Every finding on record at Damas Hospital SNF

Based on review of policies, procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to comply with the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Findings include: During observation of the residents refrigerator a unlabeled yougurt and ice cream were found.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 1. During the visual inspection of the kitchen area it was observed that Chicken was held on temperature of 132 degrees Fahrenheit on serving container on line prep not reaching the required temp of 165 degrees Fahrenheit for poultry. 2. Meat freezer floor was observed uneven and with broken cement in entrance permitting mold and ice to develop. 3. Holding racks in meat freezer were observed with rust in tubing.

Based on observations of the rooms, review of policies procedures and facility staff interview performed on 03/27/2025 from 8:00 AM through 3:00 PM, it was determined that the facility did not meet the requirements for sanitation of the air conditioner inlet grill compartment for 3 out of 3 residents' rooms. Findings include: The Supervisor (employee #2) provided facility's policy and procedure last update on 02/2025 for Reemplazo Filtros de Ductos de Aire Acondicionado. Replacement of Air Conditioning Duct Filters. Procedure: 2. The physical plant personnel will replace the air duct filters monthly. 6. The cleaning staff will clean the grill. 1. During the round provided in the rooms with the Physical Plant Manager employee #10 on 3/27/2025 from 8:00 AM to 3:00 PM, the following was observed: a. The air conditioning inlet grille compartments were observed to be dusty in rooms #309, #310, #311.

Based on dining observations, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 3 out of 21 residents of the sample selection receiving services (Residents #162, #163, #314). Findings include: 1. Resident # 314 does not take instant coffee, prefers to be prepared traditionally this was not provided. 2. Resident #162 referred to hot cereal was not palatable for her needs, she was provided with unsweetened hot cereal which she could not eat because of the flavor. 3. Resident #163 said the meat she was served was dry and was not palatable for her preference.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 03/27/2025 through 03/28/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed with the use of standards practice for prevention and requirements for temperature recording which could promote deterioration of the supply or the spread of microorganisms. This deficient practice could affect 21 out of 21 residents admitted receiving care at the facility. Findings include: The MDS Coordinator (employee #4) provided facility's policy and procedure last update on 02/2025 for Registro de Temperatura y Humedad en Almacenes de Suplidos de Materiales Medico Quirúrgicos. It was reviewed on 03/27/2025 at 1:45 PM. States that the air conditioning system temperature parameters, according to the standard, are 70 F to 75 F. In the procedure area. In section 2, it states that the physical plant will be notified if the temperature is not within the appropriate parameters and their action will be documented. 1.During the tour of the facility's storage performed on 03/27/2025 at 1:20 PM, and interview with MDS Coordinator (employee #4), it was observed that medical-surgical material storage had a temperature of 69.3 F. The daily temperature record for the month of March was observed and for this day the reading was 68.6 F, no written action taken by personnel was observed. 2. It was observed in the daily temperature records that in the months of January, February and March the temperature fluctuated between 66.1 F to 69.5 F and no written action taken by personnel was observed for these months. 47632 3. During the observations made in the wound treatment procedures by the Orthopedic Technician employee #6 on 03/28/2025 at 9:00 AM to 10:00 AM, the following were observed: a. Resident #211 is a [AGE] year-old male admitted on [DATE] with Right hip Osteoarthritis/TKR. The Orthopedic Technician employee #6 was observed providing skin wound care. When she went to change the bandages did not wash her hands with soap and water or hand sanitizer. At the time of disinfecting the wound, gloves were changed, but hands were not disinfected with soap and water or hand sanitizer. She changes gloves without washing hands with soap and water or hand sanitizer before applying Xeroform (Vaseline gauze). The Director of Nursing (DON) was interviewed on 03/28/2025 at 11:30 AM, she referred to not having a policy created on the management in the Skilled Nursing area by the Orthopedic Technician. The Orthopedic Technician job description provided by the supervisor talks about treatments and changing dressings on orthopedic surgery residents, but the facility has not created policies and procedures on how they are going to proceed at the time of a wound treatment on residents. 4. During the round provided in the rooms with the Physical Plant Manager employee #10 on 3/27/2025 from 8:00 AM to 3:00 PM, the following was observed: The Supervisor (employee #2) provided facility's policy and procedure last update on 02/2025 for Reemplazo Filtros de Ductos de Aire Acondicionado. Replacement of Filter of the Ducts of the Air Condition Procedure: 2. The physical plant personnel will replace the air duct filters monthly. 6. The cleaning staff will clean the grill. a. The air conditioning inlet grill compartments were observed to be dusty in rooms #309, #310, #311. 51637 5. During the medication pass performed on 03/27/2025 from 12:52 PM to 1:18 PM with the registered nurse (employee #7) it was observed that the nurse fails 6 of 12 opportunities to perform hand hygiene. 6. During the medication pass performed on 03/28/2025 from 7:57 AM to 8:10 AM with the registered nurse (employee #8) it was observed that the nurse fails 2 of 6 opportunities to perform hand hygiene.

Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive service in a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. This deficient practice was observed on 8 out of 9 rooms at the facility visited. Findings include: 1. During the observations performed in the residents' rooms, with Physical Plant Director employee (#10) the following was observed: a) On 03/27/2025 from 9:00 AM through 9:40 AM it was observed the nightstands had parts of the plastic cover exposed in rooms #309, #311, #318 and #319. b) On 03/27/2025 from 9:10 AM through 9:40 AM it was observed the armchairs had armrest deteriorated in rooms #309, #311, #314 and #316. c) On 03/27/2025 at 9:40 AM it was observed the table tray is uneven in room [ROOM NUMBER]. d) On 03/27/2025 at 9:51 AM no cord was available to turn on the light. e) On 03/27/2025 from 9:00 AM through 9:35 AM it was observed the bathroom grab bars were unsafe and loose in rooms #310, #311, #314, #315, #316 and #319. f) On 03/27/2025 at 9:35 AM it was observed mold in the bathroom faucet area of in room [ROOM NUMBER]. g) On 03/27/2025 at 9:32 AM it was observed deteriorated floor in room [ROOM NUMBER]. h) On 03/27/2025 from 9:00 AM through 9:40 AM it was observed parts of the floor baseboard to be detached and deteriorated in rooms #309, #314, #315 and #319. i) On 03/27/2025 at 9:32 AM, it was observed areas behind the chairs and beds were observed to littered with dirt and trash in rooms #315, #316 and #318.

Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests. Findings include: 1. During the observations performed in the resident's rooms, with Physical Plant Director employee (#10) the following was observed: a) On 03/27/2025 at 9:15 AM spider was observed behind curtains in room [ROOM NUMBER].

Based on observations, twelve records reviewed (RR) and interviews with the Director of Respiratory Therapy (employee #1) and the Supervisor of Respiratory Therapy (employee #9), it was determined that facility failed to have the capability to provide needed respiratory care/services to residents with respiratory diagnosis that requires specialized respiratory care and/or services. This deficient practice affects 1 out of 14 sample cases (SC) receiving services. (SC#513) Findings include: 1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she said that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were not notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working. 2. In an interview with the respiratory therapy director on 03/28/25 at 11:02 AM, he indicated that in cases of patients with respiratory needs, they oversee carrying out the care plan once they receive the medical order from the internal doctor or nursing recommendation. They could supply the equipment with what they have available in the hospital, but since they do not have the parameters available and the machine does not adjust to the patient's preferences since it has a mask and not a nasal cannula, it is a little complicated for them. 3. The respiratory therapy supervisor was interviewed on 03/28/2025 at 11:50 AM and reported that on 03/27/2025 all the pertinent steps were taken to address the diagnosis of resident 513, however, when calling the resident's pulmonologist, he told her that the resident had not attended a follow-up visit for two years, so he could not provide her with the parameters to be performed since she would have to undergo the sleep study again.

Based on review of twelve medical records, resident interview and interview with the Respiratory Therapy Director (employee #1) performed from 03/27/2025 thru 03/28/2025, from 8:00 AM thru 4:00 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 1 out of 12 records reviewed (RR). (RR #513) Findings include: 1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she said that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working. 2. During upon file review on 03/27/2025 at 11:20 AM it is noted that the baseline care plan within 48 hours did not include a care plan for respiratory care or use of the CPAP machine. 3. In an interview with the respiratory therapy director on 03/28/25 at 11:02 AM, he indicated that in cases of patients with respiratory needs, they oversee carrying out the care plan once they receive the medical order from the internal doctor or nursing recommendation. They could supply the equipment with what they have available in the hospital, but since they do not have the parameters available and the machine does not adjust to the residents' preferences since it has a mask and not a nasal cannula, it is a little complicated for them. 4. The facility failed to conduct and document a baseline care plan during the first 48 hours of admission that included actions to be taken to address the residents' needs.

Based on the interview and records reviewed (RR), it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident. This deficient practice was identified for 1 of 12 residents reviewed for MDS assessments. (Resident #513). Findings include: 1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she indicates that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working. 2. During the R.R. 513 on 03/27/2025 at 11:20 AM it is noted that the initial care plan did not include the diagnosis of sleep apnea or the need for a CPAP. 3. The facility failed to perform a proper comprehensive assessment that identified all the residents' diagnoses and needs.

Based on Credential files Reviewed (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training and the Hand in Hand training was provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. Findings include: During the review of SNF employee Abuse and neglected training and the Hand in Hand Training on 10/30/2024 at 1:00 pm, the following was found: 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023. The Hand-in- Hand -A training Series for Nursing Home was taken by an e-learning computer training system that individualized virtual training that the personnel take when they have time to complete the module at different times in the years. a. CFR #11 took the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease, was taken on 08/17/2024 and take 3 minutes with 30 seconds to complete them with 100% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking, taken on 08/17/2024 and take 3 minutes with 23 seconds to complete them with 100% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions on 08/17/2024 and take 3 minutes with 01 seconds to complete them with 100% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference, taken on 11/08/2023 and take 2 minutes with 15 seconds to complete them with 100% qualification in the maternal and child floor and Nineth floor that was medicine and isolation. Module #5 Preventing and Responding to abuse taken on 11/08/2023 and takes 2 minutes with 27 seconds to complete them with 100% and qualification in the maternal and child floor and Nineth floor that was medicine and isolation. This employe was transferred from Hospital setting to the SNF on 06/24/2024. b. CFR #12 took the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease, taken on 05/06/2024 and take 2 minutes with 48 seconds to complete them with 90% qualification while at the Hospital Setting. Module #2 Being with a person with Dementia: Listening and Speaking, taken on 05/06/2024 and take 2 minutes with 43 seconds to complete them with 80% qualification while at Hospital Setting. Module #3 Being with a person with Dementia: Actions and Reactions, taken on 05/06/2024 and take 3 minutes with 38 seconds to complete them with 100% qualification while at Hospital Setting. Module #4 Being with a person with Dementia: Making Difference, taken on 11/29/2023 and take 5 minutes with 11 seconds to complete them with a 75% qualification while at the Hospital Setting. Module #5 Preventing and Responding to abuse, taken on 11/29/2023 and take 2 minutes with 35 seconds to complete them with 87.50% qualification in Hospital Setting. This employe was transferred from Hospital setting to the SNF on 07/09/2024. c. CFR #13 take the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease: taken on 07/20/2024 and take 36 seconds to complete them with a 90% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 07/20/2024 and take 43 seconds to complete them with a 80% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions; taken on 07/20/2024 and take 46 seconds to complete them with 90% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference taken on 07/29/2023 and take 49 seconds to complete them with a 87.50% qualification in the SNF. Module #5 Preventing and Responding to abuse; taken on 07/29/2023 and take 2 minutes with 36 seconds to complete them with a 100% qualification in the SNF. d. CFR #14 take the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease; taken on 04/13/2024 and take 1 minute with 45 seconds to complete them with 100% qualification in Hospital Setting. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 04/13/2024 and take 2 minutes with 03 seconds to complete them with 100% qualification in Hospital Setting. Module #3 Being with a person with Dementia: Actions and Reactions, taken on 04/13/2024 and take 1 minute with 52 seconds to complete them with 100% qualification in Hospital Setting. Module #4 Being with a person with Dementia: Making Difference; taken on 03/27/2023 and take 48 seconds to complete them with 100% qualification in the Hospital Setting. Module #5 Preventing and Responding to abuse; taken on 03/27/2023 and take 24 seconds to complete them with 100% qualification in Hospital Setting. This employe was removed from Hospital setting to the SNF on 06/10/2024. e. CFR #15 take the Hand-in- Hand -A training Series for Nursing Home: Module #1 Understanding the word of Dementia: The person and the disease; taken on 10/16/2024 and take 1 minute with 40 seconds to complete them with 80% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 05/18/2023 and take 1 minute with 15 seconds to complete them with 90% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions: taken on 05/18/2023 and take 1 minute to complete them with 80% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference; taken on 12/01/2023 and take 1 minute with 58 seconds to complete with 100% qualification in the SNF. Module #5 Preventing and Responding to abuse, taken on 12/01/2023 and take 6 minutes with 48 seconds to complete them with 100% qualification in the SNF. f. CFR #16 take the Hand -in- Hand -A training Series for Nursing Home: Module #1 Understanding the word Dementia: The person and the disease; taken on 09/28/2024 and take 6 minutes with 17 seconds to complete them with 100% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/28/2024 and take 3 minutes with 49 seconds to complete them with 100% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions on 09/28/2024 and take 3 minutes with 43 seconds to complete them and qualification 100% in the SNF. Module #4 Being with a person with Dementia: Making Difference on 03/22/2023 and taking 7 minutes with 14 seconds to complete them with 100% qualification in the SNF. Module #5 Preventing and Responding to abuse; taken on 03/22/2023 and take 1 minute with 50 seconds to complete them with 100% qualification in the SNF. g. CFR #17 take the Hand-in- Hand -A training Series for Nursing Home: Module #1 Understanding the word Dementia: The person and the disease; taken on 09/04/2024 and take 4 minutes with 14 seconds to complete them with 90% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/04/2024 and take 4 minutes with 35 seconds to complete them with 90% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions; taken on 09/04/2024 and 31 seconds to complete them with 30% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference; taken on 11/22/2023 and taking 19 minutes with 16 seconds to complete them with 75% qualification in Hospital setting. Module #5 Preventing and Responding to abuse; taken on 11/22/2023 and take 1 minute with 49 seconds to complete them with 87.50% qualification in Hospital setting. This employe was removed from the Hospital setting and transferred to the SNF on 05/25/2024. 2.The facility failed to ensure to provide to all employees of the SNF with the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights. 3. During an interview with the associated DON (employye #1) on 10/30/2024 at 3:00 PM she states that the facility provides to the nursing personel education relates to abuse and neglect by e-learning computer education system and the hand in hand training by e-learning annual. That in September 2024, they provide the abuse and neglect training presential.

Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure an effective training program for all staff that includes, abuse, neglect, exploitation, misappropriation of residents property, dementia management, Residents Right and the Hand in Hand at minimum. This deficient practice was identified in 22 out of 22 credential files reviewed to investigate compliance with training requirements. (CFR #1 through #22). Findings include: During the review of SNF employee training on 10/30/2024 from 1:00 PM through 2:00 PM, the following was found: 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM, it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. 4 out of 22 (22.7%) of nursing personnel working in the SNF did not complete Pain Management. 4 out of 22 (18.2%) of nursing personnel working in the SNF did not complete Resident experience. 2. The facility failed to provide all employees of the SNF with abuse and neglect training, Pain Management, Residents, Residents and the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' right.

Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that Residents Right training is provided to all employees of the Skilled Nursing Facility (SNF). This deficient practice could affect all residents admitted at the facility. Findings include: 1. Review of 22 Credential file Review (CFR) on 10/30/2024 from 1:00 PM through at 2:00 PM it was found that 22 nursing personnel working in the SNF did not have the Residents Rights training. 2. The Facility failed to ensure to provide all employees of the SNF with the Residents Right, training to ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights.

Based on interview with the Director of nursing (employee #1) and Nursing supervisor (employee #2 )on 10/29/2024 through 10/30/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence that have and maintain sufficient nursing staff sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Findings include: 1.Director of Nursing (DON) was interviewed on 10/29/2024 at 1:00 PM and was asked by the surveyor for the categorization of residents admitted to the facility, the day alleged incidents of abuse and neglect occur on 10/20/2024. DON was asked in relation to the quantity of nursing personnel (License Practical Nurse- LPN's & Registered Nurse- RN's) assigned to be in charge of resident's care and distribution accordingly with residents categorization and needs. The DON stated during interview on 10/29/2024 at 1:30 PM that accordingly with resident categorization performed with a nurse leader in charge of this process on Sunday 20, 2024 the quantity of personnel required for a census of 19 residents, it is 3 LPN's to be assigned in charge of vital signs measure, bath assistance, feeding assistance, grooming assistance and other direct care duties and 2 Register nurses to be in charge of residents assessments, implementation of care plans and other skilled services. This implied a total of hours required of 4.5. The DON proceeds to explain that on 10/20/2024 that it was Sunday and on this 7-3 shift and based on needs on the hospital's nine floor that is the medicine ward, one of the LPNs from the SNF was moved to the 9th floor. The general nursing supervisor assigned one of the three nurses that had been planned to provide services to the SNF residents, to the 9th hospital floor medicine ward; the nurse moved to the 9th floor was an LPN nurse. The surveyor asked the DON if the movement of an LPN to the 9th floor did not affect the staffing calculated based on the needs of residents of the SNF. The DON explains that there is occasions were the calculation of staff required, takes up to a number to be sure that provider must comply with provision of services based of residents, but there are occasions in which residents that have advance in outcomes and plan of care goals and are most independent than other residents and this could implied a total of hours required of 3.5, she explain this was not necessarily reflected in the categorization calculus. She stated that there is the possibility that the calculation established be less (3.5). In this case or situation on 10/20/2024 two nurses assigned to provide be assigned in charge of vital signs measure, bath assistance, feeding assistance, grooming assistance and other direct care duties, could be sufficient and there is no difference if the general nurse supervisor assigned one of the nurses to the 9th floor. No explanation was provided by the DON of the reason why if with two nurses assigned to direct care the residents' needs were satisfied why there are three nurses assigned in some shifts. 2. Review of a summary of monthly nursing staffing for year 2024 it was identified that during January, February, March, April, May, June, July, August and September 2024 hours contact by categorization was always 4.5 no matter resident average census fluctuated between 9 and 19 residents. 3. The Nursing supervisor of SNF (employee #2) was interviewed on 10/29/2024 at 1:00 PM and was asked by the surveyor for the categorization of residents admitted to the facility, the day alleged incidents of abuse and neglect occurs on 10/20/2024. She was asked in relation to the quantity of nursing personnel (LPN's RN's) assigned to be in charge of residents care and distribution accordingly with residents categorization and needs. The Nursing supervisor stated during interview on 10/29/2024 at 9:30 AM that accordingly with resident categorization performed with a nurse leader in charge of this process on Sunday 20, 2024, the quantity of personnel required for a census of 19 residents, it is 3 LPN's to be assigned in charge of vital signs measure, bath assistance, feeding assistance, grooming assistance and other direct care duties and 2 Register nurses to be in charge of residents assessments, implementation of care plans and other skilled services. The Nursing supervisor proceed to explain on 10/29/2024 at 9:12 AM that 10/20/2024 was Sunday and on this 7-3 shift of 10/20/2024 and based on need on the hospital nine floor who is a medicine ward one LPN was assigned to the 9th floor. The general nursing supervisor assigned one of the three nurses that had been planned to provide services to SNF residents to the 9th hospital floor. The nurse who moved to the 9th floor was an LPN nurse. The surveyor asked the Nursing supervisor on 10/29/2024 at 9:40 AM if the movement of an LPN to the 9th floor affects the staffing requirement calculated based on the needs of residents of the SNF. She explain that if the calculation, establish the required quantity of nursing personnel, leadership must be cautious in assigning those personnel to other area, because no matter there is cases that there are occasions in which residents that have advance in outcomes and plan of care goals and are most independent that other residents this does not reflect on the categorization and there is the possibility that the calculation established be less, this is a process and personnel assigned based on categorization of resident needs could require different approaches to comply with rehabilitation process. The Nursing director stated that the SNF is an outcome goal required rehabilitation scenery, different from an acute care ward. Nursing supervisor (employee #2) stated on 10/29/2024 at 9:50 AM that SNF must comply with the Payroll Based Journal requirement where there is a process to comply with these requirements that acute care hospital does not need to comply, and that this is a method were SNF need to collect audited and verifiable staffing data that need to be reported to CMS. Nursing supervisor (employee #2) stated on 10/29/2024 at 9:59 AM that regardless one LPN was sent to the 9th floor by the Nursing supervisor on 10/20/2024 shift 7-3, the categorization was not changed but two instead of three nurses were assigned to provide services. 4. On year 2024 documentation of the frequency where personnel assigned to the SNF was re-assigned or sent to other hospital areas was requested by the surveyor to the Nursing supervisor (employee #2) on 10/30/2024 at 9:59 AM. The documentation presented was reviewed and analyzed with the Nursing supervisor (employee #2) 10/30/2024 at 11:59 AM, after the analysis it was identified that in the past year nursing personnel from the SNF was re-assigned to other hospital areas on 26 occasions. In all the occasions, this occurred on the 7-3 shift on different days of the weeks. The only time when personnel were re-assigned to other hospital areas on the weekend was on 10/20/2024, the day alleged events took place who was Sunday.

Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training and the Hand in Hand training was provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. Findings include: During the review of SNF employee Abuse and neglected training and the Hand in Hand Training on 10/30/2024 at 1:00 pm, the following was found: 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023. The Hand-in- Hand -A training Series for Nursing Home was taken by an e-learning computer training system that individualized virtual training that the personnel take when they have time to complete the module at different times in the years. a.CFR #11 took the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease, was taken on 08/17/2024 and take 3 minutes with 30 seconds to complete them with 100% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking, taken on 08/17/2024 and take 3 minutes with 23 seconds to complete them with 100% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions on 08/17/2024 and take 3 minutes with 01 seconds to complete them with 100% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference, taken on 11/08/2023 and take 2 minutes with 15 seconds to complete them with 100% qualification in the maternal and child floor and Nineth floor that was medicine and isolation. Module #5 Preventing and Responding to abuse taken on 11/08/2023 and takes 2 minutes with 27 seconds to complete them with 100% and qualification in the maternal and child floor and Nineth floor that was medicine and isolation. This employe was transferred from Hospital setting to the SNF on 06/24/2024. b. CFR #12 took the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease, taken on 05/06/2024 and take 2 minutes with 48 seconds to complete them with 90% qualification while at the Hospital Setting. Module #2 Being with a person with Dementia: Listening and Speaking, taken on 05/06/2024 and take 2 minutes with 43 seconds to complete them with 80% qualification while at Hospital Setting. Module #3 Being with a person with Dementia: Actions and Reactions, taken on 05/06/2024 and take 3 minutes with 38 seconds to complete them with 100% qualification while at Hospital Setting. Module #4 Being with a person with Dementia: Making Difference, taken on 11/29/2023 and take 5 minutes with 11 seconds to complete them with a 75% qualification while at the Hospital Setting. Module #5 Preventing and Responding to abuse, taken on 11/29/2023 and take 2 minutes with 35 seconds to complete them with 87.50% qualification in Hospital Setting. This employe was transferred from Hospital setting to the SNF on 07/09/2024. c. CFR #13 take the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease: taken on 07/20/2024 and take 36 seconds to complete them with a 90% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 07/20/2024 and take 43 seconds to complete them with a 80% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions; taken on 07/20/2024 and take 46 seconds to complete them with 90% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference taken on 07/29/2023 and take 49 seconds to complete them with a 87.50% qualification in the SNF. Module #5 Preventing and Responding to abuse; taken on 07/29/2023 and take 2 minutes with 36 seconds to complete them with a 100% qualification in the SNF. d. CFR #14 take the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease; taken on 04/13/2024 and take 1 minute with 45 seconds to complete them with 100% qualification in Hospital Setting. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 04/13/2024 and take 2 minutes with 03 seconds to complete them with 100% qualification in Hospital Setting. Module #3 Being with a person with Dementia: Actions and Reactions, taken on 04/13/2024 and take 1 minute with 52 seconds to complete them with 100% qualification in Hospital Setting. Module #4 Being with a person with Dementia: Making Difference; taken on 03/27/2023 and take 48 seconds to complete them with 100% qualification in the Hospital Setting. Module #5 Preventing and Responding to abuse; taken on 03/27/2023 and take 24 seconds to complete them with 100% qualification in Hospital Setting. This employe was removed from Hospital setting to the SNF on 06/10/2024. e. CFR #15 take the Hand-in- Hand -A training Series for Nursing Home: Module #1 Understanding the word of Dementia: The person and the disease; taken on 10/16/2024 and take 1 minute with 40 seconds to complete them with 80% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 05/18/2023 and take 1 minute with 15 seconds to complete them with 90% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions: taken on 05/18/2023 and take 1 minute to complete them with 80% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference; taken on 12/01/2023 and take 1 minute with 58 seconds to complete with 100% qualification in the SNF. Module #5 Preventing and Responding to abuse, taken on 12/01/2023 and take 6 minutes with 48 seconds to complete them with 100% qualification in the SNF. f. CFR #16 take the Hand -in- Hand -A training Series for Nursing Home: Module #1 Understanding the word Dementia: The person and the disease; taken on 09/28/2024 and take 6 minutes with 17 seconds to complete them with 100% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/28/2024 and take 3 minutes with 49 seconds to complete them with 100% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions on 09/28/2024 and take 3 minutes with 43 seconds to complete them and qualification 100% in the SNF. Module #4 Being with a person with Dementia: Making Difference on 03/22/2023 and taking 7 minutes with 14 seconds to complete them with 100% qualification in the SNF. Module #5 Preventing and Responding to abuse; taken on 03/22/2023 and take 1 minute with 50 seconds to complete them with 100% qualification in the SNF. g. CFR #17 take the Hand-in- Hand -A training Series for Nursing Home: Module #1 Understanding the word Dementia: The person and the disease; taken on 09/04/2024 and take 4 minutes with 14 seconds to complete them with 90% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/04/2024 and take 4 minutes with 35 seconds to complete them with 90% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions; taken on 09/04/2024 and 31 seconds to complete them with 30% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference; taken on 11/22/2023 and taking 19 minutes with 16 seconds to complete them with 75% qualification in Hospital setting. Module #5 Preventing and Responding to abuse; taken on 11/22/2023 and take 1 minute with 49 seconds to complete them with 87.50% qualification in Hospital setting. This employe was removed from the Hospital setting and transferred to the SNF on 05/25/2024. 2. Facility failed to ensure to provide to all employees of the SNF with the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights. 3. Facility failed to ensure that all employees of the SNF with the abuse and neglect training acquired the knowledge to react and respond appropriately to protect the residents' rights. 4. During an interview with the associated DON (employee #1) on 10/30/2024 at 3:00 PM she states that the facility provides to the nursing personnel education relates to abuse and neglect by e-learning computer education system and the hand in hand training by e-learning annual. That in September 2024, they provide the abuse and neglect training presential. 15884 5. No evidence was found during the compliant investigation survey Medicare Division Surveyors and Federal surveyors for a Resource and Support Survey (RSS) on October 29, 2024, through October 30, 2024, from 8:00 AM through 4:30 PM; that facility establishes and maintains communication and coordination with the Quality Assessment Performance Improvement Program to provide protection of the rights of the residents when alleged incidents of abuse and neglect were suspected, investigated and managed. 6. During an interview on 10/30/2024 at 3:00 PM with the coordinator of resident's experience and complaint management officer (employee #6) stated that she reports and response directly to administration in relation of complaints and resident satisfaction.

Based on review of facility Self-Reported incident, interviews with facility nursing supervisor and human resource officials and review of policies and procedures performed on 10/30/2024 at 11:00 AM, it was determined that the facility failed to maintain an exhaustive screening process before an employee is assigned to provide direct care to residents and form part of the facility direct care personnel. This deficient practice was identified in 2 out of 7 complaints investigated with potential abuse and neglect incidents. Findings include: Review of the facility's policy Title Abuse and Neglect effective in May 2023, policy clearly stated that it is the responsibility of the facility to screen all potential employees in relation to abuse and neglect. Policy includes provisions to be followed to ensure that diligent process must be implemented to assure history of the potential employee behavior on previous work scenario is considered before is sent to the area from which is being considered. 1. The facility report to the Puerto Rico State Agency(PRSA) Medicare Division an incident related to two suspected abuse and neglect event incidents occurred on 10/20/2024. While investigated on 10/29/2024 this incident at the facility the following was identified: a. Incident reported by facility as occurred on 10/20/2024, involves the participation of a Licensed Practical Nurse (LPN). Accordingly with the information included in the investigation of this incident performed by facility and reported to the PRSA Medicare division on 10/25/2024 the LPN involved in the incident had been previously reoriented in relation to abuse and neglect requirements and protocols. b. When the surveyor asked the facility Director of Nursing (DON) (employee #1) on 10/30/2024 at 10:25 AM, the reason why it is not included in the investigation of this case was that this LPN had been previously reoriented in relation to abuse and neglect requirements and protocols. She explains that this LPN used to work at the facility hospital, (the Skilled Nursing Facility (SNF) is a hospital-based facility) [AGE] years ago and was transferred to the SNF to take part in resident's direct care in June 2024. It was explained by the DON on 10/31/2024 at 11:00 AM that this LPN was involved in 2 incidents related to abuse and neglect while providing services on the maternity ward on January 23, 2018, and July 22, 2023, respectively. The DON explained that both incidents were related to circumstances where the LPN did not maintain emphatic communication and an approach to patients that receive services at the maternity ward. The facility documented both events and re-oriented this LPN in relation to abuse and neglect requirements and protocols. DON stated that in the year 2024 this LPN begins to show interest in being transferred to the SNF to form part of the SNF employee staff. The surveyors asked the DON if both those incidents occurred previously on January 23, 2018, and July 22, 2023, respectively were taking into consideration before granting the opportunity to this LPN to form part of the SNF employee staff. The DON respond that those incidents were considered before granted the opportunity to this LPN to form part of the SNF employee staff. c. The SNF Nursing Supervisor (employee #2) was interviewed on 10/30/2024 at 10:10 AM and was asked by the surveyor if she knows if the LPN allegedly was involved in the incident that occurred on 10/20/2024 has previous history of non-compliance with abuse and neglect protocol requirements. The SNF Nursing Supervisor stated on 10/30/2024 at 10:12 AM that she believes that there is previous history, but she does not have the details. She stated that she was not consulted, informed or asked previously to transfer this LPN to her employee staff personnel on the month of June 2024. She also stated that when an employee that is working on the hospital is going to be considered to take part in the SNF staff; the screening process is less rigorous that the screening process when new hire personnel is considered to be part of the SNF staff. d. Human Resource official (employee #9) and Director (employee #7) was asked by the surveyor on 10/30/2024 at 10:45 AM if the screening process of potential employees considered to take part of SNF staff when proceed from their same hospital is less rigorous that the screening process performed to potential employees considered to take part of SNF staff when is a new hire. The Human Resource Director stated on 10/30/2024 at 11:05 AM that the screening process varies when the staff proceed from their same hospital, because facility honor seniority who are privileged rank based on continuous employment with the facility. He explains that they consider this personnel interest to take part of facility staff of other areas, and review personnel competence, but it is not so extremely thorough exhaustive than the system when is new hire personnel considered to take part of the SNF staff.

Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect and the Hand in Hand trainings were provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. This deficient practice was identified in 7 out of 22 credential files reviewed to investigated compliance with training requirements. ( CF # 11,#12,#13,#14,#15, #16, and #17). Findings include: During the review of SNF employee Abuse and neglected and the Hand in Hand Trainings on 10/30/2024 from 1:00 PM till 2:00 PM, 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023. The Hand-in- Hand -A training Series for Nursing Home was taken by an e-learning computer training system that individualized virtual training that the personnel take when they have time to complete the module at different times in the years. a.CFR #11 took the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word Dementia: The person and the disease, was taken on 08/17/2024 and take 3 minutes with 30 seconds to complete them with 100% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking, taken on 08/17/2024 and take 3 minutes with 23 seconds to complete them with 100% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions on 08/17/2024 and take 3 minutes with 01 seconds to complete them with 100% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference, taken on 11/08/2023 and take 2 minutes with 15 seconds to complete them with 100% qualification in the maternal and child floor and Nineth floor that was medicine and isolation. Module #5 Preventing and Responding to abuse taken on 11/08/2023 and takes 2 minutes with 27 seconds to complete them with 100% and qualification in the maternal and child floor and Nineth floor that was medicine and isolation. This employe was transferred from Hospital setting to the SNF on 06/24/2024. b. CFR #12 took the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease, taken on 05/06/2024 and take 2 minutes with 48 seconds to complete them with 90% qualification while at the Hospital Setting. Module #2 Being with a person with Dementia: Listening and Speaking, taken on 05/06/2024 and take 2 minutes with 43 seconds to complete them with 80% qualification while at Hospital Setting. Module #3 Being with a person with Dementia: Actions and Reactions, taken on 05/06/2024 and take 3 minutes with 38 seconds to complete them with 100% qualification while at Hospital Setting. Module #4 Being with a person with Dementia: Making Difference, taken on 11/29/2023 and take 5 minutes with 11 seconds to complete them with a 75% qualification while at the Hospital Setting. Module #5 Preventing and Responding to abuse, taken on 11/29/2023 and take 2 minutes with 35 seconds to complete them with 87.50% qualification in Hospital Setting. This employe was transferred from Hospital setting to the SNF on 07/09/2024. c. CFR #13 take the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease: taken on 07/20/2024 and take 36 seconds to complete them with a 90% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 07/20/2024 and take 43 seconds to complete them with a 80% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions; taken on 07/20/2024 and take 46 seconds to complete them with 90% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference taken on 07/29/2023 and take 49 seconds to complete them with a 87.50% qualification in the SNF. Module #5 Preventing and Responding to abuse; taken on 07/29/2023 and take 2 minutes with 36 seconds to complete them with a 100% qualification in the SNF. d. CFR #14 take the Hand -in- Hand -A training Series for Nursing Home Module #1 Understanding the word of Dementia: The person and the disease; taken on 04/13/2024 and take 1 minute with 45 seconds to complete them with 100% qualification in Hospital Setting. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 04/13/2024 and take 2 minutes with 03 seconds to complete them with 100% qualification in Hospital Setting. Module #3 Being with a person with Dementia: Actions and Reactions, taken on 04/13/2024 and take 1 minute with 52 seconds to complete them with 100% qualification in Hospital Setting. Module #4 Being with a person with Dementia: Making Difference; taken on 03/27/2023 and take 48 seconds to complete them with 100% qualification in the Hospital Setting. Module #5 Preventing and Responding to abuse; taken on 03/27/2023 and take 24 seconds to complete them with 100% qualification in Hospital Setting. This employe was removed from Hospital setting to the SNF on 06/10/2024. e. CFR #15 take the Hand-in- Hand -A training Series for Nursing Home: Module #1 Understanding the word of Dementia: The person and the disease; taken on 10/16/2024 and take 1 minute with 40 seconds to complete them with 80% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 05/18/2023 and take 1 minute with 15 seconds to complete them with 90% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions: taken on 05/18/2023 and take 1 minute to complete them with 80% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference; taken on 12/01/2023 and take 1 minute with 58 seconds to complete with 100% qualification in the SNF. Module #5 Preventing and Responding to abuse, taken on 12/01/2023 and take 6 minutes with 48 seconds to complete them with 100% qualification in the SNF. f. CFR #16 take the Hand -in- Hand -A training Series for Nursing Home: Module #1 Understanding the word Dementia: The person and the disease; taken on 09/28/2024 and take 6 minutes with 17 seconds to complete them with 100% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/28/2024 and take 3 minutes with 49 seconds to complete them with 100% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions on 09/28/2024 and take 3 minutes with 43 seconds to complete them and qualification 100% in the SNF. Module #4 Being with a person with Dementia: Making Difference on 03/22/2023 and taking 7 minutes with 14 seconds to complete them with 100% qualification in the SNF. Module #5 Preventing and Responding to abuse; taken on 03/22/2023 and take 1 minute with 50 seconds to complete them with 100% qualification in the SNF. g. CFR #17 take the Hand-in- Hand -A training Series for Nursing Home: Module #1 Understanding the word Dementia: The person and the disease; taken on 09/04/2024 and take 4 minutes with 14 seconds to complete them with 90% qualification in the SNF. Module #2 Being with a person with Dementia: Listening and Speaking; taken on 09/04/2024 and take 4 minutes with 35 seconds to complete them with 90% qualification in the SNF. Module #3 Being with a person with Dementia: Actions and Reactions; taken on 09/04/2024 and 31 seconds to complete them with 30% qualification in the SNF. Module #4 Being with a person with Dementia: Making Difference; taken on 11/22/2023 and taking 19 minutes with 16 seconds to complete them with 75% qualification in Hospital setting. Module #5 Preventing and Responding to abuse; taken on 11/22/2023 and take 1 minute with 49 seconds to complete them with 87.50% qualification in Hospital setting. This employe was removed from the Hospital setting and transferred to the SNF on 05/25/2024. 2.The facility failed to ensure to provide to all employees of the SNF with the Hand -in- Hand -A training Series for Nursing Home 5 module in sequence time during the years and ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights. 3. During an interview with the associated DON (employee #1) on 10/30/2024 at 3:00 PM she states that the facility provides to the nursing personnel education relates to abuse and neglect by e-learning computer education system and the hand in hand training by e-learning annual. That in September 2024, they provide the abuse and neglect training presential.

Based on review of incidents and complaints during Quality assurance and performance improvement (QAPI) program review and staff interview performed on 05/17/2024 at 11:20 AM, it was determined that the facility failed to ensure that all alleged violations involving neglect are reported to the State Survey Agency within 5 working days of the incident to verified appropriate corrective action is taken. Findings include: Facility policy Title: Abuse and Neglect last updated May 2023 was review on 05/17/2024 at 2:35 PM with QAPI officer (employee #8) Policy clearly stated on the procedures that any incidents/violations that been sustained after investigation that abuse or neglect occur must be reported to the state agency and to the required state nursing examination board agency. This policy did not include provisions who establish the time period when the violation were going to be reported. 1. While the Quality assurance and performance improvement (QAPI) program review was performed on 05/17/24 at 11:23 AM it was referred by the QAPI program officer (employee # 8) refer that 15 days ago it was necessary to activate abuse and neglect protocol due to a situation that occurs on April 29, 2024 with a [AGE] years old female resident who are receiving services for rehabilitation due to a Left Knee Replacement and was admitted on [DATE]. 2.Accordingly with information provided by QAPI program officer (employee #9) and Director of Nursing (DON) (employee #10) on 05/17/24 at 11:45 AM on 04/29/24 a nurse took this resident to the shower to receive a bath. DON explain that while resident was in the bathroom, nurse in charge of her did not provide assistance with resident hygiene. Resident is ambulatory enough to reach the bathroom and need minimal assistance bathing herself. However, the nurse did not stay nearby resident room in case the resident needs help. 3. Resident felt bad that nurse did not stay nearby her room in case she needs help. Resident bathed herself and put on her clothes as the best she could with the help of her husband. Resident proceeded to speak with her husband who was there visiting the resident. Resident and her husband proceed to complain about the nurse in charge's way of acting. As result of the situation resident said that felt sad and she did not want to go to receive physical therapy treatment what was she is going to do after taking a bath. Resident stated that she does not want this nurse to be around her or provide any service. Resident also stated that she was afraid to call for assistance to go to the toilet to empty her bladder or bowel because does want that the nurse that did not help her in the shower to provide assistance. 4.Facility refer the resident to neuropsychology services on May 02,2024. Neuropsychology department provides services to resident on May 02,2024,May 03,2024 and May 06, 2024. Main goals for the neuropsychology services were to facilitate collateral training and teach her how to redirect resident fear and anxiety and to reinforce guided relaxation strategies to enhance emotional regulation and positive mood throughout stay at the rehabilitation facility. Neuropsychology personnel stated on their progress notes that the resident benefit from the replacing of the nurse (with which one resident had the incident) with another nurses and reassurance from other healthcare personnel to ease her apprehension and worry. 5. Accordingly with information provided by QAPI program officer (employee #9) on 05/17/24 at 11:55 AM facility create a temporary committee to investigate the situation (An Ad Hoc committee) and proceed immediately to activate the abuse and neglect protocol and proceed to investigate the incident on May 02, 2024. 6. This Ad Hoc committee investigate the circumstances where the incident occurs and interview personnel in charge, the resident, and her husband. The committee analyzed information collected accordingly with abuse and neglect policies and determined that neglect in relation with the management by the nurse to this resident while she was in the bathroom occurred. A final determination with the decision was informed to the administrator of the facility on May 06, 2024. Nurse was suspended from work and salary from May 02, 2024 through May 08, 2024 and transferred from the Skilled Nursing Facility (SNF) to the hospital area (this is a SNF located in an hospital). 7. Facility administrator (employee #10) stated on interview on 05/17/24 at 1:00 PM that she receives the determination performed by the Ad Hoc committee on May 06, 2024, and did not notify to the state agency or any local entity (state nursing examination board agency). 8. Facility administrator (employee #10) stated on interview on 05/17/24 at 1:12 PM that she made a phone call on May 09, 2024 to the state Medicare division office and report that an resident complaints in relation with services provided by one of the nurses however did not specify that the situation was investigate by an Ad Hoc committee and that the Ad Hoc committee determine that negligence on the management of the case occur.

Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to distribute and serve food in accordance with facility established infection control precautions. This deficiency affects 19 out of 19 cases reviewed during dining observations. Findings include: 1. During dining observations procedures performed on 05/16/24 at 12:00 PM it was identified that kitchen personnel (employee #4) brought the lunch trays in a food warmer cart. 2. Kitchen personnel (employee #5) did not check if resident was in the room before taking out the lunch tray from the food warmer cart. He took off the trays of room [ROOM NUMBER]-2, 308-2 309-2 and 311-1before checking if those residents were in the room. Since residents were not in their room, he returns the lunch tray again to the food warmer. 3. Kitchen personnel return lunch trays to the food warmer cart that had been in the environment of resident's rooms and could be in contact with room surfaces. 4. It was asked to the infection control officer (employee #3) on 05/16/24 at 2:00 PM if is correct that Kitchen personnel (employee #5) return the lunch trays to the food warmer once there had been in the environment of resident's rooms and could be in contact with room surfaces. 5. Infection control officer (employee #3) stated interview on 05/16/24 at 2:10 PM that Kitchen personnel (employee #5) must first review if the resident is in the room before taking the lunch tray from the food warmer cart. She also explains that this way it prevent that lunch trays who could had been in the environment of residents rooms and could be in contact with room surfaces be return to the food warmer cart where there are all the others lunch trays.

Based on review of Quality Assessment Performance Improvement (QAPI) activities performed on 05/16/24 through 05/17/24 from 8:00 AM till 5:00 PM and interview with the facility QAPI (employee #8) it was determined that facility failed to ensure the participation of all required members on the QAPI committee meetings. Findings include: 1. During review of facility QAPI committee meetings during year 2023 and the months of February 2024 and April 2024 the following was identified: Upon review of facility attendance list related to QAPI program committee meeting activities it was identified that the Infection Preventionist did not participate in every QAPI committee meeting. a. There is no evidence of participation of facility Infection Preventionist on QAPI committee meetings performed on May 25, 2023, September 14, 2023, October 26, 2023, February 15, 2024, and April 15, 2024. b. During interview on 05/17/24 at 1:30 PM facility QAPI (employee #8) stated that infection control officer gave her the infection control report and discusses with her relevant areas and is her as the QAPI, who present the findings on the QAPI committee meetings.

Based on recertification survey, observations interview with the MDS coordinator on 07/15/2021 at 11:20 AM it was identified that the facility failed to provide proper supervision to prevent accident for 2 out of 13 admitted resident which resulted in an Immediate Jeopardy. Findings include: 1. During the initial tour performed on 07/15/2021 on 9:00 AM, it was identified that 3 out 13 residents were with the 4 side rails up. 2. During interview with the MDS coordinator employee #1 on 7/15/2021 at 11:20 AM related to the residents with the bed rails up, employee #1 refer that the resident #106 fall on 07/09/2021 at 3:15 PM and on 07/12/2021 at 4:40 PM. Resident #106 was found by the nurse on the floor without the urinary catheter and with blood on the area. Employee #1 refer that the resident #112 fell on [DATE]. Both residents were with the side rails up. Tag F689 1. Nursing personnel will be oriented regarding frequent rounds (hourly) to residents with high risk for falls and/or entrapment. Nursing staffing will be reinforced in order to comply with this task. 2- A document was designed to monitor, and document rounds performed on high risk residents. 3- Nursing personnel will make sure beds are in the lowest position with wheels locked, ring close to resident, appropriate illumination. Also, to be included reason why resident get out of bed such as hunger, bathroom use, pain among others, as well as concurrent orientation to resident. POC on 07/16/2021 at 8:30 AM Not accepted Tag F689 1. Nursing personnel will be oriented regarding frequent rounds(hourly) to residents with high risk for falls and/or entrapment (residents 316-A, 309 B and 315 B). Nursing staffing will be reinforced in order to comply with this task starting on 07-15-2021 after 5:00 PM 2- A document was designed to monitor, and document rounds performed on high risk residents on an ongoing basis starting on 07-15-2021 at 5:00 PM. 3- Nursing personnel will make sure beds are in the lowest position with wheels locked, ring close to resident, appropriate illumination. Also, to be included reason why resident get out of bed such as hunger, bathroom use, pain among others, as well as concurrent orientation to resident. This task was started on 07-15-2021 at 5:00PM. POC on 07/16/2021 at 9:30 AM Not accepted Tag F689 1. Nursing personnel will be oriented regarding frequent rounds(hourly) to residents with high risk for falls and/or entrapment (residents 316-A, 309 B and 315 B). Nursing staffing will be reinforced in order to comply with this task starting on 07-15-2021 after 5:00 PM. 2- A document was designed to monitor, and document rounds performed on high risk residents on an ongoing basis starting on 07-15-2021 at 5:00 PM. 3- Nursing personnel will make sure beds are in the lowest position with wheels locked, ring close to resident, appropriate illumination. Also, to be included reason why resident get out of bed such as hunger, bathroom use, pain among others, as well as concurrent orientation to resident. This task was started on 07-15-2021 at 5:00PM. POC on 07/16/2021 at 9:51 AM POC Accepted and the IJ lifted on site, however deficiency practice continues in a lower SS/I. Resident # 106 is a [AGE] years old male patient admitted on [DATE] with a diagnostic of Cerebral Infarction due to embolism of unspecified cerebellar artery. 07/16/21 9:00 PM during interview with employee # 1 nursing supervisor it was identified that the Resident # 106 was transfer to CCU due to an emergency code on 7/16/2021 at 12:45 AM. The diagnostics are Retroperitoneal bleeding, [CONDITION(S)], Acute respiratory failure on Mechanical Ventilator, UTI, Urethral Trauma and Septic vs Hypovolemic shock. At the time of the note the Resident record reveal that his condition was critical, and the prognosis is guarded. Resident # 106 was discharge from the SNF on 07/16/2021 at 2:05 AM. A mechanism to ensure facility promote an environment that is free from accident over which they have the control and provides supervision to each resident to prevent accidents was not followed. These findings were identified during the initial pool process on 07/15/21 at 10:00 AM: When initial pool was performed on 07/15/2021 from 8:30 AM through 4:00 PM resident located on room 109-B was observed with 4 side rails up on the bed. This resident was observed alert and answer all the questions that were asked. On this case the 4 side rails cannot be removed easily by the resident after was applied by the staff. As the result of the use of the 4 side rails up case was selected to investigate in order to identify if resident was supervised to prevent accidents. Sample case # 112 is a [AGE] years old female resident who was admitted on [DATE] with a diagnosis of Decondition Syndrome. During admission resident was evaluated for risk of fall and identified that had risk for fall and plan of care for fall prevention was implemented. During the review of the case with the nursing supervisor (employee #1) it was identified that nursing personnel spoke with resident relative who visit the resident on 07/04/2021 and relative sign a document were facility inform that are going to maintain 4 bed side rails up in order to provide safety to the resident. This document that resident's relative sign as certification of receive information of the necessity for side rails was not signed by the physician. On 07/05/2021 at 3:40 PM resident fell down to the floor. As documented on the incident report of fall, the bed had the 4 side rails up when the resident fell down to the floor. Accordingly, with the fall incident documentation resident was identified disoriented. After the incident of fall, physician evaluate the resident and order as part of the fall prevention plan facility to keep 4 side rails on the bed (Physician order to keep 4 side rails of the bed reviewed dated 07/05/2021 at 9:00 PM). Regardless off resident has been identified with fall risk, no supervisory rounds were found documented on the medical record on 07/04/2021 or 07/05/2021 before resident [NAME] down to the floor from bed with side rails up. The last round on resident room that was found documented was a round to check for incontinence, and was found reported on 07/05/2021 at 2:00 PM, resident felt down to the floor on 07/05/2021 at 3:40 PM. Accordingly, with drug medication review performed by the pharmacy when resident was admitted to the facility on [DATE] resident was receiving [MEDICATION(S)] 5 mgs PO every 12 hours for anxiety and [MEDICATION(S)] 1 mg PO daily at 9:00 AM for anxiety. On 07/15/21 at 1:55 PM the case was discussed with the Medical Director (employee #2) who stated that this is a [AGE] years old female admitted due to Decondition Syndrome, had [CONDITION(S)], history of drug abuse and present [CONDITION(S)] on lower extremities due to abuse of injected drugs. Accordingly, with information provided by Medical Director, this [CONDITION(S)] had an impact on her muscle function and contribute to mobility issues. An order to discontinue the use of 4 bed side rails was issued by the physician on 07/15/2021 at 6:45 PM after facility being cited with this situation who result in an immediate jeopardy due to improper use of restraint devices and the failure to supervise residents who requires supervision to prevent accidents. After the fall incident on 07/05/2021 there are no evidence documented on the medical record that the resident has a medical symptom that warrant the use of the 4 side rails. Facility failed to provide supporting clinical documentation identifying medical symptoms who justify the use of this restraint. If based on clinical judgement facility determine the need for the use of 4 bed side rails during resident admission to the facility on [DATE], if resident begin to participate on her rehabilitation process and was identified alert and oriented facility could considerate the use of this type of restraint for the least amount of time possible. However, there are no clinical documented evidence that resident was combative and disoriented while facility was using the 4 bed side rails. Facility failed to promote resident environment is free from accident and provide supervision for residents who requires supervision to prevent accidents.

Based on recertification [NAME] survey, observations interview with the MDS coordinator on 07/15/2021 at 11:20 AM it was identified that the facility failed to promote the right of the resident to be free of restrain for 3 out 13 admitted resident. The facility failed to ensure that the bed rails did not put the resident in a risk of injury from falls for 3 out of 13 admitted resident and this result in and Immediate Jeopardy. Findings include: 1. During the initial tour performed on 07/15/2021 on 9:00 AM, it was identified that 3 out 13 residents were with the 4 side rails up. 2. During interview with the MDS coordinator employee #1 on 7/15/2021 at 11:20 AM related to the residents with the bed rails up employee #1 refer that the resident #106 falls on 07/09/2021 at 3:15 PM and on 07/12/2021 at 4:40 PM. Resident #106 was found by the nurse on the floor without the urinary catheter and with blood on the area. Employee #1 refer that the resident #112 fell on [DATE]. Both residents were with the side rails up. Facility's Allegation of Compliance letter: Tag F604 1- In those residents with [CONDITION(S)] and/or disorientation, the bed rail to be kept down will be the rail located on the functional lower extremity. 2- SNFs Medical Director will evaluate the need to keep rails daily. 3- SNFs, Clinical Supervisor will be responsible for monitoring compliance with the fall prevention round's document. Results of this monitoring will be presented to the institutions quality program and discussed at the SNFs monthly meeting. 07/16/2021 not accepted 8:30 AM Tag F604 1- In those residents with [CONDITION(S)] and/or disorientation, the bed rail to be kept down will be the rail located on the functional lower extremity. Started on 07-15-2021 at 5:00 PM 2- SNFs Medical Director will evaluate the need to keep rails on a daily basis to the residents 316-A, 309 B and 315 B. A round was done to the rest of residents to assure that bed rails are lowered. (10 residents). This round were started on 07-15-2021 at 5:00 PM 3- SNFs, Clinical Supervisor or team leader will be responsible for monitoring compliance with the fall prevention round's document. Monitoring will be on a daily basis for the next six months. Results of this monitoring will be discussed at the SNF, s monthly meeting and also presented monthly to the institutions quality program and discussed at quality meeting quarterly. Ongoing monitoring started 07-16-2021. 07/16/2021 not accepted 9:30 AM Tag F604 1. In those residents with [CONDITION(S)] and/or disorientation, the bed rail to be kept down will be the rail located on the functional lower extremity. Started on 07-15-2021 at 5:00PM. 2- SNFs Medical Director will evaluate the need to keep rails on a daily basis to the residents 316-A, 309 B and 315 B. A round was done to the rest of residents to assure that bed rails are lowered. (10 residents). This rounds were started on 07-15-2021 at 5:00 PM 3- SNF, s Clinical Supervisor or team leader will be responsible for monitoring compliance with the fall prevention round's document. Monitoring will be on a daily basis for the next six months. Results of this monitoring will be discussed at the SNF, s monthly meeting and also presented monthly to the institutions quality program and discussed at quality meeting quarterly. Ongoing monitoring started 07-16-2021. 4- Surrounding the residents bed with a soft mat on residents with high risk of falling is being evaluated to assure resident safety, this safety measure with be started on 07-30-2021. 07/16/2021 at 9:51 AM plan was accepted and IJ lifted on site, however the deficiency practice continued in a lower level SS\I Resident # 106 is a [AGE] years old male patient admitted on [DATE] with a diagnostic of Cerebral Infarction due to embolism of unspecified cerebellar artery. On 07/16/21 at 9:00 PM during interview with employee # 1 nursing supervisor it was identified that the Resident # 106 was transfer to Intensive Care Unit due to an emergency code on 7/16/2021 at 12:45 AM. The diagnostics are Retroperitoneal bleeding, [CONDITION(S)], Acute respiratory failure on Mechanical Ventilator, UTI, Urethral Trauma and Septic vs Hypovolemic shock. At the time of the note the Resident record reveal that his condition was critical, and the prognosis is guarded. Resident # 106 was discharge from the SNF on 07/16/2021 at 2:05 AM. A mechanism to ensure facility promote that each resident maintain his/her practicable wellbeing and use of physical restraints is use only when necessary was not followed. These findings were identified during the initial pool process on 07/15/21 at 10:00 AM: When initial pool was performed on 07/15/2021 from 8:30 AM through 4:00P M resident located on room [ROOM NUMBER]-B was observed with 4 side rails up on the bed. This resident was observed alert and answer all the questions that were asked. On this case the 4 side rails cannot be removed easily by the resident after raised by the staff. As the result of the use of physical restraints with the 4 side rails up case was selected to investigate in order to identify inappropriate use of physical restraints. Sample case # 112 is a [AGE] years old female resident who was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of the case with the nursing supervisor (employee #1) it was identified that nursing personnel spoke with resident relative who visit the resident on 07/04/2021 and relative sign a document were facility inform that are going to maintain 4 bed side rails up in order to provide safety to the resident. This document that resident's relative sign as certification that he/she received information of the necessity for side rails was not signed by the physician. On 07/05/2021 at 3:40 PM resident fell down to the floor. As documented on the incident report of falls, the bed had the 4 side rails up when the resident fell down to the floor. Accordingly, with the fall incident documentation, resident was identified disoriented. After the incident of fall, physician evaluate the resident and order as part of the fall prevention plan facility to keep 4 side rails on the bed (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Regardless off resident has been identified with fall risk, no supervisory rounds were found documented on the medical record on 07/04/2021 or 07/05/2021 before resident fell down to the floor from bed with side rails up. The last round on resident room that was found documented was a round to check for incontinence, and was found reported on 07/05/2021 at 2:00 PM, resident fell down to the floor on 07/05/2021 at 3:40 PM. Accordingly, with drug medication review performed by the pharmacy when resident was admitted to the facility on [DATE] resident was receiving [MEDICATION(S)] 5 mgs PO every 12 hours for anxiety and [MEDICATION(S)] 1 mg PO daily at 9:00 AM anxiety. On 07/15/21 at 1:55 PM the case was discussed with the Medical Director ( employee #2) who stated that this is a [AGE] years old female admitted due to Decondition Syndrome, had [CONDITION(S)], history of drug abuse and present [CONDITION(S)] on lower extremities due to abuse of injected drugs. Accordingly, with information provided by the Medical Director this [CONDITION(S)] had an impact on her muscle function and contribute to mobility issues. An order to discontinue the use of 4 bed side rails was issued by the physician on 07/15/2021 at 6:45 PM after facility being cited with this situation who result in an immediate jeopardy due to improper use of restraint devices and the failure to supervise residents who requires supervision to prevent accidents. After the fall incident on 07/05/2021 there are no evidence documented on the medical record that the resident has a medical symptom that warrant the use of the 4 side rails. Facility failed to provide supporting clinical documentation identifying medical symptoms who justify the use of this restraint. If based on clinical judgement facility determine the need for the use of 4 bed side rails during resident admission to the facility on [DATE], if resident begin to participate on her rehabilitation process and was identified alert and oriented facility could considerate the use of this type of restraint for the least amount of time possible. However, there are no clinical documented evidence that resident was combative and disoriented while facility was using the 4 bed side rails. Facility failed to ensure resident is free from physical restraints when there are no medical symptoms who justify the use of the side rails as a restriction device.

Based on recertification survey, observations, review of twelve clinical sample records, and interviews, it was determined that the facility failed to maintain adequate supervision and assistance devices to prevent accidents. The facility fail to maintain the environment free of accident hazards for 1 out of 12 resident sample. (Resident #115) Findings include: During record review of Resident #115 it was found that she have fall two times during the stay, one on 03/20/2019 at 1:40 am and the other on 03/22/2019 4:00 am. The fall report reflect on 03/20/2019 that the resident was found on the floor beside the bed with the wet floor in front of the bed. The floor was wet because the resident urinated on the floor. In the report is written that the resident refer that she was coming back from the bathroom and got dizzy and she hit on the head and right hip. The upper side rails were up. No injuries or bleeding were found. MD evaluation was perform on 03/20/2019 at 2:10 am. On 03/22/2019 at 4:00 am the report reflect that a resident start screaming Nurse a resident fell . Resident #115 was observe sitting on the floor and refer that she try to sit in between the bed rails and she slides to the floor and hit the lower back. In the incident report at the Environmental Factor is written that the four bed rails were up. The resident was evaluated by the MD on 02/22/2019 at 4:52 am and no injuries were found. 03/25/19 12:13 PM During Telephone interview with Daughter of the Resident #115 refer that my mother have two falls during the stay. The last fall was on Friday night On 03/27/2019 at 10:00 AM During interview with Resident # 115 it was identified that the resident did not recall any of the falls in the SNF. On 03/28/19 10:45 AM it was identified that Resident # 115 was evaluated by Neurocognitive Rehabilitation on 03/13/19 and identified that the patient was moderately disoriented in time and have her recent memory slightly impaired. The facility failed to maintain adequate supervision to prevent accidents. The facility fail to maintain the environment free of accident hazards.

Based on a standard and extended FOSS survey for recertification, observation tour at the Kitchen and interview with administrative dietitian (employee #1) Safety Officer (employee #9) and Physical Plant engineer (employee #5) on 5/22, 5/23, 5/24, and 5/25/17 it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 9 out of 9 residents (R) admitted at the facility. (R #1 to R#9) Findings include: Observational tour at the Kitchen perform on 5/22/17 at 10:15 am until 12:30 pm, it was found that the facility failed to establish effective infection control precautions to avoid widespread nosocomial infections. The cold storage room is located at the ground floor of this facility. During the observational tour it was found the following: 1. The cold room was found to be out of the temperature range, temperature taken revealed that the cold room was at 75 degree Fahrenheit (º F) 2. The air condition unit of the cold room not functioning and the console did not have cover on with rust and dust that was falling over the counter where the meat is prepared, 3. The vegetable refrigerator had mold around the gaskets and with white mold on the fans 4. A tray of coleslaw and three trays of cantaloupe uncover and without label in front of the refrigerators fans 5. Two refrigerators inside the cold room were filled with mold on the walls and ceilings 6. It was observed that five boxes of 10 pounds of pork chop, five boxes of 10 pounds of turkey, three boxes of 8 pounds of meat, and 8 boxes of 1 pound of chicken were left thawing on the preparing table at 75 º 'F. The boxes were not label. According to interview with the kitchen staff (Employee #2) on 5/22/17 at 10:30 am, he stated: Those boxes of meats are for production and are to be prepared. The meats were brought early today at 8:30am. They should have been labeled. According to interview with the engineer (employee #5) at 11:45 a.m. he state; Yes I know the situation and we are working on it. It is supposes that for this Friday the air conditioner of the cold room is ready. After that the other air conditioners consoles will be fix it. According to interview with the Dietitian (employee #1), at 10:35 am she state: I reported on this situation since February. Temperatures started to be out of parameters in the Formula room and in the Cold room since February. I have been reporting this situation to the physical plant department and my boss has also mentioned it in the Quality meetings. A Statement of Deficiency was provided to the facility on [DATE] at 2:15 pm notifying the IJ and requesting a Plan of Correction (POC). The facility provided a POC on 5/22/17 at 3:30 pm as follow: General instruction and corrective Actions: 1. A portable Air Conditioner will be installed on the Formula Room and the Cold room to reach the adequate temperature 70 degrees. 2. The DL Refrigeration Service Company will provide service to install the covers at the air conditioner console. The labor will be completed on Friday. 3. The vegetable fridge fans will be cleaned immediately by terminal cleaning. 4. Tray of Cole slaw and other trays will be cover with Zaron Wrap and labeled with preparation date. 5. The refrigerator and the freezer on the cold room will be cleaned by terminal cleaning including the wall and the ceiling. An onsite visit was performed on 5/23/2017 at 11:15 am to the Kitchen's cold room The POC was accepted by the surveyors on 5/22/2017 at 3:48 pm. Based on a standard and extended FOSS survey conducted on 5/22, 5/23, 5/24, and 5/25/17 for recertification, the kitchen observational tour, review of official documents and interview with the Nutrition Director (employee #1) and Physical plant director (employee #5), it was determined that the facility failed to ensure a safety place for the store, prepare and serve food under sanitary conditions which can affect 9 of 9 admitted residents (R). (R#1 to R#9) Findings include: 1. During observational tour performed on 5/22/17 at 10:05 am thru 12:05 pm it was found in the following: a. One can of plum of 104 ounces was dent and was located on the active food storage. Was immediately remove by the food storage supervisor (employee #4) b. On the lacteous refrigerator was observed a leak of water that fell on the bottles of milks that were in plastic baskets. The bottles of milks were observed wet. c. On the lacteous refrigerator was observed that boxes of eggs were wet with the splash of the water leak from the refrigerator's air conditioning unit. d. On the bread refrigerator was observed a water leak from the air conditioning unit and water on the floor. The shelves in this refrigerator had rust. e. The air conditioning units from the cold room where not functioning and had not the covers on. It was observed that the facility was using two portable air units that were maintaining a temperature of 75'F. The drainage of the portable air conditioning units was leaking water to the floor. f. It was observed five boxes of 10 pounds of pork chop, five boxes of 10 pounds of turkey, three boxes of 8 pounds of meat, and 8 boxes of 1 pound of chicken that were left on the preparing table inside the boxes at 75'F. The boxes were not label. During interview with the kitchen staff (Employee #2) on 5/22/17 at 10:30 am, he stated: Those boxes of meats are for production and are thawing to be prepared. The meats were brought early today at 8:30am. They should have been labeled. Facility fails to ensure that the regulations establish method to safely thaw frozen food are follow. g. On the second refrigerator of the cold room was observed one tray with 9 Egg beaters of 32 ounces, one of the egg beater box was broken causing a spill of 32 ounces of egg beater all over the tray. h. On the second refrigerator of the cold room was observed a bag of grated cheddar cheese that was opened and without label. i. On the cabinets of the cold room was observed a meat grinder that was uncover, on top of a piece of box, and with white stains. Also, was observed a food crusher that was uncover and on top of a tray that was with dust and white stains. During interview with the kitchen staff (employee #2) on 5/22/17 at 10:45 am, he stated: The meat grinder and the food crusher are not being used. They were cleaned and storage there. j. On cold room was observed that kitchen staff (employee #2) was peeling potatoes from a carton box and inside the box was a partially peal potato with all the pieces of the potato peel. It was observed that right next to the carton box was a tray with uncover vegetables. k. On cold room were observed two carton boxes on top of kitchen materials, the kitchen staff (Employee #2) removed them immediately. The performed a change of gloves and hand wash, however he shake the hands to remove the excess of water and then dried hands with paper. The facility failed to ensure that the kitchen staff performs hand hygiene in accordance with the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene and Glove Use (CDC, 2002) in Healthcare Settings. l. On cold room were observed green and black stains on the floor next to the refrigerators and freezer. m. In the kitchen tour were observed nesting pans, the pans were observed stacked upside down one on top of the other and they were found wet with an accumulation of water. n. On the snack refrigerator was observed bag of American cheese and a bag of turkey jam that were opened and not label. o. On the cabinets use to store the snack food were observed 4 bags of crackers (galletas exporsodas) and 2 bags of vanilla crackers that were not label. p. The refrigerator use to storage the apples, juice box, milks, milk supplements, Jell-O, yogurt, and butter while stoking the line trays was observed on 5/23/17 at 12:15 pm and maintained a temperature of 67degree Fahrenheit (º F). The yogurt internal temperature was measure and showed that it was 65.3º F. However the facility provided evidence that the immediately removed the food from that refrigerator that was expose to high temperatures to prevent residents of potential hazard food. The facility failed to store, maintain, and prepare food in a safe and sanitary manner related to maintaining food at or below 41º F. q. A sample tray was evaluated on 5/23/17 at 11:20 am and showed the following temperatures out of recommended range: (i) Rice: 132.3º F (ii) Turkey: 126.4'F A sample tray was the evaluated on the kitchen on 5/23/17 at 12:00 pm and showed the following temperatures out of recommended range: (i) Rice: 137.4'F (ii) Turkey: 124.4'F The facility failed to store, maintain, and prepare food in a safe and sanitary manner related to maintaining food at hot holding temperature of 135'F to prevent the growth of infectious organisms.

Based on a standard/extended FOSS and complaint investigation PR 598 survey conducted on 5/22, 5/23, 5/24, and 5/25/17, seven records review (RR), and review of policies and procedures (P&P's), it was determined that the facility failed to provide the necessary care to assess and manage pain of residents who had more than one medical comdition to ensure that residents (R) reach their highest practicable well-being for 1 out of 7 sample selection residents (R #6). Findings include: 1. Resident #6 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident #6 was admitted for physical therapy, occupational therapy and wound care. The resident #6 was discharge home on 5/18/17 at 12:50 pm, having a length of stay of 51 days in the facility. The close record review was performed on 5/25/17 at 2:00 pm and the following was found: a. The Minimum Data Set (MDS) report of 4/4/17 on section G0110. Activities of Daily Living (ADL) Assistance on 5/25/17 at 3:12 pm provides evidence that the resident #6 is total dependent on bed mobility and that includes how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The resident #6 needs full staff performance every time in bed mobility, one personal physical assist. b. The Minimum Data Set (MDS) report of 4/4/17 on section J0100 Pain Management on 5/25/17 at 3:12 pm provides evidences that the resident #6 is received scheduled pain medication regiment, received PRN pain medication or was offered and declined, pain is suffered occasionally, the worst pain event during the last five days was 8/10 and severe. c. During review of the nursing notes of 4/6/17 was found incongruence between the pain documentation of the nursing staff and what the patient referred. The nursing note provides evidence that the patient did not had pain, however the patient referred that he had such pain that caused him vomiting episodes. d. During review of the nursing notes of 4/6/17 was found evidence that the nursing staff did not included in her note information related of the resident #6 clinical changes and needs. e. During the Change of position form of 4/6/17 provides evidence that the nurse change the patient position at 12:00 am, 2:00 am, 4:00 am, and 6:00 am. However the patient referred that the nursing staff did not perform any changes on position after 1:35 am thru 6:00 am. f. During review of the Facility Re-assessment of Pain form was found evidence that the nursing staff documented the pain scale on 4/6/17 at 12:00 am (0/10), 4/6/17 at 4:00 am (0/10), and 4/6/17 at 6:00 am (5/10). However the resident #6 referred that the nursing staff did not come to the room from 1:35 am thru 6:00 am and that he was suffering of pain during that time. g. During review of the Medication record was observed that the patient received [MEDICATION NAME] 5/325 mg 1 tab Oral (PO) every 3 hours when needed (PRN) for pain on 4/3/17 at 9:00 am and 9:50 pm, 4/4/17 at 10:00 am and 5:30 pm, 4/5/17 at 10:00 am and 5:00 pm. However from 4/5/17 at 5:00 pm thru 4/6/17 at 6:00 am (11 hours) the patient did not received medication for pain during eleven hours. The patient referred during interview that he had such pain that caused him vomiting episodes. h. During the medical order reviews was found evidence of a telephone order from the physician of [MEDICATION NAME] 5/325 mg 1 tab PO PRN every 3 hours for pain. The medication was administered on 4/6/17 at 6:00 am. i. During the interdisciplinary group notes was found evidence that RN employee #10 oriented the resident #6 about the importance of position changes every 2 hours and to avoid the pressure on the affected area. j. During review of the nursing care plans was found evidence that the Pain, Fall, and Pressure Ulcer care plans were open. 2. The Pain care plan establishes the following: a The use of therapeutic modalities for the pain management and pain control like: Positioning. b. Administer medication according to medical order for pain management. c. Pain note in clinical file must include: sounds, complaints, facial expressions, and movements. The resident #6 referred that from 1:35 am thru 6:00am he did not received change of position and pain medications. 3. The Fall care plan establishes the following: a. Provide rounds every two hours to three hours and / or more frequent in patients identified at risk. The resident #6 referred that the nursing staff did not come to the room from 1:35 am thru 6:00 am. 4. The Pressure Ulcer care plan establishes the following: a. Perform interventions aimed at preventing the development of area and pressure ulcers b. Promote and reposition every two hours c. Keep the skin dry, clean and lubricated d. Educate the resident and family about the treatment of [REDACTED]. 5. During the complaint investigation PR 598 of the resident #6 it was found the following: a. The resident #6 called the nursing station for help in bed mobility on 4/6/17 at 1:35 am. The Registered Nurse (RN) (Employee #11) went to the room and helped him; however she did it with a rude attitude towards him. b. The resident #6 referred that when the RN (Employee #11) went to room [ROOM NUMBER]A she stated: I will not come back until 4:00 am. c. The resident #6 referred that when the practical nurse (LPN) (Employee #12) went to room [ROOM NUMBER]A she stated: you only came to this facility for physical therapy and nothing more. d. The resident #6 called the nursing station on multiple occasions for help and assistance in bed mobility because he was in pain caused by the sacral ulcer and a previous surgery. The pain caused that the resident suffer from vomit episodes. The resident referred that the nursing staff did not return to the room anymore. e. The resident #6 referred that he made a telephone call to his wife at approximately 4:00 am and she arrived to the facility on [DATE] at 4:30 am. The report of the complaint provides evidence that the wife of the resident #6 found him without bed sheets, with pain, and dirty with vomit to which she had to clean without nursing assistance. 6. The facility failed to manage pain to residents who had more than one active medical condition (pressure sore, status [REDACTED].

Based on a standard and extended FOSS survey for recertification and a complaint investigation PR 598, review of the facility's grievance and complaint registry, policies and procedures (P&P's), and interviews performed on 5/22, 5/23, 5/24, and 5/25/17 it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 13 out of 13 residents (R) admitted at the facility. (R#1 to R#13) Findings include: During the resident #6 complaint investigation performed on 5/24/17 at 10:30 am, the following was found: 1. Resident #6 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident #6 was admitted for physical therapy, occupational therapy and wound care. The resident #6 was discharge home on 5/18/17 at 12:50 pm, having a length of stay of 51 days in the facility. The close record review was performed on 5/25/17 at 2:00 pm. 2. The Resident #6 complaint allegations of 4/6/17 were the following: a. The nursing staff talked to him and treated him in a rude way. b. The nursing staff ignored when he called the nursing station. c. The nursing staff did not come to the room to change him on bed positioning. d. The nursing staff did not assess and manage the pain that the sacral ulcer caused. e. The pain provokes constantly vomit episodes to the resident #6. f. The nursing staff did not come to the room to clean resident #6. 3. During close record review (RR) of Resident #6 on 5/25/17 at 2:00 pm was found the following: a. The Minimum Data Set (MDS) report of 4/4/17 on section G0110. Activities of Daily Living (ADL) Assistance on 5/25/17 at 3:12 pm provides evidence that the resident #6 is total dependent on bed mobility and that includes how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The resident #6 needs full staff performance every time in bed mobility, one personal physical assist. b. The Minimum Data Set (MDS) report of 4/4/17 on section J0100 Pain Management on 5/25/17 at 3:12 pm provides evidences that the resident #6 is received scheduled pain medication regiment, received PRN pain medication or was offered and declined, pain is suffered occasionally, the worst pain event during the last five days was 8/10 and severe. c. During review of the nursing notes of 4/6/17 was found incongruence between the pain documentation of the nursing staff and what the patient referred. The nursing note provides evidence that the patient did not had pain, however the patient referred that he had such pain that caused him vomiting episodes. d. During review of the nursing notes of 4/6/17 was found evidence that the nursing staff did not included in her note information related of the resident #6 clinical changes and needs. e. During the Change of position form of 4/6/17 provides evidence that the nurse change the patient position at 12:00 am, 2:00 am, 4:00 am, and 6:00 am. However the patient referred that the nursing staff did not perform any changes on position after 1:35 am thru 6:00 am. f. During review of the Facility Re-assessment of Pain form was found evidence that the nursing staff documented the pain scale on 4/6/17 at 12:00 am (0/10), 4/6/17 at 4:00 am (0/10), and 4/6/17 at 6:00 am (5/10). However the resident #6 referred that the nursing staff did not come to the room from 1:35 thru 6:00 am and that he was suffering of pain during that time. g. During review of the Medication record was observed that the patient received [MEDICATION NAME] 5/325 mg 1 tab Oral (PO) every 3 hours when needed (PRN) for pain on 4/3/17 at 9:00 am and 9:50 pm, 4/4/17 at 10:00 am and 5:30 pm, 4/5/17 at 10:00 am and 5:00 pm. However from 4/5/17 at 5:00 pm thru 4/6/17 at 6:00 am (11 hours) the patient did not received medication for pain during eleven hours. The patient referred during interview that he had such pain that caused him vomiting episodes. h. During the medical order reviews was found evidence of a telephone order from the physician of [MEDICATION NAME] 5/325 mg 1 tab PO PRN every 3 hours for pain. The medication was administered on 4/6/17 at 6:00 am. i. During the interdisciplinary group notes was found evidence that RN employee #10 oriented the resident #6 about the importance of position changes every 2 hours and to avoid the pressure on the affected area. j. During review of the nursing care plans was found evidence that the Pain, Fall, and Pressure Ulcer care plans were open. The Pain care plan establishes the following: i. The use of therapeutic modalities for the pain management and pain control like: Positioning. ii. Administer medication according to medical order for pain management. iii. Pain note in clinical file must include: sounds, complaints, facial expressions, and movements. However the resident #6 referred that from 1:35 am thru 6:00am he did not received change of position and pain medications. The Fall care plan establishes the following: i. Provide rounds every two hours to three hours and / or more frequent in patients identified at risk. However the resident #6 referred that the nursing staff did not come to the room from 1:35 am thru 6:00 am. The Pressure Ulcer care plan establishes the following: i. Perform interventions aimed at preventing the development of area and pressure ulcers ii. Promote and reposition every two hours iii. Keep the skin dry, clean and lubricated iv. Educate the resident and family about the treatment of [REDACTED]. However the patient referred that the nursing staff did not reposition him after 1:35 am thru 6:00 am. He also states that he vomited and the nursing staff did not come to the room to clean him. According to telephone interview with the Resident #6 on 5/31/17 at 9:52 am, he stated: I really do not have much to tell because I have nothing against those people. I was complaining of pain and discomfort and the nurses came and treated me roughly. They also told me two comments that were not pleasant and made me feel bad and like I was not welcome. One of the nurses said she would not come to the room until it was 4:00 am. The other nurse said that I had only come to the facility for physical therapy and nothing else. I felt bad and could not move to change my position that already bothered me. I needed to change my position, which would have alleviated the pain a little. The pain became so strong that it made me vomit several times. It was not until 6:00 am that I was given pain medication, almost 4 hours after I complained. Sometimes the pain caused by the ulcer was linked to the pain caused by a surgery that was recently performed. I also suffer from pain from not being able to evacuate. In the end I decided to call my wife who was sleeping at home so she could help me. So she came to the facility at about 4:30 am and helped me clean up, change my position and fix my bed. The nurses did not come. The patient in the bed and his wife witnessed how much I called to the nursing station and all my episodes of vomiting. We waited for the shift supervisor to arrive in the morning and we complained to her. After she intervened the nurses treated us better. According to telephone interview with the wife of Resident #6 on 5/31/17 at 9:30 am, she stated: That day when the situation occurred, it seems that the nurses did not have much staff or they had their situations. My husband called me crying about 4:00 am, and he said he was being mistreated. Immediately I got dressed and went to the facility. I got there at about 4:30 am, I found my husband lying in bed with disorganized bed sheets, without pillow, with vomit, and pain. He told me that the nurses had mistreated him. He told me that at 1:35 am he called the nurses to help him because he was in pain and he was vomiting. When the nurses arrived to the room they helped him but they were very rough in providing the care to my husband. The two nurses told him inappropriate comments. One of the nurses said: I have many patients, do not bother anymore and the other nurse said: You just came here for physical therapies, and nothing else. My husband is an elderly person and has recently had an open heart surgery and that still causes him pain. He also suffered from a stroke during the surgery. I decided to help my husband myself and not disturb the nurses, but as soon as the supervisor came to the unit I went and filled the complaint form. After that day they continued to attend my husband and there was no further problems. The wife of the resident next to my husband heard everything. She testified in the complaint investigation of the facility. The most annoying thing to my husband was the rough treatment and the inappropriate comments of the nurses in charge of him. 4. The facility's grievance and complaint registry was reviewed on 5/24/17 at 10:30 am, the following was found: a. There was found evidence that two residents (resident #6 and #7) filed a grievance report on 4/6/17. b. During review of the Facility's complaint investigation for resident #6 complaint was found the following: i. The resident's #6 wife referred: The resident called at 1:35 am the nurse, employee #11 comes to the resident's room and he asked her to change his position, as per physician's orders [REDACTED]. She did the change but in a rude attitude and nurse said to my husband I will not come back until 4:00 am. Resident called back before that time because was in pain. The nurse delay; he had so much pain that he vomited. At 4:30 am I entered to the room and found my husband on the bed without linen and without pillow. Also, my husband alleges that one of the nurses told him you came here for therapy, not for anything else. c. During review of the Facility's complaint investigation for resident #7 complaint was found the following allegations: i. The resident reported what had happened to her tearfully. ii. During the night resident #7 called the nursing staff on multiple occasions for assistance with the bedpan. iii. The resident #7 referred that in one occasion urine was spilled to the bed and the nursing staff, the RN (Employee #1) and LPN (Employee #2) cleaned and changed the bed sheets. However they performed the care in a rough manner that was uncomfortable to the resident #7. iv. The resident #7 referred that on the last time that the LPN (Employee #2) assisted her with the bedpan the LPN (Employee #7) told her: I am going to train you so you can use the bedpan by yourself because you are calling too much. v. The resident asked to the LPN (Employee #7) for another sheet, however she never received it. vi. The resident informed that nursing staff left the bedpan under the patient and the she had to remove it by herself and she put it on the eating table beside the tooth brush that had been for oral care. She states that the nursing staff did not cleaned the area. vii. The resident #7 referred that one of the nurses (Employee #1 and #2) talked to her in a loud tone and with courage. d. During review of the facility complaint investigation interviews was found that resident #9 was in the same room as resident #7, and he referred: all that my roommate said is true. My roommate was educated and cooperative, but the nursing staff talked to her like they were mad with her and in a loud voice. One of them told to my roommate that she was going to train her to use the bedpan on her own. e. During review of the nursing staff roster was found evidence that from 4/6/17 thru 5/25/17 the RN (Employee #1) and the LPN (Employee #2) were working in the same unit that the resident #6 and #7. The facility maintained the resident #6 and #7 at risk of service interruption, restrictions and other forms of retaliation. Also, all other residents were exposed to abuse and neglect (census: 11 residents). 5. During review of the two facilities complaint investigation that started on 4/6/17 and was completed on 4/18/17 was found evidence that the facility's conclusions were the following: a. They found that the nursing staff (Employee #1 and #2) did not perform the correct nursing interventions with residents #6 and #7. b. They found that the nursing staff (Employee #1 and #2) had bad attitude and behavior towards the resident #6 and #7. c. The facility proceeded to send letters to inform the resident #6 and #7, and the nursing staff (Employee #1 and #2) related to the event of the facility's resolution of the investigation. d. The facility provided re-education to the LPN (Employee #2) related to Abuse and Neglect policy on 5/16/17 because she had previous involvements on related events; however the RN (Employee #1) was not re-educated. According to interview with the Quality and Risk Management Director (employee #6) on 5/24/17 at 10:30 am, she stated: The manner in which complaints and complaints are investigated in the facility is that as soon as we receive the report is send to the unit where the situation related to the complaint occurs. The unit's director and staff are responsible for conducting the interviews and then the interviews are evaluated by the hospital's grievance evaluation committee. The skilled nursing facility does not have its own committee for investigating complaints and grievances. After the committee evaluates the interviews, it sends its recommendations and the skilled nursing facility performs them. The abuse and neglect course was offered this year to all staff. According to interview with the Director of Nursing (employee #14) on 5/25/17 at 9:33 am, she stated: I have knowledge of both of the complaints. The practical nurse was reoriented about out abuse and neglect policy. The registered nurse received a warning. We do not have the habit of removing our staff from the unit during the period of an investigation. According to interview with the Administrative Supervisor (employee #3) on 5/25/17 at 2:00 pm, she stated: The two complaints were investigated at the same time, because they happened the same night. Nurses were interviewed because they had not performed the correct nursing interventions in the management of both patients. One of the patients was presenting clinical changes that required skilled nursing management and coordination with the doctor. One of the nurses denied that the patient was vomiting during that night; however I went to the room and noticed that there was a bag for vomiting that was given to the patient by the nurses. As part of the process after I formally receive the patient's complaint I interview the staff of the unit and those affected. I then deliver the interviews and evidence to the hospital's grievance evaluation committee so they can evaluate it and give the suggestions to follow. According to interview with the physician (employee #15) on 5/25/17 at 2:30 pm, he stated: That patient I remember very well, came without being able to walk to the unit. I have no complaints from him, although I am aware that the resident complained to the nursing staff. My intervention in the care of the residents is clinical, the part of complaints and quarrels are handled administratively. But I understand that while investigating an employee of the facility for abuse and neglect should be removed as the administration understands the unit. This would be the right way to protect and prevent all residents including the complainer. So that person will have no contact with the staff of the facility. I know there is a complaint investigation committee in the hospital but I do not belong to it. 6. During the facility Abuse and Neglect policies and procedures (P&P's) on 5/24/17 at 11:10 am was found that the facility failed to have a mechanism that protects and prevents from abuse and neglect the resident a filled a grievance and all other residents during the investigation processes. A Statement of Deficiency was provided to the facility on [DATE] at 4:25 pm notifying the IJ and requesting a Plan of Correction (POC). The facility provided a POC on 5/25/17 at 6:00 pm as follow: General instruction and corrective Actions: 1. The policy and procedure will be amended to include safety measures to prevent exposure of abuse and neglect to other residents meanwhile the investigation process is completed 2. The personnel involve in the allegation will be remove immediately from the skilled nursing facility until the allegation is fully investigated 3. As immediate corrective action the two (2) nurses were remove from the facility 4. The policy will be amended to shorten the time of the investigation when abuse or neglect allegation are suspected The POC was accepted by the surveyors on 5/25/2017 at 6:05 pm. A mechanism establish by the facility to ensure and protect the residents and to be used with the staff being investigated. During the abuse and neglect investigation process, the Abuse and Neglect Detection and Prevention program was reviewed on 5/24/17 at 11:10 am and it was found that the program, standard and procedure during an employee's investigation that is being investigated for abuse or negligence does not indicate what action to take with the employee during the investigation. No action was provide to protect the resident and / or other residents admitted during the investigation. It was also found during the review of the policies that do not have an independent committee from the hospital to carry out investigations of the cases that occur in the Skilled nursing home. Interview with) 5/24/17 at 9:30 am state I did not participate in the investigations of the complaints; Director of Nursing (employee #14 that is done by the Department of Legal Affairs of the hospital. Interview with the Administrative supervisor (employee #3) performed on 5/24/17 at 1:00 pm she cite: I do part of the investigation, I present it to the committee of complaints from the hospital and I only hear the decision that they take. I do not take decisions in that committee. This committee attends to all complaints from both the hospital and the Skilled Nursing

Based on observations, review of eight clinical records and policies/procedures (P&P) and interview, it was determined that the facility failed to provide the necessary care to assess and manage pain to ensure that residents (R) reach their highest practicable well-being for two out of eight sample selection residents (R #1 and R #3 ). Findings include: 1. RR# 3 was admitted on [DATE] after a Left Total Knee Replacement. On 5/12/15, the resident woke up early (8:30 am) as every day to receive physical therapy. At 10:00 am and 11:30 am she was not taken to the physical therapy because the RN that was administering medications failed to provide her early pain medication such as: [MEDICATION NAME] 5/325 mg 1 tab po every 3 hours. The resident has to wait 3 hours to receive her pain medication, (Cross Reference TAG 281). a. At 10:00 am the surveyor requested the RN to administer pain medication so the resident could go early to her physical therapy. At 11:30 am an observational tour was performed and the resident was lying on bed finishing her lunch meal. When asked on how she spent her therapy sessions she stated: "Two times the escort came for me and because the RN did not give me the pain medication she (escort) told me I can not take you to the therapy because you have to take your pain medication, I'm still waiting for the medication". At 1:00 pm the MAR indicated [REDACTED]. The resident has to wait until 1:30 pm to attend her physical and occupational therapies. b. The surveyor requested the Nursing Supervisor (employee # 4) a copy of the rehabilitation scheduled program and stated: "I have to request a copy to the Physical Therapy Supervisor because I don't have any. For more than 2 months I don't receive a copy of the residents scheduled Rehabilitation Program". When the scheduled program arrived to the facility, resident #3 had scheduled at 9:30 am occupational therapy and at 1:00 pm the physical therapy. However, the resident did not receive her treatments according to the scheduled program. c. The nursing staff failed to administered pain medications in a timely manner before the resident performs her rehabilitation sessions with decreased pain manifestation. Without a scheduled rehabilitation program the nursing staff can not be organized for determining the order which residents go to the treatments areas. d. The lack of coordination between the rehabilitation program therapists and the nursing staff cause late treatment interventions affecting the quality of care. 2. Resident #1 is an [AGE] years old female admitted on [DATE] for a Right [MEDICAL CONDITION]. During the observational initial tour it was observed patient 5/11/15 at 9:00 am complain for pain. The MDS Coordinator employee #8 stated that the resident daughter does not want that she takes medications for pains because she can get addicted to it. On 5/11/15 at 1:30 pm surveyor asked the resident if she was taking her pain medication. Resident said that she was oriented by the doctor and now she is taking the medication. Resident state " I felt relieve when I took the pill " . " At this moment I ' m waiting for my pill " . b. On 5/12/15 at 1:30 pm she was not taken to the physical therapy because the register nurse that was administering medications failed to provide her early pain medication such as: [MEDICATION NAME] 5/325 mg 1 tab po every 3 hours. c. At 11:30 am the surveyor asked to the register nurse when she is going to administer pain medication so the resident could go to her physical therapy. At 11:50 am surveyor performed an observational tour and the resident was sitting on her bed finishing lunch. When surveyor asked if the register nurse administer her pain medication she indicates that she is still waiting for the medication to go take her physical and occupational therapy. At 2:30 another observational tour was performed and the patient still lying in her bed waiting for the escort to take her to the physical therapy. The resident has to wait until 3:00 pm to attend her physical and occupational therapies.

A mechanism to ensure that facility failed to aggressively identify the need for medically-related social services, and pursue the provision of these services to meet the resident's needs was not followed, not performed accordingly with the following findings: 2. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 5/11/15 at 11:55 am and provided evidence that resident received neurocognitive rehabilitation screening on 5/8/15 at 9:00 pm due to sadness and death wishes that he referred during admission to the facility on [DATE]. Based on neurocognitive rehabilitation screening performed on 5/8/15 at 9:00 pm resident was diagnosed with [REDACTED]. The recommendations for the management of this condition was neurocognitive rehabilitation follow-up to provide adaptive coping strategies to deal with the depressive mood and facilitate neurocognitive strategies to support adaptative emotional regulation and positive mood throughout hospitalization . Resident was also evaluated by the psychiatrist on 5/9/15 at 2:50 pm who ordered Cymbalta 50 mgs PO in am. Plan of care for Mood State was developed on 5/8/15 by the interdisciplinary team members. Accordingly with this plan of care emotional counseling were going to be provided and monitoring on mood state were going to be performed, however no documentation was found on the progress notes of nursing personnel ,physician, social work and rehabilitation personnel related with activities performed to emotional counseling were going to be provided and monitoring on mood state from 5/8/15 through 5/11/15. The clinical record was reviewed on 5/11/15 at 11:55 am and provide evidence that recreational therapist went on 5/8/15 to perform initial evaluation to the resident to identify resident preferences for recreational activities, however resident refuse to answer to her the questions and stated that he does not want to participate in any recreational activity. During interview on 5/11/15 at 1:00 pm resident stated that he had weight loss, chewing problems and also complaints of the taste of the food that was receiving. That nutritionist went to evaluate him during morning but before the evaluation and since his admission on 5/7/15 he was not eating great quantity of the food receiving because he do not liked it. Resident caregiver report on 5/11/15 at 11:58 that resident was not eating well since admission to the facility on [DATE] due to complaint on taste of food. She also stated that relatives are available to bring home cook food in an effort to deal with resident poor appetite status, however no coordination or arrangements were perform in order to liberalize resident diet to improve food intake. No evidence was found documented on the medical record of efforts performed in order to promote resident motivation to participate in recreational activities either individual or in group. No involvement of resident relatives was found to be performed in order to provide materials or suggest activities that can be performed by them to motivate the resident to participate or participate with them in activities that resident could perform in his room with his relatives. Evidence that facility provide medically-related social services and participate in the care planning to assist this resident in maintaining or improving his ability to manage his everyday physical, mental, and psychosocial needs were not found documented. Facility failed to evidence that social services maintain contact with resident's relatives and involve them in an effort to promote resident participation on rehabilitation and health care activities to reach his rehabilitation goals and improvement. Based on eight sample records review (RR), policies and procedures review (P&P's) and interviews with the Social Worker (employee # 9) performed from 5/12 thru 5/14/15 from 8:30 am thru 5:30 pm, it was determine that the facility failed to ensure that residents with compromised emotional status received social services according to residents needs, as seen on 2 out of 8 sample records review (RR#3 and RR # 4). Findings include: 1. Resident #3 is a [AGE] years old female who was admitted on [DATE] due to left Total Knee Replacement. The Neuropsychologist performed an evaluation on 5/8/15 and concluded that resident has a [DIAGNOSES REDACTED]. As part of the treatment that was recommended is to give family education and a referral to an outpatient psychological clinic. Also, the Psychiatrist performed an evaluation on 5/11/15 at 8:20 am and recommended contact with Social Worker for after care evaluation. The Psychiatrist recommended to administered Abilify 2 mg by mouth in am to potentiate the effectiveness of Paxil 40 mg by mouth daily. The physician ordered Abilify and the resident referred that she is receiving that medication on a daily basis, (Cross Reference TAG 279). a. During RR performed on 5/12/15 at 9:00 am, on the Minimum Data Set (MDS) nursing staff identified on Care Area Summary (CAA) the mood state as a care area trigged that needed to establish a care planning. On section D for Mood, the RN identified that resident is feeling down and depressed for several days (2-6 days) and has trouble falling asleep and that she is not moving around. During interview with RN (employee # 17) performed on 5/13/15 at 4:00 pm, she stated: "As soon as the neuropsychologist notified about the suicidal attempt of this resident, I called the General Supervisor. The resident was changed from room # 307 to the nearest room of the nurse station. I did not call the Social Worker because it was 5:00 pm or later and they are not at their office. I did not call the physician. I activated the suicidal attempt protocol. It consists of performing frequently observational tours and to activate the plan of care. Resident's status was informed during shift changes at 11:00 pm and it was pending the discussion of the plan of care with the resident and her signature". b. The RN failed to identify the interventions established on the suicidal attempt plan of care and no daily reevaluation of it was performed by the nursing staff since 5/9/15. c. The Social Worker performed an initial evaluation 5/8/15 at 11:30 am and identified that resident is taking psychotropic medications due to Depression. Also, identified anxiety concerns and sleeps disorder and that resident follows her mental disorder treatment that her psychiatrist ordered. However, the plan of care and the daily progress notes do not show the social interventions that help the resident to deal with her sadness and anxiety concerns, considering that the Psychiatrist recommendation was Social Worker interventions. d. The Social Worker failed to demonstrate that her interventions are integrated in a manner that resident can improve her emotional status and can comply with the rehabilitation goals through her participation on different rehabilitation activities. The first days after admission, it was observed that the resident did not want to participate on group recreational activities. The following days after 5/11/15, the social progress notes were related to the discharge planning process and the coordination of continuity of care at home with a Home Health Agency. No evidence was found of a referral to outpatient mental clinic for follow up according to the Neuropsychologist recommendation.

Based on observations, review of eight clinical records and policies/procedures (P&P) and interview, it was determined that the facility failed to provide the necessary care to assess and manage pain to ensure that residents reach their highest practicable well-being for one out of eight sample selection residents (resident #1). Findings include: Resident #1 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. For the ulcer care management the physician ordered local care with santyl [MEDICATION NAME] and to cover with hydrosfera blue and a secondary bandage according with the ulcer specialist nurse recommendations who evaluated the case after admission. During the survey on 1/29/13 at 11:30 am, permission was requested of the resident's relative (relative interview #12) to observe the ulcer care procedure, and the resident's relative agreed. The resident's family remained in the room because she wanted to give emotional support to the resident to ensure that she remained calm. The ulcer specialist nurse (employee #6) began to provide ulcer care to the resident and the resident was constantly moaning in pain. The resident's relative told the ulcer specialist nurse that they should have given her pain medications before the procedure because she had previously reported to nursing personnel that the resident was experiencing pain during the procedure and the physician had ordered pain medication. However the ulcer care procedure was finished without given her pain medications. Ultran 50 mgs 1 tablet was administered after the procedure. The assessment of this resident was primarily focused on the ulcer rather that on the resident comfort. The facility failed to make a comprehensive assessment before the ulcer care procedure to ensure that the appropriateness of this resident's pain assessment was adequate.