely intervention, and limited involvement of the resident's representative in care decisions. During an interview with ADON on 4/10/2026 at 12:12 p.m., ADON stated that when a resident falls, staff are expected to obtain vital signs, initiate neurological checks, notify the DON and Administrator, physician and RP of the resident. She stated that notification should still occur, even if delayed until morning. She further stated that failure to notify the RP would prevent proper communication and advocacy for the resident and limit the family's awareness of the resident's condition and care needs. During an interview with LVN C on 4/10/2026 at 12:28 p.m., she stated she was not informed the RP had not been notified of the unwitnessed fall dated 3/19/2026, and it was not reported during shift change. She stated that in the event of fall, staff are expected to RP of the resident. She stated that failure to notify the RP would prevent family awareness of potential injuries and delay the representative's involvement in the resident's care and decision making. During a telephone interview with LVN B on 4/14/2028 at 7:58 a.m., LVN B stated that the incident occurred during the night shift. She stated that she notified the physician and the Administrator; however, she did not notify Resident #1's RP because it occurred in the middle of the night, there was no apparent injury, and she did not want to wake the family. LVN B stated that she reported the incident to the day shift nurse but was unable to recall the name of the nurse. She stated that the RP may not be aware of changes in the resident's condition, which could impact ability to make informed decisions regarding the resident's care and services if not notified. She stated that she was expected to notify the RP but failed to do so due to the time of the incident and concern about disturbing the family. Record review of the facility document titled Resident Rights revised on February 2021, and document titled Falls - Clinical Protocol revised in March 2018, did not address the facility's notification of falls to resident responsible party.

Based on observation, interview and record review the facility failed to provide personal privacy when providing personal care for 1 (Resident #1) of 5 residents observed for personal care. -CNA A failed to provide privacy for Resident #1during incontinent care This failure placed residents at risk for their loss of dignity, respect, and psychological distress. Findings:Record review of Resident #1's face sheet dated 09/06/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 05/08/24. Resident diagnoses included age related cataract, overactive bladder, hemiplegia (complete paralysis or loss of strength on one side of the body) and hemiparesis (partial weakness or loss of muscle strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), epilepsy (when nerve cell activity in the brain is disrupted, causing seizures), and anxiety (continuous worry, fear, and nervousness that can interfere with daily life). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact.[JM1] Record review of Resident #1's Comprehensive Care Plan dated 05/16/24 and revised 08/01/25 revealed that resident was being care planned for bladder incontinence. Observation of incontinent care for Resident #1 on 09/26/25 at 11:30AM by CNA A. CNA A entered Resident #1's room and proceeded to transfer Resident #1 from her wheelchair to her bed. Resident #1's roommate was sitting in a chair on the left side of Resident #1's bed in a recliner chair. CNA A did not pull Resident #1's privacy curtains. CNA A proceeded to remove Resident #1's pants that were soiled in urine. Resident #1's brief was heavily soiled in urine. After cleaning resident, CNA A then placed a clean brief on resident along with clean pants. Interview on 09/26/25 at 11:45AM, CNA A said she worked at the facility full time for over 2 years. CNA A said she worked the 6AM-6PM shift. CNA A said she should have pulled Resident #1's privacy curtains when providing care for Resident #1. CNA A said she was nervous and therefore made a mistake.Interview on 09/26/25 at 12:45PM, the DON said whenever a resident is administered care including incontinent care they should be provided privacy by pulling the privacy curtains due to most of the residents having roommates. The DON said by doing this, it not only promotes resident dignity, but it also promotes a sense of security. Interview on 09/30/25 at 11:30AM, Resident #1 said when she was being provided with incontinent care, she preferred that the staff pulled her curtain for her privacy. Resident #1 said it was important to pull her privacy curtain because she never knew when someone might come into the room leaving her exposed. Resident #1 said if this happened, she would be embarrassed. Record review of the Nursing facility policy on Resident Rights dated February 2021 reflected in part: .Employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review the facility failed to provide resident with care and services for 1 (Resident #1) of 5 residents reviewed for activities of daily living care, in that: CNA B failed to check Resident #1 for incontinence and provided incontinent care every 2-3 hours. CNA A failed to thoroughly clean Resident #1 during incontinent care when resident pants were soiled and brief was heavily soiled in urine. This failure placed resident at risk for not being provided the care and services needed. Findings: Record review of Resident #1's face sheet dated 09/06/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 05/08/24. Resident diagnoses included age related cataract, overactive bladder, hemiplegia (complete paralysis or loss of strength on one side of the body) and hemiparesis (partial weakness or loss of muscle strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), epilepsy (when nerve cell activity in the brain is disrupted, causing seizures), and anxiety (continuous worry, fear, and nervousness that can interfere with daily life). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Further review section GG Functional abilities reflected that resident was dependent on toileting hygiene and required partial to moderate assistance with personal hygiene. Further review section H-Bladder and Bowel reflected that Resident #1 was always incontinent with urine and frequently incontinent of bowel. Record review of Resident #1's Comprehensive Care Plan dated 05/16/24 and revised 08/01/25 revealed that resident was being care planned for bladder incontinence with an intervention to check and change resident every 2-3 hours and PRN. Further review of interventions included wash, rinse, and dry resident perineum (the area of the skin and underlying tissue located between the anus {where stool exits the body}) and the vulva (area outside of a female genital area located at the entrance of the vagina). Observation on 09/26/25 at 11:28AM of Resident #1 sitting in wheelchair by the nurse station telling the staff she needed to be changed. Observation on 09/26/25 at 11:30AM of CNA A providing incontinent care for Resident #1. CNA A entered Resident #1's room wearing gloves and carrying a pack of disposable wipes. CNA A proceeded to transfer the resident from the wheelchair to her bed. CNA A proceeded to remove Resident #1's pants that were soiled in urine. Resident #1's brief was heavily soiled in urine. CNA A began to clean resident first starting with the buttocks clean back and forward with the same wipe instead of cleaning resident one wipe at a time. After cleaning resident buttocks, CNA A then placed a clean brief on resident without cleaning resident perineal area (area located between the anus and external genitalia in both male and females). After cleaning resident, CNA A then changed her gloves and placed cleaned pants on resident. Interview on 09/26/25 at 11:37AM, Resident #1 said the last time her brief had been changed was on the night shift around 5:30AM. The resident said she had not refused care. Interview on 09/26/25 at 11:45AM with CNA A said she worked at the facility full time for over 2 years. CNA A said she worked the 6AM-6PM shift. CNA A said she was supposed to wash her hands before placing on gloves to care for Resident #1. CNA A said Resident #1 was a heavy wetter. CNA A said she should have cleaned Resident #1 from front to back instead of starting with resident buttocks. CNA A said providing incontinent care at least every 2-hours and as needed, cleaning the residents thoroughly from front to back was important in preventing the spread of bacteria that could lead to urinary tract infections. CNA A said the reason she was making mistakes was because she was nervous. CNA A said she was not the CNA for Resident #1 and that CNA B was. CNA A said she was just helping CNA B. Interview on 09/26/25 at 12:45PM the DON said incontinent care should be provided to the residents every 2 hours and as needed. Interview on 09/26/25 at 1:25PM CNA B said she worked at the facility from 6AM-6PM full time since July of 2025. CNA B said she was the CNA assigned to Resident #1. CNA B said the last time she provided incontinent care for Resident #1 was between 7:30AM or 7:45AM but missed the next round for incontinent care. CNA B said incontinent care should be provided to the residents at least every 2 hours and that was the facility policy. Record review of the Nursing facility policy on Perineal Care dated February 2018 reflected in part: .The purpose of this policy procedure are to provide cleanliness and comfort to the resident to prevent infection and skin irritation, and to observe the resident's skin condition.For female residents.wash perineal area front to back separate the labia and was area downward form front to back.Continue to wash the perineum moving from inside outward to the thigh, rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.rinse and dry thoroughly.

Based on observation, interview and record review the facility failed to establish and maintain, and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 (Resident #1) reviewed for infection control. -CNA A did not practice hand washing/hand hygiene prior, during, and after providing incontinent care for Resident #1 -CNA A did not transport soiled linen in plastic bag. -CNA A removed disposable wipes from Resident #1's room and placed them back on cart in the hallway. These failures placed residents at risk for infections and cross contamination. Findings: Record review of Resident #1's face sheet dated 09/06/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 05/08/24. Resident diagnoses included age related cataract, overactive bladder, hemiplegia (complete paralysis or loss of strength on one side of the body) and hemiparesis (partial weakness or loss of muscle strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), epilepsy (when nerve cell activity in the brain is disrupted, causing seizures), and anxiety (continuous worry, fear, and nervousness that can interfere with daily life). Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Further review section GG Functional abilities reflected that resident was dependent on toileting hygiene and required partial to moderate assistance with personal hygiene. Further review section H-Bladder and Bowel reflected that Resident #1 was always incontinent with urine and frequently incontinent of bowel. Record review of Resident #1's Comprehensive Care Plan dated 05/16/24 and revised 08/01/25 revealed that resident was being care planned for bladder incontinence. Observation on 09/26/25 at 11:30AM of CNA A providing incontinent care for Resident #1. CNA A entered the resident room wearing gloves and carrying a pack of disposable wipes. CNA A proceeded to transfer the resident from the wheelchair to her bed. CNA A proceeded to remove Resident #1's pants that were soiled in urine. Resident #1's brief was heavily soiled in urine. CNA A did not change gloves and sanitize her hands instead, proceeded to provide incontinent care. When CNA A completed incontinent care, she did not change gloves, wash or sanitize her hands but proceeded to transport the soiled linen in her hands walking out of the room down the hallway. After CNA A placed the soiled linen inside of the barrel, she removed her gloves and sanitized her hands. CNA A returned to Resident #1's room and removed the package of disposable wipes from resident room and placed the wipes back on the cart in the hallway. Interview on 09/26/25 at 11:45AM with CNA A said she worked at the facility full time for over 2 years. CNA A said she worked the 6AM-6PM shift. CNA A said she was supposed to wash her hands before placing on gloves to care for Resident #1. CNA A said soiled linen was supposed to be transported inside of a bag for infection control. CNA A said she was instructed not to leave disposable wipes in a resident's room when done providing care, but to return them to the cart in the hallway. CNA A said she was told this because staff were overstocking the resident rooms with personal care items. CNA A said she received in-service on this last week. CNA A said the reason she was making mistakes was because she was nervous. Interview on 09/26/25 at 12:45PM the DON said she was the Infection Control Preventionist. The DON said the staff should be practicing hand hygiene before, during, and after care. The DON said soiled linen should be transported in a bag for infection control and to prevent cross contamination. The DON said once personal care items including disposable wipes are taken in the resident room, staff should not be taking them out of the room to place back on the cart. The DON said this placed the residents at risk for cross contamination. The DON said the staff was in-serviced on not leaving personal care items at the bedside but inside the resident drawer. Record review of the facility policy on Infection Control dated October 2018 reflected in part: .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. Record review of the facility policy on Departmental (Environmental Services) Laundry and Linen dated January 2014 reflected in part: .The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.Consider all soiled linen to be potentially infectious and handle with standard precautions. Record review of the facility policy on Handwashing/Hand Hygiene dated October 2023 reflected in part: .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for hand hygiene.Immediately before touching resident.After touching a resident.Immediately after glove removal.The use of gloves does not replace handwashing/hand hygiene.

Based on interview and record review the facility failed to ensure within 14 days after a facility completed a resident assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 15 residents (Resident #34) reviewed for MDS transmission. The facility failed to transmit a completed Quarterly MDS assessment for Resident #34 within 14 days of completion. This failure could place residents at-risk of not having their assessment/s completed timely, which could result in denial of services and or denial of payment for services. Findings include: Record review of Resident #34's admission Record revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #34 had diagnoses which included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), Alzheimer's Disease with late onset (a progressive disease that destroys memory and other important mental functions), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis and weakness on one side of the body caused by damage to brain after a blood clot or stroke), dysphagia (difficulty swallowing foods or liquids), type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy) and gastrostomy status (surgical procedure that creates an opening through the abdominal wall into the stomach for the purpose of feeding or receiving nutrition). Record review of Resident #34's Quarterly MDS assessment, dated 1/14/25, revealed the assessment was signed as completed on 1/15/25 and accepted by the CMS system on 1/31/25. The date of 1/31/25 was highlighted in red. Telephone interview on 6/18/25 at 1:01 PM with the Director of Reimbursement, she said the red highlighted date of 1/31/25 meant that the Quarterly assessment was accepted and or transmitted late. She said if the ARD was 1/14/25 and the assessment was signed as completed on 1/15/25, but the accepted transmission date was on 1/31/25, that was a 16- day instead of 14-day transmission timeframe and 16 days would be late. The Director of Reimbursement said the completion, submission, and transmission of any facility MDS assessments were the responsibility of the facility MDS Coordinator, but the facility was without an on-site MDS Coordinator for many months. She said the facility used the RAI as the policy and procedure for completion, accuracy, submission, and transmission of MDS assessments. Interview on 6/18/25 at 1:03 PM with the Corporate VP of Operations, she said the facility did not have an assessment policy and the facility used the RAI Manual for assessments. She said the expectation of the facility was for the RAI Manual to be followed, and moving forward, the responsibility for MDS assessments at the facility were the MDS Coordinators. Interview on 6/18/25 at 1:12 PM with MDS Coordinator A, she said she was not employed at the facility when Resident #34's Quarterly MDS assessment was completed back on 1/15/25. MDS Coordinator A said they had only worked at the facility since 6/2/25 and said the facility used the RAI Manual as its policy and procedure completing MDS assessments. She said according to the RAI Manual Resident #34's 1/14/25 Quarterly MDS assessment, should have been transmitted by the 14th day and not the 16th day. MDS Coordinator A said they had been trained by the Director of Reimbursement. Follow up interview with MDS Coordinator A on 6/18/25 at 2:54 PM, they said Resident #34 could potentially not receive needed therapy or services due to assessments not being transmitted on time. She also said there could be a delay in reimbursement, or payments could be taken back by CMS if assessments were not completed, submitted, or transmitted correctly according to the RAI Manual. Record review of the CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment, revised 11/2019, revealed: 5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing. Assessment Transmission .All other MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 resident (Resident #257) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Buspirone HCI 10MG, Klonopin 0.5 MG, Olanzapine 5 MG and Veriafaxine HCI ER 75 MG that was administered to Resident #257. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings include: Record review of Resident #257's face sheet dated 03/26/24 revealed she was an [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of Cerebral infraction , Major Depressive Disorder, Unspecified fracture of upper end of left Humerus, Bacteria Pneumonia, UTI, Esophageal Reflux Disease, Anemia, Hypo-Osmolality and Hyponatremia, Epilepsy, Altered Mental Status. Record review of the comprehensive MDS assessment, dated 03/26/2024, revealed Resident #257 was able to complete MDS. Interview on 4/22/24 at 9:00am with MDS Nurse Resident was able to complete MDS and she was not able to put BIMS score in. Based off interaction with Resident # 257 her BIMS would be 13. The MDS nurse stated that Resident # 257 may have had some short term and long-term memory problems but was not sure due to Resident being in and out of facility. Record review of Resident #257 revealed that Resident# 257 uses antipsychotic medication Venfaxine HCL ER 75 MG related to Depressive Disorder, medication was given on the following dates 3/30,31/24, Buspirone HCI 7.5 MG was given on3/27, 3/28,3/29,3/30,3/31, 4/1, 4/21/4/22Olanzapine 5MG was given on the following dates3/21,3/22 and Klonopin 0.5 MG on 4/22/24 Record review of Resident #257 physician's order summary report revealed the following order: Medication is to be given as follow: Buspirone HCI 10MG 1 tablet orally twice a day, Klonopin 0.5 MG 1 tablet once a day, Olanzapine 5 MG and Veriafaxine HCI ER 75MG 1 tablet once a day. Record review of Resident #257 history and physical dated 3/27/24 revealed the following anti psych medications: Venlafaxine HCi 75 MG tablet with food orally once a day, Buspirone HCI 7.5 MG tablet orally twice a day, Fluoxetine HCI 20 MG tablet 1 tablet orally once a day. Record review of Resident #257 history and physical dated 3/27/24 revealed the following diagnosis of Resident #257: Seizure, HLD, GERD, HTN, Anxiety, MDD and CVA Interview on 4/23/24 at 10:00 am with DON stated orders to give Resident#257 antipsychotic medication came from the doctor of Oceans Behavior Hospital and our doctor here at the facility followed the orders from the hospital and medication was for her behaviors of yelling, smearing feces and throwing herself to the floor. Interview on 04/23/24 at 10:43 AM, the DON stated [NAME] a nurse received an order for a psychotropic, they should make sure they have consents. If a resident does not have consent the nurse should contact the management nurse and the management nurse would let the doctor know. The DON stated all charge nurse should check for signed consents on a daily basis due to medications changes on daily basis. The DON was asked why it is important to inform a resident of the risk and benefits of the medication. The DON stated that it is every resident's right to be informed about the treatment and medication they received. Interview on 04/23/24 at 11:05 AM, the charge nurse stated that she was aware that Resident #257 was diagnosed with depression and had been order the medication, related to yelling out, mood disturbance, and agitation. The Charge Nurse stated Resident #257 was initially admitted on [DATE] with the diagnosis of depression. The Charge Nurse stated that Resident #257 was initially ordered Venfaxine HCL ER 75 MG 1 capsule by mouth daily with a started date of 3/26/24 related to Resident #257 behavior of yelling out. The Charge Nurse stated that Resident #257 had frequency changes to the medication on 3/29/24 and an additional change to the medication frequency on 3/29/24 to 75 MG 2 capsule by mouth daily. The surveyor requested the documented consent for antipsychotic medication treatment for Resident #257. The Charge Nurse stated that the facility did not have a current consent for treatment. The Charge Nurse stated that she was working on obtaining consent from Resident #257's POA. The Charge Nurse stated Resident #257 was always in out of psych hospital since her admission. The Charge Nurse was asked why it is important to inform a resident of the risk and benefits of the medication. The Charge Nurse stated that it is every resident's right to be informed about the treatment and medication they received. Record review of the facility's policy last revised January 2023, titled Psychotropic medication use, revealed the following: o Prior to administration of or with a change in the dosage of an antipsychotic medication, the facility shall obtain informed consent from the resident/resident representative. This will be documented on form 3713 in conjunction with the resident/resident representative, attending physician and/or psychiatrist and the facility staff.

Based on interview and record review, the facility failed to ensure resident assessments were completed,, electronically transmitted, encoded accurately and , MDS data entered to the CMS System within 7 to14 days after the death for 1 of 16 residents (CR #56) reviewed for encoding and transmitting resident assessments: - The facility failed to encode and transmit MDS data after the a Death in Facility for CR #56 within the required timeframe This failure could place discharged residents at risk of not having their assessments transmitted/exported timely. Findings include: Record review of Resident #56's electronic face sheet dated 4/24/24 revealed a -[AGE] year-old female admitted to facility 03/12/24. Her diagnoses included Malignant neoplasm (Cancer) of left lung. Record review of CR #56's MDS assessment dated [DATE] indicated section A identifying information was initiated and signed by the MDS coordinator as completed on 04/01/24. Record review of the MDS revealed no RN signature as completed. Record review of nurse's notes dated 03/15/24 read in part 3/15/2024 04:55 Nursing Progress Note: Hospice nurse notified local PD and res son. Meds released to [NAME] PD. Nursing 3/15/2024 04:01 Nursing Progress Note: Hospice nurse here and pronounced time of death. Nursing 3/15/2024 03:40 Nursing Progress Note: Resident noted to have no respiration, no heartbeat. Pupils non-reactive to light. Notified Hospice. During an interview with MDS Coordinator and the DON on 04/24/24 at 4:50PM, she looked at the MDS and said CR #56 came to the facility to die. She said the MDS was not completed because she had to work on the floor. She said that was when she was needed to work the floor. Policy on MDS completion was requested on 04/24/24 at 5:00 PM The MDS Coordinator said she followed the RAI manual in submitting the MDS.

Based on Record review and interview, the facility failed to develop and implement a Baseline Care Plan for resident 1 of 1 (CR #56) reviewed for baseline care plans. The facility failed to initiate a Baseline Care plan within 48 hours of admission for CR # 56 admitted for respite care on 03/12/24. This failure could place the resident at risk of not receiving person-centered care that is needed for communicating with staff to ensure the resident's needs are met. Findings include: Record review of Resident #56's electronic face sheet dated 4/24/24 revealed a -[AGE] year-old female admitted to facility 03/12/24. Her diagnoses included Malignant neoplasm (Cancer) of left lung. Record review of CR #56's MDS assessment dated [DATE] indicated section A identifying information was initiated and signed by the MDS coordinator as completed on 04/01/24. Record review of the MDS revealed no RN signature as completed. Record review of nurse's notes dated 03/15/24 read in part 3/15/2024 04:55 Nursing Progress Note: Hospice nurse notified the local PD and responsible party. Meds released to local PD. 3/15/2024 04:01 Nursing Progress Note: Hospice nurse here and pronounced time of death. 3/15/2024 03:40 Nursing Progress Note: Res noted to have no respiration, no apical heartbeat. Pupils non-reactive to light. Notified Hospice. Record review of Resident #56's physician orders 03/12/24 revealed Resident #56 was admitted to the facility on hospice. Record review of Resident # 56 clinical records revealed no further documentation. During an interview with DON and the MDS coordinator on 04/24/24 at 4:00pm, the MDS coordinator said Resident # 56 came to the facility to die. The DON said there was no interim plan of care. She said it was the facility's policy to complete and interim plan of care within 48 hours of admission by the admitting nurse or the next nurse on duty. She said this was overlooked due to the fact that the resident was at the facility for a short stay. Record review of facility's policy titled Baseline care plan dated 2001 updated 2016 read in part- Policy Statement A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders. b. Physician orders. c. Dietary orders. d. Therapy services. e. social services; and f. PASARR recommendation, if applicable. 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on observation, record review, and interview, the facility failed to follow written policies on permitting residents to return to the facility after they were hospitalized or placed on therapeutic leave for 1(CR #1) of 11 residents reviewed for admission, transfer, and discharge. The facility failed to readmit CR #1 after he was hospitalized . This failure could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health. Findings include: Record review of CR #1's face sheet dated 10/25/23 revealed he was [AGE] year-old male admitted to the facility on [DATE] . His diagnoses included, Heart disease, essential hypertension (High blood pressure), Dementia, unspecified severity with other behavior, heart disease, chronic obstructive pulmonary disease, alcohol abuse, insomnia (difficulty falling asleep), legal blindness, hypothyroidism (thyroid disease), vitamin d deficiency, glaucoma, respiratory disorders, and major depression Record review of CR #1's Quarterly MDS assessment dated [DATE] indicated his BIMS score was coded as severely impaired. Record review of his PASRR assessment indicated he was positive for mental illness. Record review of CR #1's nurse note dated 3/14/2023 12:08 read in part : Patient transferred to local behavioral hospital. 3/14/2023 10:10 Nursing progress note: pt initiated physical aggression and struck another resident on the face and was unprovoked. resident taken to room again and continues q 15 min checks. 3/14/2023 08:10 Nursing progress note: pt initiated physical aggression and struck 3 employees. pt isolated in assigned room and placed on q15min checks. Record review of CR #1's clinical records revealed no evidence of discharge letter that was provided to CR #1. During an interview on 10/24/23 at 1:40 PM, Hospital staff said CR #1 was admitted to the hospital on 03/14/23 due to behavior. She said on 03/24/23, CR #1 was cleared for discharged . She said several attempts were made by the hospital, to discharge CR# 1 back, but the facility refused to accept CR #1 back. In an interview with the Social Service Director on 10/25/23 at 3:30 PM, she said CR #1 had behavior problems and was attacking staff and residents. She said the former administrator said not take the resident back because the facility could not meet the needs of CR #1. In an interview with the Administrator and DON on 10/25/23 at 5:30 PM, the Administrator said the DON and herself were new to the facility. The DON said she started September 25th . The Administrator said most of the staff at the facility are new. The ADON just started about a week ago. The Administrator said normally the facility would accept residents sent out for treatment back and re assess the resident to see what can be done and if unmanageable the facility would assist the resident in locating a place that can meet the needs of the resident. Record review of facility's policy dated 2001 Revised December 2016 did not address emergency discharge and permitting residents to return to the facility after being sent out to hospital for evaluation.

Based on observation, interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that [NAME] professional standards of quality care for 1 (Resident #120) of 5 Residents reviewed for care plans. -The facility failed to develop a 48-hour baseline care plan for smoking, with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #120. This deficient practice could affect the residents not having their individual, medical, functional, and psychosocial needs identified, appropriately addressed, and could cause physical or psychosocial decline in health. Findings include: An observation and interview on 2/10/2023 at 12:30 pm., with Resident #120, Resident #120 was standing in her room, groomed, she said that when the smokers went out to smoke at least 1 to 2 staff were present to supervise them all the time. Interview on 2/22/2023 at 11:14 am., with the MDS Coordinator, she said that the MDS assessment for Resident #120 had not been completed, that the facility had 14 days after admission to get the MDS completed based on the RAI manual. Interview on 2/24/2023 at 10:22 am., with the MDS Coordinator, she said that Resident #120's baseline was not completed for smoking. She said she has the responsibility to make sure this is done. She said that Resident #120 had the potential to have unsafe smoking habits and/or environment without the base line care plan to address smoking. Record review of the facility admission record dated 2/22/2023 revealed Resident #120 was admitted on [DATE]. Resident #120 was a 60-year- old female. Resident #120 had diagnoses that included pneumonia (an infection of the lungs that can cause mild to severe illness in people of all ages) and hypertension (elevated blood pressure is defined as a systolic pressure 120 to 129, and a diastolic pressure less than 80). Record review of the 48-hour baseline care plan dated, 2/14/2023 for Resident #120 revealed there was no baseline care plan initiated for smoking. Record review of Resident #120's Admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that the MDS had not been completed. Record review of the facility smoker list, no date provided revealed that Resident #120 was listed as a smoker. Record review of the facility policy entitled Care Plans-Baseline, dated revised December 2016, read in part .a baseline plan of care to meet the resident's immediate needs shall be developed for each resident withing forty-eight (48) hours of admission .

Based on record review and interview the facility failed to revise and update a Comprehensive care plan for 1 (Resident #8), of 24 residents reviewed for comprehensive care plans in that: Resident #8 readmitted to the facility with an active diagnosis of Urinary Tract Infection (UTI) and the care plan did not address her diagnosis of infection. Resident #8's care plan did not address her antibiotic medication. These failures could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs. The Findings Include: Resident #8 Record review of an undated facility Admission Record revealed Resident #8 was an [AGE] year old female who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, urinary tract infection, with an onset date of 12/27/2022 and Rank, Primary, abnormalities of gait (a person's manner of walking) and mobility, cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and other specified aftercare. Record review of Resident #8's Quarterly/5-day MDS dated [DATE] revealed she had a BIMS score of 9 indicating she had a moderate cognitive impairment. Further record review of section I, Active Diagnoses, revealed she coded under infections Urinary Tract Infection (UTI) (Last 30 Days). In section N for Medications, she was coded under medications received . within the last 7 days or since admission/entry or reentry for 7 days of antibiotics. Record review of Resident #8's physician Order Summary Report dated as Active Orders As Of: 01/01/2023 revealed the following entry, Amoxicillin Capsule 500 MG Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED .for 10 Days .Communication Method .Verbal .Order Status .Active .Order Date .12/27/2022 .Start Date .12/27/2022 .End Date 01/06/2023. Amoxicillin Tablet 500 MG 1 Tablet by mouth every 12 hours related to URINARY TRACT INFECTION, SITE NOT SPECIFIED .for 5 Days ADMINISTER 1 TABLET Q12HR X 5 DAYS .Communication Method .Verbal .Order Status .Active .Order Date .01/01/2023 .Start Date .01/01/2023 .End Date .01/06/2023. Cefdinir Capsule 300 MG Give 1 capsule by mouth two times a day for UTI for 14 Days .Communication Method .Phone .Order Status .Active .Order Date .12/26/2022 .Start Date .12/27/2022 .End Date .01/10/2023. Record review of Resident #8's MA Administration Record dated 12/1/2022-12/31/2022 and read in part, Amoxicillin Capsule 500 MG Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 10 Days .and was initialed with a check mark as being administered on 12/27/22, 12/28/22, 12/29/22, 12/30/22, and 12/31/22. Record review of Resident #8's MA Administration Record dated 1/1/2023-1/31/2023 and read in part, Amoxicillin Capsule 500 MG Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 10 Days .and was initialed with a check mark as being administered on 1/1/23. Record review of Resident #8's MA Administration Record dated 1/1/2023-1/31/2023 and read in part, Amoxicillin Tablet 500 MG Give 1 tablet every 12 hours related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 5 Days .and was initialed with a check mark as being administered on 1/1/23, 1/2/23, 1/3/23, 1/4/23, 1/5/23, and 1/6/23. Record review of Resident #8's Care Plan which read Last Care Plan Review Completed: 02/23/2023, revealed her care plan area relating to Resident #8's UTI or any antibiotic medication had not been updated since 06/07/2022, with the following entry: RESOLVED: Resident #8 has (sic) A Urinary Tract Infection .Date Initiated: 03/28/2022 .Revision on: 06/07/2022 .Resolved Date .06/07/2022 .RESOLVED: Give antibiotic therapy as ordered .Date Initiated: 03/28/2022 .Revision on: 06/07/2022 .Resolved Date: 06/07/2022. Record review of Resident # 8's Care Plan which read Last Care Plan Review Completed: 02/23/2023, revealed the resident did not have a plan of care addressing her UTI or prescribed antibiotic medication upon readmission to the facility on [DATE]. Interview with DON and Corporate Nurse on 2/23/23 at 3:21 pm who both said that the MDS Coordinator completed both the comprehensive and acute care plans and would be the person responsible for any resident care plans and or revisions. When they were asked about the care plan for Resident #8, the DON said that there may be resolved care plans that would include the completed antibiotic medication/s and last readmission with a UTI. In a follow up interview with DON on 2/23/23 at 3:53 pm the DON returned with the resolved copies of Resident #8's comprehensive care plans. When the DON was advised that both the current and resolved copies of the care plans, she provided, did not include the 12/27/22 readmission diagnosis of UTI or her prescribed antibiotic medications, the DON said she did not know why the diagnosis and antibiotic medications had not been care planned. The DON said that she did not know how the diagnosis and antibiotic medications had been missed by the MDS Coordinator. When asked who was responsible for ensuring the MDS Coordinator revised and updated the resident care plans, the DON said that there was a Corporate MDS Coordinator that would be the facility MDS Coordinator's oversight. The DON said she did not know the last time the Corporate MDS Coordinator checked or audited the MDS Coordinator's work. Interview with MDS Coordinator on 2/24/23 at 10:06 am who said that she had worked at the facility since September 2022. She said that she had been trained for her position as the facility MDS Coordinator, by the Corporate MDS Coordinator. The MDS Coordinator said that she was responsible for Resident #8's comprehensive, acute and baseline hour care plans. She said that whenever a resident admits or readmits to the facility, she reviews any hospital medical records, physician orders and clinical progress notes to determine what to care plan. When asked why Resident #8 did not have a care plan that addressed her readmission diagnosis of UTI and prescribed antibiotic medication in and round 12/26/22, she said that she just missed it. She said that she must have just missed those care plans and did not know why or how they were missed. The MDS Coordinator said that she realized the mistake when the surveyor requested copies of the resolved and current comprehensive care plans. When asked what could happen as a result of residents' not being accurately or appropriately care planned in a timely manner, she said that a resident could potentially not receive the proper care or medications. The Corporate MDS Coordinator was not interviewed. Record review of facility policy and procedure titled Care Planning-Interdisciplinary Team and dated as Revised September 2013 read in part: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) . Record review of facility policy and procedure titled Care Plans, Comprehensive Person-Centered and dated as Revised December 2016 read in part: 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 .8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change .14. The Interdisciplinary Team must review and update the care plan: c. When the resident has been readmitted to the facility from a hospital stay . Record review of an undated facility policy and procedure titled POLICY AND PROCEDURE (sic) COMPREHNSIVE CARE PLANNING .PURPOSE: ENSURE EVERY RESIDENT HAS A COMPREHENSIVE, COMPLETE, ACCURATE, AND ALL INCLUSIVE SPECIFIC CARE PLAN WRITTEN TIMELY TO MEET ALL REQUIREMENTS OF THE RAI AND REGULATORY PROCESS TO INCLUDE INPUT FROM ALL IDT MEMBERS.

Based on interview and record review the facility failed to implement the admission policy to ensure resident personal property was accounted for upon admission for 3 of 4 residents reviewed for personal inventory list. (Residents #1, #2, and #3) -The facility did not have an inventory of personal property list for Residents #1, #2, and #3. This failure could place residents at risk of not having personal property replaced in the event of damage or loss. Findings included: 1. Review of the face sheet dated 01/14/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included heart attack, mental disorder characterized by a disconnection from reality, and a group of thinking and social symptoms that interferes with daily functioning. Record review of the EMR and hard chart from 12/28/22 through 01/20/23 indicated Resident #1 had no Inventory of Personal Effects. 2. Review of the face sheet dated 01/14/23 indicated Resident #2 was an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease, major depression disorder, and a group of thinking and social symptoms that interferes with daily functioning. Record review of the EMR and hard chart from 12/29/22 through 01/20/23 indicated Resident #2 had no Inventory of Personal Effects. 3. During a phone interview on 01/13/23 at 03:53 p.m. the RP for Resident #3 said the facility did not have them fill out an Inventory of Personal Effects form when Resident #3 admitted . They said Resident #3 had dentures missing and the facility said told them they did not know the resident had dentures. Review of the face sheet dated 01/14/23 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included low red blood counts, protein-calorie malnutrition, stroke, and high blood pressure. She discharged to the hospital on 12/12/22 and did not return to the facility. Record review of the EMR and hard chart from 05/14/22 through 12/12/22 indicated Resident #3 had no Inventory of Personal Effects. During an interview on 01/14/23 at 03:25 p.m. the ADM and DON said the Inventory of Personal Effects was given to the resident RP upon admission for them to fill out what they had brought for the resident. The ADM said the RP was to turn in when completed. During an interview on 01/14/23 at 05:20 p.m. the ADM and DON said there were no Inventory of Personal Effects done on Residents #1, #2, or #3. They said without an inventory list of personal items they would not know what a resident had with them when they admitted so they could be responsible for replacing something a resident did not have. An Admitting the Resident: Role of the Nursing Assistant policy revised September 2013 indicated Inventorying the Resident's Personal Effects: To inventory the resident's personal effects, you should: 1. Ask family members to remain in the room to witness the inventory. 2. Tell the resident that you are going to inventory his or her personal effects. 3. Complete the resident identification portion of the inventory record (i.e. name, room number, date of admission, etc.). 4. Inventory all clothing, equipment, valuables, etc. Record: a. The quantity of each item; b. the description of each item; and c. other identifying factors as necessary or appropriate. 5. When all personal items have been inventoried and recorded on the Inventory of Personal Effects Record, sign your name and title and instruct the family member that witnessed the inventory to also sign the form. 6. Provide the resident and/or family member with a copy of the completed and signed inventory record. (Note: The original copy of the inventory record must be provided to the supervisor.) 14. Give the original copy of the Inventory of Personal Effects Record to the nurse supervisor .

Based on interview and record review the facility failed to complete a baseline care plan for 2 of 4 residents reviewed for baseline care plans. (Residents #1 and #2) -The facility had an incomplete Baseline Care Plan for Residents #1 and #2. This failure could place residents at risk of not having their care needs met. Findings included: 1. Review of the face sheet dated 01/14/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included heart attack, mental disorder characterized by a disconnection from reality, and a group of thinking and social symptoms that interferes with daily functioning. Record review of physician orders indicated Resident #1 had the following: -an order dated 12/28/22 for a fall mat, -an order dated 12/29/22 for treatment to skin tear; and -an order dated 12/29/22 for PT. Record review of a Mini Nutritional assessment dated [DATE] for Resident #1 indicated she had a BMI of less than 19, had a group of thinking and social symptoms that interferes with daily functioning., and a score of 7 indicating she was malnourished. Record review of the Nursing Progress Notes indicated Resident #1 on 12/28/22 had wandering behaviors, physical and verbal behaviors, getting out of the wheelchair and ambulating, had an unsteady gait, bed placed in low position, and fall mat placed on the floor. On 12/29/22 she had an unwitnessed fall with a skin tear to the left upper arm, neuro checks were initiated, verbal behaviors, exit seeking behaviors, and family requesting placement on the secured unit. Record review of a Dehydration Risk assessment dated [DATE] indicated Resident #1 was at high risk for dehydration. Record review of the Baseline Care Plan initiated on 12/28/22 for Resident #1 indicated the following: -Fall/Safety Risk section not complete; -Skin Condition section left blank; -Dehydration Risk section left blank; and -Behavior Symptom section left blank. 2. Review of the face sheet dated 01/14/23 indicated Resident #2 was an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease, major depression disorder, and a group of thinking and social symptoms that interferes with daily functioning. Record review of a Dehydration Risk assessment dated [DATE] for Resident #2 indicated he was at risk for dehydration. Record review of a Mini Nutritional assessment dated [DATE] for Resident #2 indicated he had Alzheimer's disease and a group of thinking and social symptoms that interferes with daily functioning, and a score of 10 indicating he was at risk of malnutrition. Record review of the Baseline Care Plan initiated on 12/29/22 for Resident #2 indicated the following: -Dehydration Risk section left blank; and -Nutrition section left blank. Record review of the Weights and Vitals Summary indicated Resident #2 on 12/29/22 was 65 inches tall and weighed 180 pounds, on 01/05/23 he weighed 169.8 pounds-a weight loss of 5.7% from the previous weight, and on 01/10/23 he weighed 170.3 pounds-a weight loss of 5.3% from the initial weight. Record review of the Baseline Care Plan dated 12/29/22 for Resident #2 had no indication of updates on 01/05/23 or 01/10/23 to address the significant weight loss. During an interview on 01/14/23 at 03:25 p.m. the DON said baseline care plans were to be done within the first 48 hours of admission. She said information on them should include anything going on with the resident prior to admission based on the physician orders, history and physical from the hospital, diagnoses, and anything that happens with them during the first 48 hours at the facility. She said she and the MDS nurse had just started working at the facility about 2 weeks ago. She said the MDS person would be responsible for Baseline Care Plans but she did not know who was responsible before. Record review of a Care Plans-Baseline policy revised December 2016 indicated Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 4 of 4 residents reviewed for clinical records. (Residents #1, #2, #3, and #4) -The facility failed to document Residents #1, #2, #3, and #4's meal intakes. This failure could place residents at risk for incomplete information in their clinical records. Findings include: 1. Review of the face sheet dated 01/14/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included heart attack, mental disorder characterized by a disconnection from reality, and a group of thinking and social symptoms that interferes with daily functioning. Record review of the EMR meal intake documentation from 12/29/22 through 01/13/23 for Resident #1 indicated the following: -on 12/30/22 through 01/01/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/04/23 and 01/05/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/06/23 there was no documentation for dinner meal intake; -on 01/07/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/09/23 and 01/10/23 there was no documentation for dinner meal intake; and -on 01/13/23 there was no documentation for dinner meal intake. 2. Review of the face sheet dated 01/14/23 indicated Resident #2 was an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease, major depression disorder, and a group of thinking and social symptoms that interferes with daily functioning. Record review of the EMR meal intake documentation from 12/29/22 through 01/11/23 for Resident #2 indicated the following: -on 12/30/22 there was no documentation of the dinner meal intake; -on 12/31/22 and 01/01/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/03/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/06/23 there was no documentation for dinner meal intake; -on 01/07/23 and 1/13/23 there was no documentation of breakfast, lunch, or dinner meal intakes; 3. Review of the face sheet dated 01/14/23 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included low red blood counts, protein-calorie malnutrition, stroke, and high blood pressure. Record review of the EMR meal intake documentation from 11/01/22 through 11/30/22 for Resident #3 indicated the following: -on 11/01/22 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 11/02/22 and 11/03/22 N/A was documented of dinner meal intake; -on 11/04/22 there was no documentation of dinner meal intake; -on 11/07/22 and 11/08/22 N/A was documented of dinner meal intake; -on 11/09/22 there was no documentation of breakfast or lunch meal intakes; -on 11/11/22 through 11/13/22 N/A was documented of dinner meal intake; -on 11/14/22 there was no documentation of dinner meal intake; -on 11/15/22 there was no documentation of lunch or dinner meal intakes; -on 11/16/22 and 11/17/22 N/A was documented of dinner meal intake; -on 11/19/22 there was no documentation of dinner meal intake; -on 11/21/22 through 11/23/22 there was no documentation of dinner meal intake; -on 11/24/22 there was no documentation of breakfast or lunch meal intakes; -on 11/25/22 through 11/27/22 N/A was documented of dinner meal intake; -on 11/28/22 there was no documentation of dinner meal intake; and -on 11/30/22 N/A was documented of dinner meal intake. Record review of the EMR meal intake documentation from 12/01/22 through 12/11/22 for Resident #3 indicated the following: -on 12/01/22 N/A was documented of dinner meal intake; -on 12/03/22 there was no documentation of dinner meal intake and N/A was documented of dinner meal intake; -on 12/04/22 there was no documentation of breakfast or lunch meal intakes; -on 12/05/22 and 12/06/22 N/A was documented of dinner meal intake; and -on 12/09/22 through 12/11/22 N/A was documented of dinner meal intake. 4. Review of the face sheet dated 01/14/23 indicated Resident #4 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease, high blood pressure, moderate protein-calorie malnutrition, and history of stroke. Record review of the EMR meal intake documentation from 12/16/22 through 12/31/22 for Resident #4 indicated the following: -on 12/16/22 and 12/17/22 there was no documentation of the dinner meal intake; -on 12/19/22 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 12/20/22 and 12/21/22 there was no documentation of the dinner meal intake; -on 12/22/22 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 12/24/22 there was no documentation of the lunch or dinner meal intakes; -on 12/25/22 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 12/26/22 there was no documentation of the dinner meal intake; -on 12/28/22 and 12/29/22 there was no documentation of breakfast, lunch, or dinner meal intakes; and -on 12/31/22 there was no documentation of the dinner meal intake. Record review of the EMR meal intake documentation from 01/01/23 through 01/13/23 for Resident #4 indicated the following: -on 01/01/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/03/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/05/23 there was no documentation for dinner meal intake; -on 01/06/23 and 01/08/23 there was no documentation of breakfast, lunch, or dinner meal intakes; -on 01/09/23 and 01/10/23 there was no documentation for dinner meal intake; and -on 01/13/23 there was no documentation for dinner meal intake. During an interview on 01/13/23 at 02:25 p.m. CNAs B and C said if they were responsible for documenting the meal intakes. They said if they noticed documentation of meal intakes were not done then they would notify their charge nurse. During an interview on 01/14/23 at 05:20 p.m. LVN A indicated CNAs were to document meal intakes and notify the CN if not done. During an interview on 01/14/23 at 03:40 PM the ADM and DON said the CNAs were to document the meal intakes after each meal. They said they were using staffing agency and they would not always document the meal intakes on the residents. They said it was the CNAs responsibility for documenting the meal intakes. They said they were not aware the meal intakes had missing documentation. They said meal intake documentation was important to when residents had weight loss because they were not eating enough then adjustments needed to be made to increase the calorie intake. Record review of a Charting and Documentation policy revised July 2017 indicated Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: 1. Documentation in the medical record maybe electronic, manual, or a combination 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #1) reviewed for pharmacy services. Medication Aide A, who was not a certified medication aide, was allowed to pass medication to facility residents independently. Medication Aide A failed to adequately review Resident #1's MAR (Medication Administration Record) and administered double the prescribed dose of antibiotic medication for four days (07/08/2022, 07/09/2022, 07/10/2022, 07/13/2022). These failures placed residents whose medications were supervised by facility staff at risk of experiencing serious health side effects from possible errors to their medication regimen. Findings include: Record review of Resident #1's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with urinary tract infection (common infection that happens when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), dysphagia (difficulty swallowing), dementia without behavioral disturbance (a chronic persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), chronic obstructive pulmonary disease (a group of lung conditions that cause breathing difficulties), [CONDITION(S)] (a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease, stage 3 (longstanding disease of the kidneys leading to renal failure), history of [CONDITION(S)] (a brief stroke) and cerebral infarction (a stroke; disrupted blood flow to the brain due to problems with the blood vessels that supply it), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear). Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS score of 10 (moderate cognitive impairment); she required extensive physical assistance from at least one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; she ambulated with the assistance of a walker or wheelchair; and she was occasionally incontinent of bladder and frequently incontinent of bowel. Record review of Resident #1's care plan revised on 02/02/2022 revealed she was dependent of staff for activities, cognitive stimulation, and social interaction; she was cognitively impaired; and she was at risk for and had multiple falls. Observation and interview with Resident #1 and her family member on 07/22/2022 at 2:30 p.m. revealed she was in laying in a low bed with fall mat and her family member at bedside. Resident #1 was alert and looked to her family member for answers to questions. Resident #1 said she was fine, and she felt better than she felt when she had the urinary tract infection. Resident #1's family member said the facility notified her of the medication error (07/8-10/2022). The family member stated Resident #1 had mood changes from day to day, so she did not think getting the extra doses of antibiotic medication had any negative effects on her. The family member said Resident #1's doctor ordered laboratory tests and found nothing abnormal. The family member said the facility staff had Resident #1 up and walking and the urinary tract infection was gone. Record review of Resident #1's physician's orders for July 2022 revealed: [MEDICATION(S)] Tablet 100 MG, Give 2 tablets by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 10 Days, take with food, Order Status: Discontinued, Order Date: 07/07/2022, Start Date: 07/07/2022, End Date: 07/17/2022 Record review of Resident #1's MAR for July 2022 revealed: [MEDICATION(S)] Tablet 100 MG, Give 2 tablets by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 10 Days, take with food, D/C Date: 07/14/2022 Further review of the MAR for July 2022 revealed the medication was administered by Medication Aide A on 07/08/2022, 07/09/2022, 07/10/2022, and 07/13/2022 at 7:00 a.m. and 6:00 p.m. On 07/14/2022, Medication Aide A entered a code of 9 (Other/See Nurse Notes) for the 7:00 a.m. dose. Record review of Resident #1's progress notes for July 2022 revealed: On 07/07/2022 at 2:09 p.m., LVN B wrote, Resident returned from hospital, accompanied by EMS via stretcher. Resident has diagnosis: [CONDITION(S)]. New rx for antibiotic [MEDICATION(S)] 100mg q12h x 10 days. Resident received fluids as well. Resident is resting in bed comfortably. She states, I feel better. Vital Signs wnl, no complaints at this time. Call light within reach. Will continue to monitor and follow plan of care. On 07/14/2022 at 12:39 p.m., Medication Aide A wrote, [MEDICATION(S)] Tablet 100 MG Give 2 tablet by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 10 Days take with food, medication error. Record review of, Medication Incident Report, dated 07/14/2022 revealed the ADON wrote, . Date of Occurrence: 07/08/2022 to 07/13/2022, Time: 7 a.m. & 7 p.m., Medication not administered as ordered . Description of Incident: Administered 2- 200 MG tablets [MEDICATION(S)] BID; order was for 1- 200 MG tablet [MEDICATION(S)] BID . Physician's statement or orders: D/C remaining doses [MEDICATION(S)] and get STAT CBC/CMP . Persons involved: Medication Aide A. Person discovering incident: Medication Aide A, Date: 07/14/2022. Remarks by person committing violation: I read the order but did not see the change in MG (dosage). Action taken to correct or prevent reoccurrence: Inservice 6 Rights . Reviewed by: Administrator . Record review of, Staff Meeting, dated 07/14/2022 revealed, Topic: Reviewed the 6 rights of medication administration: right patient, right medication, right dose, right time, right route, right documentation . signed by Medication Aide A . Record review of Medication Aide A's employee record revealed she was hired by the facility as a CNA on 04/12/2021. She was hired as a medication aide on 06/15/2022. Record review of Medication Aide A's, Certificate of Graduation revealed she completed the 140 hours required by HHSC at an approved school (Number S2734) for the medication aide program on 06/10/2022. In an interview with the Administrator and ADON on 07/22/2022 at 12:30 p.m., the Administrator said Medication Aide A recently had a medication error with Resident #1. The ADON said [MEDICATION(S)] 100 MG to be given (2) twice daily was entered in the computer as per the physician's order for 200 MG, but the pharmacy delivered 200 MG tablets instead of the 100 MG tablets. The ADON said when she researched the medication, she only saw that the tablets came in 100 MG but when the pharmacy delivered the 200 MG tablets, a note was entered in Resident #1's electronic MAR. The ADON said nobody caught the mistake timely and Medication Aide A passed the medication incorrectly. The ADON said there was a gray box at the bottom of the order on Resident #1's electronic MAR which stated the pharmacy delivered 200 MG tablets. The ADON said had Medication Aide A seen the note in the gray box, she should have consulted a nurse on her shift and notified them that the order did not match. The ADON said the nurse could have corrected the order in the computer (electronic MAR). The Administrator said Medication Aide A administered the wrong medication to Resident #1 on 07/08/2022, 07/09/2022, 07/10/2022, and 07/13/2022. The Administrator said another medication aide worked the other days and did not make the mistake. The ADON said on 07/13/2022, Medication Aide A realized the other medication aide only signed out one tablet and she had been signing out two. The ADON said Resident #1 did not experience any change in condition. The ADON said Resident #1's NP was notified and the laboratory tests he ordered were normal. The ADON said the NP discontinued the medication early because he said Resident #1 received enough of the medication. The ADON said to monitor Resident #1's symptoms but there were no other orders. The Administrator said Medication Aide A was a CMA (certified medication aide) at the facility. The Administrator said all of their CMA's were certified. The ADON said Medication Aide A had already completed her course at an approved medication aide program. The ADON said Medication Aide A had already taken her certification test on 07/06/2022 but had not received her scores or official certification number. The Administrator said they hired Medication Aide A and allowed her to work independently because she told them her teacher at the medication aide program said she and the other students who completed the program could work after they completed the program and before they actually received their certification. The Administrator said they took Medication Aide A's word for it and did not verify the information before she was hired. The Administrator said they were not really sure how the medication aide program worked, but they should have verified the information. In an interview with Medication Aide A on 07/22/2022 at 1:15 p.m., she said she was reading the very top of Resident #1's electronic MAR, but she should have read the little print as well. She said the top of the MAR indicated to give two pills, but the box at the bottom said to give one 200 MG pill. She said she thought the pills in the blister packs were 100 MG and she did not verify it like she should have. Medication Aide A said she noticed the tablets were coming up short and she realized the mistake when a nurse (unidentified nurse) asked her about the amount of tablets left in the blister pack. She said Resident #1 did not experience any side effects. She said she wrote a progress note when she realized the error. Medication Aide A said she took an exit exam and received a certificate from the school where she completed her coursework. She said she took the state exam two weeks prior (07/06/2022) but had not received her test scores because the lady who graded the hand-written tests went on vacation. She said she and the other people who took the test that day (07/06/2022) were told by the [NAME] she did not know when they would get the scores and not to call the state about the tests because the lady who graded the tests was going on vacation. Medication Aide A said she was told by her teacher and staff at her school that she could pass medication alone before passing the state test as long as she completed the program. She said she had not received her test scores or official certification number. In a telephone interview with Resident #1's NP on 07/22/2022 at 1:50 p.m., he said the facility staff called him the day they realized the medication error. He said he did not go see Resident #1, but he ordered labs and reviewed them. The NP said Resident #1's white blood cells, kidneys, and liver enzymes were ok. He said the facility staff never reported any side effects and they usually kept him well informed. He said side effects of the antibiotic medication would have been nausea, diarrhea, and vomiting. He said the medication also could have resulted in low white blood cells. He said he did not have any concerns. Record review of, Administering Medications, revised 01/01 revealed, Policy Statement, Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Policy Interpretation and Implementation. 1. Only persons licensed or permitted by this State may prepare, administer or record the administration of medications (physicians, pharmacists, RNs, LPNs/LVNs, Certified Medication Aides . 3. Medications must be administered in a timely manner (1 hour before or 1 hour after) and in accordance with the attending physician's written/verbal orders . 8. The individual administering the medication must ensure that the right medication, the right dosage, the right time and the right method of administration are verified before the medication is administered .

Based on interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 3 residents reviewed for pressure injuries. (CR #1) -The facility did not identify the development of 2 large facility acquired Stage III pressure injuries for CR #1. -The facility did not prevent the development of two facility acquired Stage III pressure injury for CR #1. This failure could place 3 residents who had pressure injuries at risk for new development or worsening of existing pressure injuries. Findings included: Record review of CR #1's admission record revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a cognitive pattern BIMS score of 10 indicating she was moderately impaired. CR #1's Activities of Daily Living (ADL) Assistance revealed transfers required extensive assistance with 2 persons assisting her. Bed mobility, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene required extensive assistance with one person assisting her. CR #1 required total assistance with bathing with one person assisting her. CR #1 triggered for risk of pressure ulcers but was not found to have any stage able pressure ulcers. The resident triggered for unstageable pressure ulcer with slough and/or eschar on the foot. The devices for skin conditions are pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention, pressure injury care, application of ointment/medication and application of dressings to feet. Record review of CR #1's Care Plan dated 6/2/2020 revealed impaired cognitive function or impaired thought processes road track (r/t) dementia and the interventions included keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Resident has potential for pressure injury development r/t limited physical mobility with interventions/tasks to follow facility policies /protocols for the prevention of skin breakdown. Inform CR #1's family of any new skin breakdown and notify nurse immediately of any new areas of skin breakdown: Redness, blisters, bruises, discoloration noted during bath or daily care. Initiate a stop and Watch Alert for changes in skin. CR #1 is on Anticoagulant therapy (Eliquis) r/t [MEDICAL CONDITION] with interventions to daily skin inspection. Report abnormalities to the nurse. She had potential impairment to skin integrity r/t [DIAGNOSES REDACTED]. Keep fingernails short. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of weekly skin assessment dated [DATE] at 9:32 a.m. revealed normal skin color, warm temperature, no bruises, skin tears, abrasions, lacerations, surgical incisions, rashes, and no moisture. Record review of weekly skin assessments from June 2020 to 7/21/20 did not reveal any skin conditions related to CR #1's buttocks. Record review of Nurses Notes from 6/1/2020 to 7/26/2020 did not reveal any skin conditions related to CR #1's buttocks. Record review of CR #1's weekly ulcer assessment dated [DATE] at 2:33 p.m. revealed ulcer on right buttock identified on 7/27/2020 with length 6.7 cm and width 7.8 cm depth 0.0 with wound bed character being moist, redness around wound, and [MEDICAL CONDITION] present. The interventions are to cleanse, apply xeroform to open site, apply [MEDICATION NAME] to closed site, cover with clean foam dressing daily. The pressure reducing devices revealed an air mattress, wheelchair cushion, pillows to float heels and podus boot. Notification to nurse practitioner was sent and they received physician orders. Record review of CR #1's weekly ulcer assessment dated [DATE] at 2:15 p.m. revealed ulcer of left buttock identified on 7/27/2020 with length 3.5 cm and width 3.0 cm and depth 0.0, multiplying the length and width is 1.8-12.0, no tunneling, moist bed character, red around wound, and [MEDICAL CONDITION] present. The interventions are to cleanse, apply xeroform to open site, apply [MEDICATION NAME] to closed site, cover with clean foam dressing daily. The pressure reducing devices revealed an air mattress, wheelchair cushion, pillows to float heels and podus boot. Notification to nurse practitioner was sent and they received physician orders. Record review of CR #1's nursing progress notes dated 7/27/2020 at 3:31 p.m. revealed this nurse found DTI to left buttock and right buttock. Both right and left buttock have open areas to DTI sites. DTIs with open areas were reported to Nurse Practitioner and representative party. In an interview on 8/13/2020 at 11:30 a.m. with ADON she said she was the one who identified CR #1's wound and that it was not noted before. On 7/21/2020 the facility completed her weekly skin assessment and they did not observe any bruising. CR #1 was getting her shower and the CNA said dry blood was on the resident's brief. The resident received her showers on Monday, Wednesday and Friday. The ADON said there were no pressure sores noted the day before. The ADON said no one identified the pressure sore before. CR #1 was on an air mattress and getting supplements. She notified the physician and he gave the resident a treatment plan. CR #1 was sent out to the hospital that day because she had pneumonia and she was not eating right. In an interview on 8/13/2020 at 11:40 a.m. with CNA A she said CR #1 had what looked like elephant skin that was brown and blue. She said she care for CR #1 before she went out to the hospital and she did not see any wounds. She also cared for CR #1 a week or two before the resident left. CNA A said the resident had always looked that way since she started working at the facility in June. CNA A said sometimes the staff would put zinc on it. In an interview on 8/14/2020 at 12:15 p.m. with Charge Nurse she said CR #1 did not have any pressure sores, only on her heel. She said it does not normally happen that a large pressure sore just appears. The Charge Nurse said CR #1 had not been eating nutritiously for some time. CR #1 was not accepting the shakes and her family member was bringing her food. The Charge Nurse said the facility staff could not put the resident on her right side and that they normally put her on her left side because she swelled so bad due to paralysis. CR #1 would always turn back over to her back. She said they made frequent observations and due to [MEDICAL CONDITION], she seldom got up in her wheelchair. CR #1 was not compliant with changing her briefs and she had been at the facility for years. Record review of CR #1's Care Plan dated 6/2/2020 revealed an ADL Self Care Performance Deficit r/t flaccid [MEDICAL CONDITION] affecting right dominant side and that she used removable soft brace on right hand. The goal was that CR #1 would maintain current level of function in bed, mobility, transfers, eating, dressing, toilet use and personal hygiene. None of the interventions stated that resident could not lay on her right side. In an interview on 8/14/2020 at 12:25 p.m. with CNA B she said she would talk CR #1 into getting her showers and that she did not want to get up a lot. CR #1 appeared depressed because she no longer did the things she used to do, like playing bingo. CNA B had been previously been assigned to care for CR #1 and she stopped wanting to eat her favorite foods and that she did not know how the wound just appeared and no one saw it. In a telephone interview while at the facility on 8/14/2020 at 12:49 p.m. with the ADON, who is also the wound care nurse said CR #1 had her right heel stage III pressure ulcer since March. The ADON said she did not believe that no one saw the pressure ulcer. CR #1 had not been eating well and her weight was declining. The ADON said she had seen pressure ulcers develop overnight. She said a CNA found the pressure ulcer and reported it to her, but she could not recall who it was. The resident got her shower on a Monday and the CNA noted that CR #1 had dried blood. When the facility staff put on her brief they found the pressure sores. The ADON said the CNA's changed the resident over the weekend and they had not identified any pressure sores The last weekly skin assessment was on 7/21/2020. CR #1 was not due for another skin assessment until 7/28/2020. The ADON said the wound care doctor had not been to the facility for a few weeks. The wound care doctor did not come to the facility on [DATE]. The Charge Nurses complete the weekly skin assessments. CR #1 was repositioned every 2 hours, but a lot of times she moved out of position. She was on an air mattress since day 1 of being in the facility. If facility staff know the resident is non-compliant, they should go back to the resident more frequently. The ADON said the facility staff tried to do that and they educated the resident as well. In a telephone interview while at the facility on 8/14/2020 at 1:10 p.m. with CNA A said CR #1 had elephant skin and she asked the Nurse what it was, and they said it was scar tissue from the past. She said she had never seen scar tissue look like that before. It was brownish, but it stayed the same. CNA A had never seen such a large pressure sore develop overnight. In a telephone interview on 8/14/2020 at 1:40 p.m. with Local Wound Care she said the Wound Care Physician had not seen CR #1 for wound care for pressure wounds to her buttocks while at the facility. In an interview on 8/14/2020 at 2:00 p.m. with CNA C she said CNA B was giving her shower on 7/27/2020 and that is when the pressure ulcers were discovered on her buttocks. When her shower was done, they brought the resident to her room and laid her down and looked at her buttocks and they saw the pressure sores. The wounds were reported to the Charge Nurse, the ADON and the DON came to see the wounds. CNA C said the wound came out of nowhere. CNA C said the pressure sore was not deep. In an interview on 8/14/2020 at 2:30 p.m. with the Administrator said she had seen pressure ulcers develop quickly before. She said CR #1 did not let them change her brief and she sat in the wheelchair on her buttocks. The Administrator said the odor would be strong. CR #1 was also non-compliant in repositioning because she wanted to watch television. CR #1 did not want to be turned and she sat in urine. Sometimes the facility had to call the residents family member or CNA B that she liked to get her to change her brief. Record review of CR #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed in section for Behavior that CR #1 had a score of 0 for resisting care, revealing behavior was not exhibited. The question was: Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Record review of the Care plan dated 6/2/2020 did not reveal that CR#1 was care planned for behaviors or denying care. In an interview on 8/14/2020 at 2:50 p.m. with the DON she said the facility had an air mattress, supplements, podus boot for the heel wound, wheelchair cushion, floated heels, Vitamin C, arginate, liquid protein, stayed in contact with family member, they did weekly updates, and educated the resident about repositioning. Sometimes CR #1 allowed the facility staff to reposition her. The facility tried to turn the resident's bed, but she would not allow them to do it. CR #1 was sent out to a local hospital on [DATE] because of pneumonia and she was septic from the weekend to Monday. In an interview on 8/14/2020 at 3:20 p.m. with the DON she said the ADON oversees the assessments, but the Charge Nurses complete the weekly assessments. The DON said she stages the pressure ulcers. The DON said the facility in serviced staff to tell the nurse about new skin conditions such as bruises, scratches, wounds, and red area. The DON said the staff turn every resident who cannot do it for themselves every 2 hours. The DON said CR#1 had a Stage III pressure ulcer on her left and right buttock. Record review of facility policy on Pressure Ulcer Protocols and Prevention dated 10/1/2016 revealed Nursing home residents, due to comorbidities and underlying clinical conditions, may develop pressure ulcers during their stay at the facility, but pressure ulcer prevention should be performed daily to deter ulcers from forming .This includes all residents not just high risk for pressure ulcer residents should be monitored closely. Here are some examples of preventative measures, but this list is not encompassing: * Turn and reposition every 2 hours or more frequently as needed. * Pressure relieving devices, such as: heel protectors, wedges, mattresses, etc. * Frequent incontinent care, if resident is incontinent, if not frequent rounds for accidents. * Barrier creams to be applied as needed. * Any changes in skin should be reported to charge nurse immediately, especially on shower days. * Skin assessments weekly to monitor and look for changes in skin. * Quarterly pressure ulcer risk assessments or when a significant change is noted. * Monitor weights monthly, and place on interventions for any flagging significant weight loss.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for recognizing, preventing and controlling infections for 4 of 4 residents (CR #1, CR #3, and Residents #2, #4) reviewed for infection control. The facility failed to establish surveillance and identify possible cases of scabies, a highly transmissible skin mite that causes rashes, when CR #1, CR #3 and Residents # 2 and #4 had scattered rashes. This failure could affect all residents in the facility, by placing them at risk for cross-contamination, spread of infection and decreased quality of life. Findings include: CR #1 Record review of CR #1 face sheet revealed a [AGE] years old female admitted to facility [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Progress Notes dated [DATE] noted has identified possible drug allergy for [MEDICATION NAME] solution 2 mg/ml, 0.5 ml as needed for pain as ordered. Further noted [MEDICATION NAME] initial dosed for allergic reaction was effective. Record review of CR #1's Progress Notes dated [DATE], [DATE], [DATE] and [DATE] revealed [MEDICATION NAME] cream 2.5 % applied to rashes topically two times a day all over body. During telephone interview on [DATE] at 1:00 pm, Hospice LVN stated CR #1 's POA called due to her concern that the resident possibly had scabies, since 2 of her family members who visited her just got diagnosed with [REDACTED]. She added the family members told her even if CR #1 was dying, they wanted the resident to get treated [MEDICATION NAME]. She added after the family member's call, she was going to see her, but CR #1 passed away same day/Friday last week. During telephone interview [DATE] at 9:30 am, CR #1's family member stated that 3 of CR #1's family members got diagnosed with [REDACTED]. She said she did not touch her family members and they visited CR #1 at different times. She added they were told CR #1 had a medication reaction to the [MEDICATION NAME]. Resident #2 Record review of Resident #2 clinical record revealed [AGE] years old female admitted to facility [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2 's Dermatopathology Report dated [DATE] revealed Clinical Diagnosis: [REDACTED]. Record review of the Medical Director witness statement dated [DATE] read in part, I interpreted the report (Dermatopathology Report) for her (surveyor), and explained what clinical [DIAGNOSES REDACTED]. The final pathologic [DIAGNOSES REDACTED]. Cannot completely r/o arthropod bite. No mite or mite parts seen . L12.0 Urticarial [DIAGNOSES REDACTED] is the [DIAGNOSES REDACTED]. When the surveyor asked me if we had any confirmed cases of scabies in the facility, I stated we did not. We treat [MEDICATION NAME] and empirically. The only way to confirm a [DIAGNOSES REDACTED]. Record review of Resident #2's Progress Notes dated [DATE] revealed informed dermatologist of what the facility treated Resident with and dermatologist agreed with treatment. The dermatologist stated if for some reason the rash comes back, to call him so he could prescribe an alternate medication that he recommends. During observation and interview on [DATE] at 12:00 pm, Resident #2 when asked, she stated she was itching mostly on her back and neck. Observed CR #2 with red rashes scattered on her upper back and right lower back. During interview on [DATE] at 12:30 pm DON stated she called Resident #2's dermatologist office when it opened this morning, to let them know that Resident #2 still had rashes on her upper and lower back. She stated Resident #2's family member took her to the dermatologist related to a chronic skin condition and brought the skin test result to facility on [DATE]. DON stated they did not have control over Resident #2's skin (scrape) results dated [DATE], and the dermatologist office did not fax the test results. During interview on [DATE] at 12:30 am Regional Nurse explained that the facility did not get Resident #2 's skin scrape test results right away due to results in the past and from her experience, it could take several days to get results. During interview on [DATE] at 2:10 pm Medical Director when asked, stated he was not going to order a skin scrape test for Resident #2. CR#3 Record review of CR #3 's clinical record revealed a [AGE] years old female was readmitted to facility [DATE] with [DIAGNOSES REDACTED]. Record review of CR #3 's Physician order [REDACTED]. Apply topically from the neck to the soles of the feet, leave on for 8 hrs and shower off. Record review of CR #3 's Physician order [REDACTED]. On [DATE] noted discontinued contact isolation for [MEDICATION NAME]. During interview on [DATE] at 1:00 pm MA A stated she knew last month, Resident #2 and#4 were placed on isolation due to scattered rashes. She added staff were not told of any [DIAGNOSES REDACTED]. During interview on [DATE] at 12:40 pm Wound nurse stated she knew CR #3 was on contact isolation for one day. She stated CR #3 was transferred to secured unit after treatment and then shortly again transferred to a behavioral hospital, and the resident was still there. Resident #4 Record review of Resident #4's clinical record revealed a [AGE] years old female admitted to facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's Progress Notes dated [DATE] noted order for [MEDICATION NAME] cream 2.5 % apply to rash on torso and bilateral upper extremities and upper/lower back on right side and chest. On [DATE] noted [MEDICATION NAME] cream to arms, legs and torso. On [DATE] noted [MEDICATION NAME] apply to torso and extremities topically every shift for rash for 2 weeks, applied to arms, hands, chest, neck and back. Record review of Resident #4's Progress Notes dated on [DATE], [DATE], [DATE], [DATE], and [DATE] revealed [MEDICATION NAME] cream 2.5 % apply to Torso and Extremities topically to rash q shift for 2 weeks. Further noted [DATE] [MEDICATION NAME] 4 mg tablet (a steroid medication to treat inflammation and allergies [REDACTED]. Record review of Resident #4's Progress notes dated [DATE] revealed resident was noted to have a rash. Record review of a progress note dated [DATE] revealed Resident #4 was treated with [MEDICATION NAME] Cream 5% for itching. During interview on [DATE] at 10:15 am Assistant Activity Director stated she saw physically 5 residents with rashes. She said one resident was covered with the cream then had a shower, but was not placed on contact isolation. During interview on [DATE] at 10:50 am Activity Director stated she knew the 2 residents who had rashes. She said she saw one resident had a rash at the back of his hands and they told her it was itchy. During interview on [DATE] at 9:40 am, CNA B stated thought she was breaking out with hives and was itching, she continued working for 4 days. She stated she asked the ADON, and she told her she had scabies and she needed to see the MD. She added she never had it or had seen it before, and it was all over from neck - down her body. She stated she took care of CR #1 and Residents # 2, 4 and CR #3. During interview on [DATE] at 11:00 am ADON stated she did not tell CNA B she had scabies. ADON stated CNA B complained to her she had itching and to let her physician assess it when she went to the doctor. ADON added CNA B said she was itchy and showed her arms with few raised pimples. During interview [DATE] at 12:15 pm, LVN M stated CR #1, who died Friday/last week, was not prescribed [MEDICATION NAME] cream. She said CR #1 had rashes all over her body and they were treated with [MEDICATION NAME] cream two times a day as ordered. She added residents with rashes were treated with [MEDICATION NAME] for a week, and if it did not work the [MEDICATION NAME] was prescribed. She stated she saw her own physician last week due to scattered rashes, and the doctor ordered [MEDICATION NAME] and she applied it this Saturday and was back to work yesterday. She stated she had the [DIAGNOSES REDACTED].#1 and Residents # 2, 4, and CR #3. During interview on [DATE] at 10:00 am RDO stated the facility just started this am to isolate the residents until confirmation from the physician to give us direction. He stated he advised staff this morning to continue skin assessments initiated yesterday by Regional Nurse. RDO stated one of the 3 residents isolated for suspicious rashes was Resident #2. RDO stated in the meantime they were waiting for the Medical Director to give directions, and he would be there at 1:30 pm. He said they were continuing all residents skin assessments until everybody was assessed. RDO stated he knew facility had some residents with suspicious rashes and possibly skin bumps, and DON did not know what the rashes were. The DON was taking directions from him and Regional Nurse. During interview on [DATE] at 12:50 pm, Regional Nurse stated on any changes of condition, staff were to inform Hospice and they would evaluate resident. She added that wound nurse initiated all residents' skin assessments yesterday late afternoon., and still on-going. She said when they got to the facility this morning, regional staff advised the DON to in-service staff. She stated she was here yesterday, and stated she only knew of one CNA and one LVN that saw their physician and were prescribed [MEDICATION NAME]. During interview [DATE] at 12:50 pm Wound nurse stated she saw 2 residents earlier with scratches related to itching during assessment, one had it on her chest and another on upper left arm. She stated the rashes were red, raised, small bumps and scattered. She stated they placed 3 residents on contact isolation as a precaution today and the medical director to assess them around 1:30 pm. During interview on [DATE] at 4:00 pm Wound nurse stated the skin assessments rounds completed and no further rashes were noted. They stated Medical Director discontinued the contact isolation of 3 residents placed on contact isolation this morning because the rashes were not due to scabies. During interview on [DATE] at 5:00 pm RDO acknowledged the 9 residents identified with rashes last month. He informed surveyor that he will take care of it and will continue monitoring the residents. Record review of facility Policy on Transmission Based Precautions dated ,[DATE] revealed Transmission Based Precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. Record review of CDC Guidelines for Scabies, Multiple Cases dated [DATE] read in part, Below are suggestions for developing guidelines for preventing, detecting and responding to multiple cases of non-crusted scabies. Establish surveillance. Have an active program for early detection of infested patients and staff. Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; suspected cases should be evaluated and confirmed by obtaining skin scrapings.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment on 3 of 3 units (Landing, Harbor, and Memory Haven) reviewed for environment in that:: - Resident room walls, door frames, furniture, and bathrooms had areas with scraped paint, stained flooring and ceiling tiles. - Resident rooms, bathrooms and hallways had lighting that did not work. These failures placed all residents at risk of living in an unsafe, unsanitary, and uncomfortable environment and a diminished quality of life. Findings include: Observation on 11/19/19 at 09:37 AM revealed Resident room [ROOM NUMBER]B had a small chair by the corner of the room that had a cloth seat. The seat of the chair had a brown substance with an odor that was smeared on the chair. The bathroom sink had rust-colored stain inside the toilet bowl. Observation on 11/19/19 at 09:41 AM revealed Resident room [ROOM NUMBER]A was very dim and had a burned-out bulb in the main ceiling light in the room. Observation on 11/19/19 at 09:45 AM revealed Resident room [ROOM NUMBER]B had an over-bed light with a short string of 3 inches long. Observation on 11/19/19 at 09:48 AM revealed Resident room [ROOM NUMBER]A had a foul odor in the bathroom. Observation on 11/19/19 at 09:49 AM revealed Resident room [ROOM NUMBER]B had an over-bed light with a short string of 3 inches long and the paint was scraped on the side of the bed by the window. Observation on 11/19/19 at 09:59 AM Resident room [ROOM NUMBER]B revealed the wall was scraped by the bed and window area. Observation on 11/19/19 at 10:01 AM #51A had a bathroom door that was scraped and a patch on wall that was not painted. Observation on 11/19/19 at 10:16 AM revealed the wall was scraped by the head of bed, there was an over-bed light with a short string of 3 inches long, the bathroom was dimly lit, there was a scraped spot on the wall by the toilet, the toilet was stained brown on the inside rim, the toilet seat had worn paint and there was wood showing through. There were gray spots on the divider curtain. Observation on 11/19/19 at 10:17 AM revealed the divider curtain had gray spots on it. Observation on 11/19/19 at 10:25 AM revealed Resident room # 54B had a bathroom door that had a gray/black area. Observation on 11/19/19 at 10:28 AM revealed Resident room [ROOM NUMBER]A had a scrape on toilet lid and an unpainted area on the wall where a mirror had been. Observation on 11/19/19 at 10:32 AM revealed Resident room [ROOM NUMBER]A had a door that was scraped. Observation on 11/19/19 at 10:33 AM revealed Resident room [ROOM NUMBER] had a used/urine filled diaper on the floor of the bathroom. Observation on 11/19/19 at 10:00 AM revealed Resident room [ROOM NUMBER] had a screw on the railing, so the divider curtain could not close and a stain on the curtain. Observation on 11/19/19 10:32 AM revealed Resident room [ROOM NUMBER] had scraped paint on the wall by the side of the bed. Observation on 11/19/19 at 11:00 AM revealed the Kitchen door that opened to dining room was scuffed/scraped. Observations on 11/21/19 at 2:50 - 3:01 PM revealed: - Resident room [ROOM NUMBER]: Scraped paint on room door. - The Cozy Corner room [ROOM NUMBER]: Room door, closet door and the corner of the wall had scraped paint. - The fire doors on the front resident hall had scraped paint. - Resident Room # 9 had a closet door with scraped paint. - Resident room [ROOM NUMBER] had scraped pain on areas of the room door and door jam, and the closet door. - Resident room [ROOM NUMBER] had an area on the wall by the window with scraped paint. - Resident room [ROOM NUMBER] had a door with scraped paint. - Resident room [ROOM NUMBER] had a door with scraped paint. - The wall by the second nursing station was scraped up. During an interview with the Administrator on 11/20/19 at 12:30 PM she said she had only worked in the facility for 2 weeks, but she had already seen improvement with environmental concerns. She said the maintenance staff was working very hard to keep up with any concerns that were brought to their attention. During an interview on 11/21/19 at 4:45 p.m. the Maintenance Supervisor said he had been working in the facility for 2 months. He said he repaired things as he saw them or as reported. He said some of the concerns were not written in the Maintenance books, staff just verbally told him if things needed repair/repainting. Record review of the Maintenance Supervisor Job Description, undated, revealed in part: .the Maintenance supervisor ensures the building and equipment are maintained in good working order and facility grounds are maintained in accordance with facility policies. Record review of the Policies and Procedures revealed, in part: - Work/Homelike Environment, dated as revised in 12/2004 - A safe and healthful homelike environment will be provided for all employees, residents and visitors.

Based on observation, interview, and record review the facility failed to ensure each resident's entire drug/medication regimen was free from unnecessary medication for 2 of 6 residents (Resident #25, and Resident #68) reviewed for unnecessary medications in that: - Resident #25, Resident #68 has received [MEDICAL CONDITION] medications without documented [DIAGNOSES REDACTED]. - Resident #25, Resident #68 has prescribed PRN (as needed) [MEDICAL CONDITION] medications without end date and without justifications for its use beyond 14 days. This failure affected 2 residents and placed them at risk for adverse consequences such as impairment or decline in individual's mental, physical and psychosocial condition. Findings include: Resident #25 Record review of Resident #25's face sheet revealed she was [AGE] years old. She was admitted on [DATE] and was readmitted on [DATE]. Her diagnoses included [MEDICAL CONDITION], acute [MEDICAL CONDITION], major [MEDICAL CONDITION], chronic [MEDICAL CONDITION], unspecified [MEDICAL CONDITIONS], cognitive communication deficit, [MEDICAL CONDITION], diabetes mellitus, hypertension, and [MEDICAL CONDITION]. Record review of Resident #25's significant change MDS assessment dated as completed on 9/12/19 revealed a BIMS score of 12 out of 15, indicating that she was moderately cognitively impaired. She required limited assistance with bed mobility, transfer, and personal hygiene. She needed supervision when eating and using the toilet. She required extensive assistance when dressing. Her active diagnoses section revealed she was not coded as diagnosed with [REDACTED]. Record review of Resident #25's Order Summary Report dated 11/21/19 revealed: [MEDICATION NAME] Tablet 0.5 MG (milligrams) give one tablet by mouth every two hours as needed for Anxiety. [MEDICATION NAME] Tablet 0.5 MG give two tablets by mouth every two hours for Anxiety. Both orders had a start date of 9/10/19 without an end date. There was no [DIAGNOSES REDACTED]. Record review of Resident #25's (MONTH) 2019 MAR indicated [REDACTED]. Record review of Resident #25's (MONTH) 2019 TAR revealed Anti-anxiety behavior monitoring that showed verbal aggression as coded by number 2 on (MONTH) 4,12, and 14, 2019. However, there was no coding for anxiousness or nervousness that was documented. Record review of Resident #25's Comprehensive Care Plan initiated 12/27/17 revealed care plans for: [MEDICAL CONDITION], [MEDICAL CONDITIONS](Gastro-[MEDICAL CONDITION] reflux), hypertension, [MEDICAL CONDITION], diabetes mellitus, visual function, fall with no injury, resistive to care, verbal threats, and pain. During an observation and interview of Resident #25 on 11/19/19 at 12:30 pm, she was sitting on the edge of her bed eating her lunch with her food on the bedside table in front of her. She said she was ok in the facility, the staff were helping her and she was also getting her medications. During an interview and record review with the DON on 11/21/19 at 12:54 pm she said all PRN [MEDICAL CONDITION] medications should not exceed 14 days. When asked why anti-anxiety medications for Resident #25 exceeded 14 days, she said it exceeded 14 days because Resident #25 was on Hospice care. She showed the surveyor a copy an admission order from the physician but no justification for PRN orders to exceed 14 days. During an interview with the Regional Nurse on 11/21/19 at 12:59 she said all the facility's prescribed medication should have a diagnosis. Resident #68 Record review of Resident #68's face sheet revealed he was [AGE] years old. He admitted in the facility on 10/08/19. His diagnoses included [MEDICAL CONDITION], unspecified dementia, [MEDICAL CONDITION] disorder, major [MEDICAL CONDITION], constipation. Record review of Resident #68's admission MDS assessment dated as completed on 10/15/19 revealed no score for BIMS. He was coded by the facility staff has having severely impaired cognition. He required extensive assistance with bed mobility, transfer, and eating. He was totally dependent on the staff for dressing, toilet use, and personal hygiene. His active diagnoses did not include anxiety. Record review of Resident #68's Order Summary Report dated 11/21/19 revealed an order for [REDACTED]. Record review of Resident #68's (MONTH) 2019 MAR indicated [REDACTED]. Record review of Resident #68's (MONTH) 2019 TAR revealed no documentation of any anxiousness/nervousness. Record review of Resident #68's Comprehensive Care Plan dated 11/21/19 for, .requires [MEDICAL CONDITION] medications [MEDICATION NAME] for [DIAGNOSES REDACTED]. During an observation and interview of Resident #68 on 11/19/19 at 10:08 am, he was on his bed lying with his blanket covering him. He said it was cold today, but he was fine. He said his medications were being given to him. During an interview with Med Aide A on 11/20/19 at 1:34 pm, she said Resident #25 showed some behaviors several days ago, but she did not observe Resident #68 to show behaviors or anxiety. During an interview and record review with the DON on 11/21/19 at 12:54 pm she said all PRN [MEDICAL CONDITION] medications should not exceed 14 days. When asked why anti-anxiety medications for Resident #68 exceeded 14 days, she said it exceeded 14 days because Resident #68 was on Hospice care. She showed the surveyor a copy an admission order from the physician but no justification for PRN orders to exceed 14 days. Record review of the facility's policy titled, [MEDICAL CONDITION] Drug Use dated 01/01 revealed: [MEDICAL CONDITION] drug therapy shall be used only when it is necessary to treat a specific condition .2. The attending physician must include a reason or symptoms with any order for [MEDICAL CONDITION] drug therapy.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 7% based on 2 errors out 27 opportunities, which involved 1 of 2 residents (Resident #36) and one of two staff (LVN A) observed during medication administration, in that: -LVN A failed to administer the medication via the correct route or method. -LVN A failed to administer the correct dosage of the medication. These failures affected 1 resident and placed her at risk of inadequate therapeutic outcomes, increased negative side effects, and a possible subsequent decline in health. Findings include: Record review of Resident #36's face sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE] and was readmitted on [DATE] and 9/26/19. Her [DIAGNOSES REDACTED]. Observation and interview during medication pass on 11/20/19 at 8:25 am revealed LVN A administered crushed [MEDICATION NAME] 300 mg via peg tube to Resident #36. It was noted there was still ample amount of medication left in the medication cup used. Further observation revealed, LVN A administered [MEDICATION NAME] 0.125 mg 2 tablets. After several failed attempts to administer the medication to Resident #36 sublingually, she administered it via the peg tube of Resident #36. LVN A said there was at least 10% amount of [MEDICATION NAME] left in the medication cup when asked, How much do you think was left in the cup? Record review of Resident #36's MAR for (MONTH) 2019 revealed, Resident #36 was administered [MEDICATION NAME] capsule 300 mg 1 capsule via [DEVICE] and [MEDICATION NAME] Tablet 0.125 mg 2 tablets sublingually every 8 hours from (MONTH) 1, 2019 to (MONTH) 20, 2019. Record review of Resident #36's physician's orders [REDACTED]. [MEDICATION NAME] Tablet 0.125 mg 2 tablets sublingually every 8 hours for increased secretions. Interview on 11/21/19 at 10:34 am LVN A said there was about 10 to 15% of Resident #36's [MEDICATION NAME] left in the medication cup after she administered it during the morning med pass on 11/20/19. When asked if she always had some amount of [MEDICATION NAME] left in the cup when she administered the medication she said, No I did it last yesterday I usually do it first. When asked if she considered it under-dosing, LVN A said, Yes. She also said, she did not know why she gave the [MEDICATION NAME] via the pe[DEVICE] for Resident #36, but she was aware that it should be given sublingually (under the tongue). Record review facility's policy and procedure entitled Administering Medications dated 01/01 revealed POLICY STATEMENT .Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. 8. The individual administering the medication must ensure that the right medication, the right dosage, the right time, and the right method of administration are verified before the medication is administered.