Every finding on record at Golden Creek Healthcare and Rehabilitation Center

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and document a care plan conference following a quarterly or annual MDS for 3 of 5 residents (Resident #34, #35 and #51) reviewed for care plan conferences. The facility failed to document a care conference for Resident #34, Resident #35 and Resident #51. This failure could place residents at risk of not having their physical, mental and psychosocial needs met. Findings included:Resident #51Record review of Resident #51's admission record, dated 07/01/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: Parkinson's disease (a movement disorder of the nervous system that worsens over time), obstructive sleep apnea (the muscles in the throat relax excessively during sleep, causing the airway to narrow or close and temporary pauses in breathing), and essential hypertension (high blood pressure). Record review of Resident #51's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #51's care plan, dated 05/17/2022 and last revised on 02/09/2026, reflected a focus of I have a GG ADL self-care performance deficit r/t Dementia, Impaired balance, my need for assistance/support may fluctuate based on fatigue, time of day, pain, and/or motivation. Adjust assistance/support to accommodate my immediate needs with interventions that included IDT review of performance for ARD date: 5/27/2026.Resident #35Record review of Resident #35's admission record, dated 07/01/2026, reflected a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: Essential Hypertension (high blood pressure), weakness, and repeated falls.Record review of Resident #35's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #35's care plan, dated 11/21/2025 and last revised on 02/12/2026, reflected a focus of I have a GG ADL self-care performance deficit r/t Activity Intolerance, Disease Process: T8/T12 vertebral fracture [fracture in the mid-spine], TLSO External device [a brace used for spine fractures], Impaired balance, spinal stenosis [narrowing of the spinal canal], cord compression, essential tremors. Adjust assistance/support to accommodate my immediate needs with interventions that included IDT review of performance for ARD: 6/8/26. During an interview on 06/30/2026 at 09:41 AM, Resident #35 stated he had not been invited to nor attended any care plan meetings. During an interview on 07/01/2026 at 12:13 PM, the MDS stated Resident #35 was supposed to have a care plan meeting the previous week, but the facility was a little behind in the IDT care plan meetings because the SW had just started working 2 weeks prior. Resident #34Record review of Resident #34's admission record, dated 06/29/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: Creutzfeldt-[NAME] Disease (a rare, rapidly worsening brain disorder that causes memory problems, involuntary movements, blindness and deafness), muscle weakness, and dysphagia (difficulty swallowing). Record review of Resident #34's Quarterly MDS, dated [DATE], reflected a BIMS was not conducted because Resident #34 was rarely/never understood. Record review of Resident #34's care plan, dated 10/29/2019 and last revised on 02/19/2026 reflected a focus of The resident has a GG ADL self-care performance deficit r/t Activity Intolerance, Disease Process of VARIANT CREUTZFELDT-[NAME] DISEASE with interventions that included IDT review of performance for ARD: 6/12/26. A request was made to the ADM on 07/01/2026 at 03:02 PM for care plan conference documentation since 01/01/2026 for Resident #51, Resident #35 and Resident #34. The ADM did not provide documentation prior to exit on 07/01/2026 at 07:15 PM. During an interview on 07/01/2026 at 05:44 PM, the MDS stated the SW was responsible for scheduling care plan meetings. She stated care plan meetings were held 72 hours after admission to the facility, quarterly, annually and with any significant change in condition. The MDS stated the resident, their family or responsible party, and representatives from activities, therapy, nursing, dietary, the SW, and any ancillary services the resident was enrolled in were invited to the care plan meetings. The MDS stated care plan meetings were to involve the resident and/or their family in the plan of care for the resident and to discuss any changes that needed to be made. She stated the care plan conference was supposed to be documented on a care plan form. She stated she was now responsible for documenting the conferences but previously it was the SW responsibility. She stated if care plan conferences were not conducted then the resident could feel like they do not know or have control with what was happening to them. The MDS stated if the conference was not documented then the staff may not know what the resident's concerns were. During an interview on 07/01/2026 at 06:00 PM, the SW stated she had worked at the facility for 2 weeks. She stated she was responsible for scheduling the care plan conferences. The SW stated that prior to her hire, the MDS was responsible for scheduling the care plan conferences. She stated care plan conferences were held upon admission to the facility, quarterly and as needed. The SW stated the care plan conferences were held to check in with the resident and their responsible party to make sure the facility had a list of goals to accomplish, likes, dislikes, allergies, concerns, and to ensure that staff are meeting the goals set forth and change the goals or preferences. She stated care plan conferences are typically documented in the progress notes as well as a care plan evaluation should be completed. She stated the SW was responsible for the documentation. The SW stated a resident could have a change in preferences with the facility not knowing if the care plan conferences were not held. She stated the charge nurse or dietary would not know a resident's preferences or the results of the care plan conference if it was not documented in the electronic health record. During an interview on 07/01/2026 at 06:30 PM, the DON stated the SW was responsible for scheduling the care plan conferences. She stated the care plan conferences were held to update the resident's preferences, plan of care and goals. The DON stated the care plan conference was documented on a form in the computer by the MDS or the SW. The DON stated there might be a break in communication and goals for the residents if the care plan conference was not held. She stated the facility would not be able to look at what was discussed during the care plan conference if it was not documented. During an interview on 07/01/2026 at 06:48 PM, the ADM stated the IDT team was responsible for scheduling the care plan conference. She stated the care plan conferences were scheduled upon admission, quarterly, annually, for change of condition and as needed. The ADM stated the care plan conferences were held quarterly to discuss continuity of care, any changes with the residents, and anything else that may be going on with the residents. She stated the care plan conference should have been documented on the care plan conference assessment and documented in the progress notes as well. She stated the IDT team was responsible for documenting the outcome of the care plan conference. The ADM stated the residents would not be able to voice their concerns or be made aware of any changes and the effect of the change on the residents if a care plan conference was not conducted. She stated if the care plan conference was not documented then the staff may not know the needs and preferences of the residents. Review of facility policy titled Care Plans, Comprehensive Person-Centered, dated 10/2022 and last revised 06/02/2025, reflected Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. Participate in the planning process. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).14. The Interdisciplinary Team must review and update the care plan:.d. At least quarterly, in conjunction with the required quarterly MDS assessment.15. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one facilities reviewed for the pest control program.The facility failed to keep flies out of resident rooms, the facility kitchen, the facility dining room, and the facility common areas.This failure placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life.Findings included:During an observation on 06/29/2026 at 11:47 AM, a fly was observed landing on a table on the 100 hallway.During an observation on 06/29/2026 at 12:44 PM, 2 flies were observed landing on a female resident's face while staff were feeding her in the main dining room.During an observation on 06/29/2026 at 02:13 PM, 2 flies were observed flying around room [ROOM NUMBER].During an observation on 06/29/2026 at 02:35 PM, 2 flies were observed flying around room [ROOM NUMBER].During an observation on 06/29/2026 at 03:31 PM, a fly sticky trap was observed hanging over the foot of the bed in room [ROOM NUMBER]-A. The sticky paper contained 10 dead flies.During an observation on 06/30/2026 at 12:00 PM, 2 flies were observed flying around on the 200 hallway. During a confidential resident group meeting on an undisclosed time and date a fly was observed in the meeting area. The group of residents stated the flies had been an issue for a long time and stated the facility needed to get rid of them. One confidential resident held up a fly swatter and stated he needed to carry it everywhere.During an interview on 07/01/2026 at 11:02 AM, the LSM stated she had worked at the facility for about 4 years. She stated she had observed flies in the facility. She stated the flies had been discussed during the morning manager's meeting and pest control was making more frequent visits due to the heat. The LSM stated the facility was doing things like increasing the number of fly trap lights. She stated the pest control company stated the increase in flies was due to the rain and heat. She stated she thought the flies were getting in through the smokers' door due to the door being opened for extended periods of time to let the residents in and out. The LSM stated the flies could affect the residents because they are a nuisance and could possibly spread germs and infection.During an interview on 07/01/2026 at 04:35 PM, the pest control representative stated the facility received monthly treatments and as needed treatments for concerns. He stated the pest control company made as needed visits on 06/04/2026, 06/13/2026 and 06/22/2026 for targeted fly treatments. He stated those treatments included spraying any problem areas inside the facility and around the facility including bait treatments and around the dumpster. The pest control representative stated the facility had a battle with getting rid of the flies due to the fields around the facility and the door being opened frequently due to visitors and deliveries. The pest control representative stated the flies could be a general nuisance to the residents.During an interview on 07/01/2026 at 04:45 PM, CNA D stated the policy for pest control was to report it to the nurse and document the sighting in the binder at the nurse's station. She stated she was unsure how often pest control visited the facility. She stated having flies in the building was unsanitary and could make the residents sick.During an interview on 07/01/2026 at 04:57 PM, MA E stated all staff were responsible for observing for pests/insects during their rounds. She stated they were supposed to notify the MAIN and the ADM of any pests so that pest control can come out and treat. MA E stated she was unsure how often the facility had pest control come out to perform a treatment. She stated she had not received any complaints from residents, but the flies are nasty and could cause illness in the residents. MA E stated she was not sure why there were so many flies in the facility.During an interview on 07/01/2026 at 05:09 PM, CNA C stated the policy for pest control included ensuring the resident was safe from the pest then staff were to notify the MAIN and the ADM. She stated that lately pest control had been treating the facility for flies once a week. She stated she had received complaints from the resident related to the flies in the facility recently. CNA C stated all staff were responsible for monitoring for pests through observation during their rounds. She stated the flies were a nuisance and could cause cross contamination and illness to the residents.During an interview on 07/01/2026 at 05:18 PM, RN G stated the policy related to pest control was to notify the ADM and the MAIN of any pest sightings and they will call pest control in to spray for pests. She stated pest control came to the facility to treat for pests every 2-3 months. She stated all staff were responsible for monitoring for pests by observing for pests during their rounds. RN G stated flies are dirty and they can get in the trash then land on the resident's food or water and cause infection, including stomach issues. She stated there were so many flies because there may be some trash that was left out and the door are constantly open.During an interview on 07/01/2026 at 05:34 PM, LVN F stated the policy for pest control was to report any sightings of pests to the MAIN and to the ADM. She stated she had seen a few flies here and there in the facility. She stated she had received some complaints about the flies from the residents, but she stated she usually used a fly swatter to kill the flies. LVN F stated the MAIN was responsible for monitoring for pests in the facility when he did his walking rounds. She stated the flies were an annoyance to the residents. LVN F stated she was unsure why there were so many flies in the facility.During an interview on 07/01/2026 at 05:44 PM, the MDS stated the pest control company was coming out about once a week to treat for flies. She stated she had seen some flies in the facility. The MDS stated she had not received any complaints from residents about the flies, but if she received a complaint from a resident, she would fill out a grievance form. The MDS stated the MAIN was responsible for monitoring for pests in the facility. She stated the flies could land on the resident's food and cause possible illness and they are aggravating. The MDS stated the flies were getting in through the door when it was held open for the smokers to go in and out. During an interview on 07/01/2026 at 06:00 PM, the SW stated the pest control had come out a couple times to treat for flies since she started 2 weeks prior to the interview. She stated she had seen flies in the facility but had not received any complaints from residents about them. The SW stated the flies in the facility could affect the residents because they were unsanitary and annoying. She stated the MAIN was responsible for monitoring for pests.During an interview on 07/01/2026 at 06:13 PM, the ADON stated the policy for pest control was to kill the pest, notify the MAIN, write down the sighting in the pest control binder, and report the sighting in the morning meeting. She stated pest control had been to the facility on a weekly basis lately. She stated she had seen some flies in the facility and told the MAIN about the flies, but she did not write the sightings down in the binder. The ADON stated the MAIN was responsible for monitoring for pests in the facility. She stated the flies could affect the residents because the flies are annoying.During an interview on 07/01/2026 at 06:26 PM, the MAIN stated the policy for pest control was to have pest control come out once a month and if there are concerns then more frequently. He stated pest control had come to the facility 2 times a week. He stated he had seen flies in the facility. The MAIN stated if he received a concern about pests then he would spray for the pest and have the pest control company come out the next day to treat for the pest. He stated he monitored for pests by observations during his rounds. The MAIN stated the flies could lay eggs on the residents and make the residents sick. He stated the flies were because of the dairy farm next door and the neighbors tall grass.During an interview on 07/01/2026 at 06:30 PM, the DON stated the policy for pest control was to have pest control treat the facility regularly and let the ADM know if there are any concerns about pests. She stated pest control had treated the facility weekly recently. The DON stated she had seen flies in the facility and had received complaints about flies from the residents. She stated flies could land on things and they have germs, so the flies could possibly cause infections. The DON stated she was not sure why there were so many flies in the facility.During an interview on 07/01/2026 at 06:48 PM, the ADM stated the policy for pest control was to identify any pest control issue, notify the MAIN and herself, MAIN will contact pest control and will treat until pest control can arrive to treat for the pest. The ADM stated pest control treated the facility as they needed to. The ADM stated she had seen flies in the facility and had received complaints from residents related to the flies. The ADM stated all staff were responsible for monitoring for pests during their rounds. She stated the flies can carry infection to the residents that can be worrisome.Record review of pest control service log reflected no documented sightings of pests since 2/22. The logbook was documented as checked on 2/26, 3/6/26, 3/26, 4/1, 4/15, 5/27, 6/4/26, 6/13, 6/22, and 6/23.Record review of pest control invoice dated 06/04/2026 reflected Service Description.Fly Wipe Down Full Facility.Record review of pest control invoice dated 06/13/2026 reflected Service Description.Service for filth flies on facility exterior.Record review of pest control invoice dated 06/22/2026 reflected Service Description.Fly Wipe Down Targeted at Specific Small Areas.Review of facility policy titled Pest Control, dated May 2008, reflected Policy StatementOur facility shall maintain an effective pest control program.Policy Interpretation and Implementation1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly store, label, and date all food items located in the kitchen facility refrigerator, freezer and in the dry food pantry area on 06/29/2026, 06/30/2026 and 07/01/2026. 2. The facility failed to properly clean and sanitize food storage containers on 06/29/2026, 06/30/2026 and 07/01/2026. 3. The facility failed to discard dented soup can and expired instant potatoes from dry food area on 06/29/2026, 06/30/2026 and 07/01/2026. 4. The facility failed to ensure kitchen trashcan was covered with lid on 7/01/2026.5. The facility failed properly clean and sanitize food plate warmer dispenser on 7/01/2026.These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Findings: Observation during the initial tour of the kitchen on 06/29/2026 beginning at 8:59 AM revealed the following: Walk in refrigerator:*1 container with approximately 20-25 individual servings of salad dressing labeled with name and 6/28, no year or discard dates*1 storage bag of yellow shredded cheese, dated 6/11,no year, no use by or discard dates*1 storage bag of white shredded cheese, dated 6/2, no year, no food name, no use by or discard date*1 tray with 5 prepared fruit bowls, dated 6/28/26, no discard date.*1 square storage container that resembled jelly dated 6/13/26, no name, no discard date.*1 container covered with foil labeled chicken noodle soup, dated 6/28/26, no discard date.*1 container covered with foil labeled boiled eggs, no discard date.Walk in freezer:*1 opened to air bag of beef pattie fritters, no open, no discard date.Dry food storage room: *1 large 20 liter container with dirt and residue on lid and container, labeled sweet cornbread , dated 1/14/26,no discard date, the label did not reflect what was in the container which were noodles*1 large 20 liter container with dirty lid, labeled cornbread mix, dated 2/2, no year, no discard date. *1 large 20 liter container with dirty lid, labeled noodles, dated 2/27, no year, no discard date*1 open container of peanut butter, sticky substance on lid, no discard date.*2 individual 1 cup containers which resembled cereal inside, no name, open date, no discard date *1 gallon storage bag of cereal dated 4/15, no food name, no year, no discard date *2 large packages of hot dog buns, no received date, no expiration date listed on buns*12 loaves of bread with best buy date of 05/23/2026, no received, no pulled date, no discard date *1 foiled wrapped circle food item (shape of tortilla) dated 6/20/2026, no product name, no discard date *1 storage bag containing 3 packets of potatoes with expiration date of 6/12/2026 *1 -50 ounce can of cream of mushroom soup with 2 dents in the can Interview on 06/29/2026 at 9:29 AM, the Dietary Manager stated the loaves of bread had previously been frozen. She stated all of the bread was delivered to facility frozen. Observation during the follow-up tour of the kitchen on 06/30/2026 beginning at 3:15 PM, revealed the following:Walk in refrigerator:*1 square storage container that resembled jelly dated 6/13/26, no name, no discard date.*1 container covered with foil labeled chicken noodle soup, dated 6/28/26, no discard date.*1 container covered with foil labeled butter potatoes, dated 6/28/26, no discard date *1 container covered with foil labeled [NAME] eggs, dated 6/29/26, no discard date Dry storage:*1 large 20 liter container with dirt and residue on lid and container, labeled sweet cornbread , dated 1/14/26,no discard date, the label did not reflect what was in the container which was noodles*1 large 20 liter container with dirty lid, labeled cornbread mix, dated 2/2, no year, no discard date. *1 large 20 liter container with dirty lid, labeled noodles, dated 2/27, no year, no discard date*1 open container of peanut butter, sticky substance on lid, no discard date *2 large packages of hot dog buns, no received date, no expiration date listed on buns *1 foiled wrapped circle food item (shape of tortilla) dated 6/20/2026, no product name, no discard date *1 storage bag containing 3 packets of potatoes with expiration date of 6/12/2026 *1- 50 ounce can of cream of mushroom soup with 2 dents in the can Observation and interviews during the final tour of the kitchen on 07/01/2026 beginning at 10:20 AM, revealed the following: Kitchen food prep area: *1 large gray trash container with trash inside in food prep area, no lid noted *1 Heated plate warmer dispenser with clean plates for lunch meal, the outside of dispenser was unclean with leftover food debris on top and inside the dispenser Walk in refrigerator:*1 square storage container that resembled jelly dated 6/13/26, no name, no discard date.Dry storage:*1 large 20- liter container with dirt and residue on lid and container, labeled sweet cornbread , dated 1/14/26,no discard date, the label did not reflect what was in the container which was noodles*1 large 20-liter container with dirty lid, labeled cornbread mix, dated 2/2, no year, no discard date. *1 large 20-liter container with dirty lid, labeled noodles, dated 2/27, no year, no discard date*1 large package of hot dog buns, no received date, no expiration date listed on buns *1 foiled wrapped circle food item (shape of tortilla) dated 6/20/2026, no product name, no discard date *1 storage bag containing 3 packets of potatoes with expiration date of 6/12/2026 *1- 50 ounce can of cream of mushroom soup with 2 dents in the can. Interview on 07/01/2026, at 10:37 AM [NAME] A stated she has been employed with the facility for 20 years. [NAME] A stated that food items were labeled with the name of the item and the date they are prepared or opened. [NAME] A stated that cooked food items are labeled with the name and date prepared and are generally used within 2 to 3 days. [NAME] A stated the dented cans are removed from the dry food storage area and placed in the Dietary Manager's office. [NAME] A stated that staff wiped the tops of containers in the dry food storage area sometimes. [NAME] A stated there was no written schedule for cleaning the storage containers and that they are cleaned only when needed or when a spill or mess occurs. [NAME] A stated that trash cans should always have lids in place when not in active use. [NAME] A further stated that failure to follow food storage and sanitation protocols, including proper container cleaning and keeping trash cans covered, could result in food contamination and cause residents to become ill. Interview and observation conducted with the DM on 07/01/2026 at 10:44 AM., she stated she has worked for the facility for many years. The DM described her expectations for kitchen operations and food safety practices. She stated staff are expected to follow the facility's labeling and dating procedures, she stated she repeated it all the time to kitchen staff. The DM stated food products should be labeled with the date received and the date opened. She stated cooked food items should be labeled with the name of the food and the date prepared. The DM stated that all cooked food was discarded after 72 hours and she was the one who discards the food. She stated one of the cooks would be responsible for discarding if she was off work. The DM stated she checked food expiration dates weekly and discarded expired food items. When asked how the discard/expiration date is determined by kitchen staff for food removed from its original packaging, she stated, I have never been asked that question, but it makes sense. The DM stated that any spills or messes are cleaned up daily. She stated a part-time weekend employee also came in to just label and date food items. She further stated that storage containers are cleaned daily if they are used and they are washed before being refilled with a new product after the previous product has been emptied. The DM stated dented cans should be removed from storage shelves and expired food items should be discarded. The DM was escorted to the refrigerator and dry food storage areas and showed the observed food storage and sanitation concerns. She stated she was surprised the weekend employee did not clean the storage containers, she pulled the containers to be cleaned. The DM stated trash cans should have lids in place whenever they are not in active use. She stated that failure to properly label and date food, discard expired food items, maintain sanitary food storage containers, remove dented cans, and keep trash cans covered could result in food contamination, cross-contamination, and foodborne illness, causing residents to become sick. Interview conducted with Kitchen Aide B on 07/01/2026 at 4:30 PM. Kitchen Aide B stated she has worked at the facility for approximately one and a half years. She stated she was trained by the DM on kitchen protocols. Regarding food labeling and dating, Kitchen Aide B stated that opened food products were to be labeled with the date opened, a discard/use-by date of within three days, and the employee's initials. She stated food products are to be used or discarded by the labeled use-by date.Regarding the dry storage area, Kitchen Aide B stated the area was to be cleaned daily before staff leave for the day. She further stated that all trash cans are required to have the lids on them. Kitchen Aide B stated that dented food cans are to be given to the DM for evaluation and should not be used. Kitchen Aide B stated that failure to properly follow food labeling, dating, and sanitation procedures could result in residents becoming ill from contaminated or spoiled food. Record Review of the facility's policy with a revision date of 03/05/2026, titled Food Receiving and Storage Policy revealed: Policy StatementThe facility will ensure that all food received, stored, and maintained in the facility is handled safely, protected from contamination, and maintained at appropriate temperatures to ensure food quality and resident safety.Food storage areas, refrigerators, freezers, and dry storage rooms will be maintained in a sanitary condition and monitored to ensure compliance with safe food handling practices.Food ReceivingFood deliveries will be inspected by Food Service staff or designated personnel upon arrival.The following procedures will be followed:. All deliveries will be inspected for safe transport, damage, contamination, and quality before acceptance.2. Food Labeling and DatingFood removed from original packaging must be labeled with the product name and date.Prepared foods stored in refrigerators must include a use by date.Opened containers must be sealed or covered and dated. Expired foods must be immediately removed from storage areas. Bread products, beverages, and opened items must be dated when opened and used according to safe storage timelines. 4. Dry StorageDry food storage areas will be maintained in a clean, safe, and pest-free environment.Storage ContainersFoods stored in bins must be: Removed from original packaging and placed in clean labeled bins, or Kept in the original packaging with proper labeling and dating Storage bins must be emptied, cleaned, and dried before refilling.Additional Dry Storage RulesOpened foods must be tightly sealed and dated.Dented cans must be removed or labeled Do Not Use. Record Review of facility's policy named Food-related Garbage and Refuse Disposal dated October 2022, revised 3/5/2026 revealed: 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 8 residents (Resident #51) reviewed for infection control.CNA D failed to change her gloves or clean her hands when moving from a dirty to clean site while performing peri-care for Resident #51 on 07/01/2026 at 03:15 PM.This failure could place residents at risk for cross contamination and the spread of infection.Findings included:Record review of Resident #51's admission record, dated 07/01/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnosis of Parkinson's disease (a movement disorder of the nervous system that worsens over time). Record review of Resident #51's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Review of section GG - Functional Abilities reflected Resident #51 was dependent on staff for toileting hygiene. Review of section H - Bladder and Bowel reflected Resident #51 was frequently incontinent of bladder and bowel. Record review of Resident #51's care plan, dated 05/17/2022, reflected a focus of I am incontinence[sic] of bowel and bladder with interventions/tasks that included Check resident every two hours and assist with toileting as needed. Clean peri-area with each incontinence episode.During an observation on 07/01/2026 at 03:15 PM, CNA D was cleansing Resident #51's peri-area from front to back. CNA D removed the soiled brief and discarded it. CNA D then applied a clean brief and did not change her gloves or wash her hands when moving from a dirty surface to clean surface. During an interview on 07/01/2026 at 04:45 PM, CNA D stated she was trained on providing peri-care and infection control in March 2026 when she was hired. She stated she was not trained to change her gloves when providing pericare and going from a dirty surface to a clean surface. CNA D stated it was important to wash hands and use hand sanitizer to prevent infections. During an interview on 07/01/2026 at 06:13 PM, the ADON stated she was responsible for the infection prevention and control program. She stated she expected staff to change gloves and perform hand hygiene when they go from a dirty surface to a clean surface when providing peri-care to prevent the spread of infection. She stated all of nursing management were responsible for monitoring hand hygiene with peri-care when they perform random checks. The ADON stated she also had skills check-off with 2-3 random staff monthly. During an interview on 07/01/2026 at 06:30 PM, the DON stated she expected staff to perform hand hygiene and change gloves after removing the dirty brief and prior to placing the clean brief to prevent infection. She stated the ADON was responsible for monitoring hand hygiene with skills checkoffs. During an interview on 07/01/2026 at 06:48 PM, the ADM stated she expected staff to change gloves and perform hand hygiene between each step while performing peri-care. She stated it was important to perform hand hygiene and change gloves to prevent cross contamination. The ADM stated the nurses were responsible for monitoring the CNAs hand hygiene during peri-care during their walking observations. Review of facility policy titled Perineal Care, dated 02/2023 and last revised 03/03/2026, reflected no mention of changing gloves during perineal care. Review of facility skills checkoff titled Pericare-Incontinent Care, dated 10/2020 and last revised 06/24/2025, reflected .Wash hands dry thoroughly/sanitize and apply gloves when going from dirty to clean.

Based on observation, interview, and record review, the facility failed to make sure that drugs were stored properly, and only authorized persons have access for 3 of 5 medication carts (MC #1, MC #2, and MC #3) reviewed for drug storage.The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors.The facility failed to ensure MC #2, was locked, medications secured, and not accessible to other staff, residents, or visitors.The facility failed to ensure MC #3, was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:During an observation on 04/28/2026 at 4:00a.m., revealed MC #1, MC #2, and MC #3, were along the wall on the nurses' station and unlocked. LVN B walked right past all three medication carts and did not lock them. MC #1, MC #2, and MC #3 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box.During an interview with LVN B on 04/28/2026 at 04:13a.m., he said he had been trained on medication storage. He said the policy was staff must lock the medication carts any time the nurse was not in the cart or out of sight of the cart. He said the nurse was responsible for locking the medication cart. He said if staff left the medication cart unlocked and unattended someone could steal medication. He said all staff monitored to ensure that the medication carts were locked. He said staff monitored the medication carts through observation. He said he left the medication cart unlocked because he was monitoring them. He said he did not see the surveyor taking pictures and opening the drawers on the medication carts. He said the medication carts should have been locked.An observation of the nurses' station on 04/28/2026 at 4:49a.m., revealed MC #3 was unlocked. There were no staff members around or near the medication cart. Two residents were up in their wheelchairs about 50 feet from the medication cart.During an interview with LVN C on 04/28/2026 at 4:57a.m., he said he had been trained on medication storage. He said the training covered safety. He said the policy for the medication carts were safety first. He said he was responsible for ensuring the medication cart was locked. He said he had a key, and he was only on the locked down unit for two minutes. He said he could not see MC #3 from behind the secured door. He said he understood that when he left the medication cart alone someone could do anything with the medication cart. He said all staff monitored to ensure the medication carts were locked. He said they monitored because the nurses have the key. He said he left the cart unlocked for three minutes to give some medicine to a resident. He said the best thing to do was to lock the medication cart.Observation of hall four on 04/28/2026 at 5:27a.m., revealed that LVN B was in a residents room with the door cracked open and the medication cart was along the wall unattended and unlocked.During an interview with the ADON on 04/28/2026 at 8:15a.m., said she had been trained on medication administration. She said she last had the training in March. She said the medication cart policy was that the carts should always be locked if the nurse or medication aide was not standing in front of them. She said the nurse or medication aide assigned to the cart was responsible for locking the medication cart. She said a lot can happen if the cart was left unlocked and unattended. She said of course anyone could get into the medication carts. She said the DON, ADON and ADM monitored to ensure the carts were locked. She said the DON, ADON and ADM monitored through observation. She said she did not know why LVN B and LVN C kept leaving the medication carts unlocked.During an interview with the DON on 04/28/2026 at 08:31a.m., she said she had been trained on medication storage. She said the policy was that the medication cart was to be locked when staff were not in or around the medication cart. She said the person who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended a resident could get into the cart and take medications that did not belong to them. She said the DON and ADON monitored to ensure staff were locking the medication cart. She said the ADON and DON monitored by doing observations. She said she did not know why LVN B and LVN C left the medication carts unlocked.During an interview with the ADM on 04/28/2026 at 1:01p.m., revealed she had not been trained on medication administration. She said her expectation was for the medication carts to be always locked when not attended. She said the person who utilized the cart at that time was responsible for locking the cart. She said if left unattended and unlocked someone who was not authorized would have access to the cart. She said the DON and ADON should be monitoring to ensure the carts are locked. She said the DON and ADON monitored through rounds. She said she did not know why LVN B and LVN C left the medication carts unlocked.Record review of Storage of Medications Policy dated 06/24/2025 revealed The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 resident (Resident #1) of 12 residents (Resident #1) reviewed for privacy and confidentiality.The facility failed to ensure Resident #1's privacy curtain was used and the door to his room was closed when CNA A was providing incontinent care. This failure could place residents at risk of feeling embarrassed and diminishing the resident's quality of life.Findings Included:Record review of Resident #1's face sheet, dated 04/28/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's disease (progressive neurological disorder that primarily affects movement), Multiple Sclerosis (autoimmune disease that affects the nervous system), protein-calorie malnutrition (inadequate intake of both protein and calories), type 2 diabetes mellitus with hyperglycemia (high blood sugar), major depressive disorder (mental health disorder characterized by persistent depressed mood), and muscle weakness.Record review of Resident #1's Quarterly MDS Assessment, dated 02/11/2026, reflected Resident #1 had a BIMS score of 13 indicating intact cognitive response. Resident #1 was dependent on staff for the following ADLs: toileting hygiene, and lower and upper body dressing.Record review of Resident #1's Comprehensive Care Plan, revised on 01/11/2026, reflected Resident #1 was on an anti-depression medication related to major depressive disorder (recurrent mild). Intervention: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, and close the door. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. The care plan also revealed Resident #1 had an ADL self-care performance deficit related to Parkinson's and multiple sclerosis. Interventions were Report any changes to the nurse. Use short, simple instructions: Encourage the resident to fully participate as possible as tolerated with each interaction. Praise all effort at self-care. During an observation of hall one on 04/28/2026 at 4:08a.m., CNA A was providing incontinent care to Resident #1. CNA A had the resident's room door open and did not pull the privacy curtain therefore exposing Resident #1 who was nude from the waist down.During an interview with CNA A on 04/28/2026 at 4:16a.m., she said she had been trained on resident rights. She said she just did her certification three months ago. She said she did not remember what was covered in the training. She said the policy for providing privacy when providing incontinent care was that staff were to knock and pull the privacy curtain depending on the care she was providing. She also said she was supposed to close the door to the resident's room. She said all staff were responsible for providing the resident with privacy. She said if staff did not provide privacy to the resident, the resident may feel exposed or unsafe. She said the nurse monitored to ensure staff were providing privacy during care. She said the nurse monitored through observation. She said she did not have a reason for not providing privacy to Resident #1.During an interview with Resident #1 on 04/28/2026 at 7:20a.m., he said staff often leave his door open when providing care on the night shift. He said he wanted staff to pull the curtain and close the door every time he was provided with incontinent care. He said it upset him when staff changed him and did not close the door or pull the curtain closed.During an interview with the ADON on 04/28/2026 at 8:18a.m., she said she had been trained on resident rights. She said she had the training in the last month. She said the policy was that staff were to have the curtain pulled and the door always closed when providing incontinent care. She said whoever provided care to the resident was responsible for providing privacy. She said if staff did not provide privacy during incontinent care the resident may feel embarrassed. She said all the directors monitored to ensure that staff were providing privacy when giving incontinent care. She said the directors monitored by walking up and down the halls. She said she did not know why CNA A did not close the door or pull the curtain when she provided incontinent care to Resident #1.During an interview with the DON on 04/28/2026 at 8:42a.m., she said she had been trained on resident rights. She said she last had the training in September 2025. She said the policy was that all staff were to provide privacy to the resident when giving care. She said the aides were responsible for providing privacy to the resident when providing incontinent care. She said the resident would feel embarrassed if staff did not provide privacy during incontinent care. She said if a resident was alert, oriented or not cognitive it did not matter, staff were to provide privacy to the resident. She said the DON and ADON monitored to ensure staff are providing privacy when doing incontinent care. She said the DON and ADON monitored through observations. She said she thought CNA A did not take the time and thought about what she was doing when she did not close the door or the privacy curtain when providing incontinent care.During an interview with the ADM on 04/28/2026 at 1:05p.m., she said she had not been trained on incontinent care. She said her expectation on incontinent care was that the residents are provided with incontinent care as needed. She said her expectation was that staff provide the resident with privacy while getting incontinent care. She said the nursing staff that was providing care for the resident at the time was responsible for providing privacy. She said the resident may not feel particularly good or embarrassed. She said the nurses, ADON and DON monitored to ensure staff are providing privacy during incontinent care. She said the ADON, DON and Nurses monitored during rounds, and competency check offs. She said she did not know why CNA A did not provide privacy to Resident #1. Record review of Perineal Care Policy dated 03/03/2026 revealed The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Steps in the Procedure:1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached.2. Explain procedure to resident.3. Provide privacy4. Wash hands and apply gloves. Toilet resident if on toileting program (even if wet) and or remove brief.5. Place bed protector under resident's buttocks. Record review of Resident Rights Policy dated 03/06/2026 revealed The following rights are guaranteed to residents of Texas nursing facilities under federal law and Texas law. Facilities are required to protect and promote these rights for every resident. Privacy and Confidentiality To privacy during personal care, visits, and phone calls.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of ten residents reviewed for care plans. The facility failed to ensure a comprehensive care plan was developed for Residents #1 that addressed physician ordered orthopedic devices, behaviors involving orthopedic devices, and an ordered sitter during scheduled dialysis. This failure could place residents at risk for not attaining the highest practicable well-being possible. Findings Include:Review of Resident #1's face sheet, dated 08/06/25, reflected a [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dependance on renal dialysis (occurs when a person's kidneys are no longer able to adequately filter waste and excess fluid from the blood, necessitating regular dialysis treatments to sustain life), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and unspecified psychosis not due to a substance or known (indicates a psychotic disorder where the cause is not clearly identified as being due to substance use or a medical condition). Review of Resident #1's care plan, revised on 04/03/25, reflected Resident #1 needed dialysis related to renal failure. Resident #1's care plan did not reflect the dialysis MD order that required Resident #1 have a sitter during her dialysis treatments. Resident #1's care plan did not reflect her orders for ordered orthopedic devices of resting hand splint and palm protector on LUE or behaviors involving orthopedic devices. Review of Resident #1's Resident Assessment and Care Screening MDS dated [DATE] reflected a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident #1's physical therapy order, dated 05/22/23, reflected Resident #1 was to wear resting hand splint on left hand don (to put on, specifically clothing or equipment) after breakfast and doff (to take off, specifically clothing or equipment) after lunch as tolerated. Resident #1 was also ordered skin checks by nursing, pre and post wear, and report any changes immediately every day and evening shift. Review of Resident #1's physical therapy order, dated 07/06/25, reflected Resident #1 was to wear palm protector on LUE. [NAME] splint after lunch and doff splint before dinner and skin checks pre and post splint wear and report any concerns immediately every day and evening shift for therapy.Review of Resident #1's MD dialysis order dated 12/19/24 reflected patient must be accompanied by a sitter for all dialysis treatments for safety. Interview on 08/06/25 at 11:08 am with a Dialysis Nurse A, via telephone, from Resident #1's dialysis clinic, reflected the dialysis MD said Resident #1 needed a sitter during her dialysis treatments because Resident #1 pulled out her needle and had been sent to the hospital because she lost a lot of blood. The dialysis nurse said sometimes Resident #1 had a sitter from the facility and sometimes the sitter was a family member. The dialysis nurse said Resident #1 missed 2 dialysis appointments (she said she could not recall the dates) because Resident #1 did not have a sitter, and they sent Resident #1 back to the facility without dialysis. She said if Resident #1 missed treatments Resident #1 could have a buildup of potassium and increased confusion because of toxin build up and an increase in fluid overload. She said she was not informed by the facility of any negative side effects because of Resident #1's missed dialysis appointments, and she said that she was not concerned about Resident #1 and fluid overload because Resident #1 was usually underweight when she was weighed at dialysis.Interview on 08/06/25 at 1:14 pm with the OTA revealed Resident #1's orthopedic devices were ordered to prevent future contractions, problems with skin integrity, and to not lose hand range of motion. Interview on 08/07/25 at 2:06 pm with CNA reflected Resident #1 was constantly taking off her orthopedic devices and he informed the nurses of this behavior. Interview on 08/06/25 with LVN B at 12:38 pm reflected a care plan was how the facility was caring for residents and should be very detailed. She said the LVNs and DON were responsible for resident care plans. LVN B said Resident #1 did tend to rip off the orthopedic devices. She said it was a part of her job to report Resident #1 was not wearing her orthopedic devices and this behavior needed to be care planned. She said care planning was important for residents to get the proper care they needed and avoid a negative effect. Interview on 08/06/25 at 3:33 pm with the MDS Coordinator revealed she was the person who was overall responsible for the care plans. She said a care plan paints a picture of what the resident needs. She said a care plan should absolutely be person centered and include resident behaviors and diagnoses. She said she worked the floor sometimes doing resident care. She stated staff talked about resident behaviors in the morning meetings, but she was not aware of Resident #1's behavior of her removing her orthopedic devices. If a resident had an orthopedic device, it needed to be care planned. She said that orthopedic devices are many times used as a preventive device and the reason a resident was prescribed an orthopedic device should be care planned. She said the negative effect of not care planning for an orthopedic device was that it could be essential to the resident's care and be needed to prevent skin breakdown or nails that were growing too long. She said it was important that Resident #1's dialysis MD order for a sitter during dialysis should be care planned because Resident #1's dialysis clinic would not allow Resident #1 to have her dialysis treatment if a sitter was not at dialysis. Interview on 08/07/25 at 4:21 pm with the ADON reflected that the care plan was the resident bible or resident outline of their needs and wants. She said refusal of care should be care planned to include Resident #1's refusal or removal of her orthopedic devices. She said she was aware that sometimes Resident #1 removed her orthopedic devices. Resident #1 took them off herself. She said the aides and nurses have told her that Resident #1 sometimes removed her orthopedics devices. She said that having this behavior care planned forecasts what her care should have been, and it could explain if she did not have improvement from the prescribed orthopedic devices. She said it should be care planned that Resident #1 was required by the dialysis MD that she have a sitter at dialysis because if it was not care planned it could result in the refusal of the dialysis facility to allow her dialysis. She said everyone was responsible for care plans. Interview on 08/07/25 at 4:58 pm with the DON reflected a care plan was the individualized care for that resident and included the type of care the facility would provide for that resident. She stated care plans should be person centered based on the resident specific needs. She said orthopedic devices should be care planned because the facility needed to know the devices the resident needed and what they were used for to provide proper care. She said a resident's refusal to wear orthopedic devices should be care planned because there were interventions in the care plan to help with resident refusal. She said care plans were the responsibility for all facility departments for all the different aspects necessary for resident care. She said it was important to care plan the need of a sitter at dialysis for Resident #1 because it was necessary to the care of Resident #1.

Based on observation, interview, and record review the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for one of five residents (Resident #1) reviewed for quality of care.The facility failed to ensure Resident #1, on 08/06/25, was wearing her physical therapy ordered resting hand splint for left hand. This failure could place residents at risk of not maintaining the mobility necessary maintain the highest practicable well-being. Findings Include:Review of Resident #1's face sheet dated 08/06/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependance on renal dialysis (occurs when a person's kidneys are no longer able to adequately filter waste and excess fluid from the blood, necessitating regular dialysis treatments to sustain life), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and unspecified psychosis not due to a substance or known ( indicates a psychotic disorder where the cause is not clearly identified as being due to substance use or a medical condition).Review of Resident #1's care plan reflected Resident #1 had a care plan focus revision dated 04/21/2025 of activities of daily living self-care performance deficit related to history of CVA (a medical term for stroke) with increased weakness impaired cognition. Intervention dated 04/18/2025 monitor/document/report to medical doctor as needed signs and symptoms of immobility: contractures forming or worsening.Review of Resident #1's Resident Assessment and Care Screening MDS dated [DATE] reflected a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident #1's physical therapy order dated 05/22/23, no discontinued date, reflected Resident #1 was to wear resting hand splint on left hand don (to put on, specifically clothing or equipment) after breakfast and doff (to take off, specifically clothing or equipment) after lunch as tolerated and skin checks by nursing pre and post wear and report any changes immediately every day and evening shift.Review of Resident #1's eMAR dated 08/06/25 documented by LVN B for Resident #1 to wear resting hand splint on left hand don (to put on, specifically clothing or equipment) after breakfast and doff (to take off, specifically clothing or equipment) after lunch as tolerated and skin checks by nursing pre and post wear and report any changes immediately every day and evening shift reflected hand splint applied to left hand. Observation on 08/06/25 at 12:10 pm with LVN B of Resident #1's left hand reflected no hand splint.Interview on 08/06/25 at 12:38 pm with LVN B reflected facility policy was that nurses documented in the eMAR that a treatment had been administered after it had been administered. She stated she did not put Resident #1's resting hand splint on her left hand but documented that she had done so. LVN B said usually the aides were good and knew when to put on resident orthopedic devices. She said she charted it was on, but it was off, and she should have made sure it was on. She said it was her responsibility to make sure that Resident #1's orthopedic hand splint was on Resident #1 because obviously it was not. She said if Resident #1's hand splint was not applied; Resident #1 could suffer a hand contracture. Interview on 08/06/25 at 1:14 pm with the OTA revealed Resident #1's orthopedic devices were ordered to prevent future contractions, problems with skin integrity, and to not lose hand range of motion. Interview on 08/07/25 at 2:06 pm with CNA reflected Resident #1 was constantly taking off her orthopedic devices and he informed the nurses of this behavior.Interview on 08/06/25 at 4:21 pm with the ADON reflected nurses document in the eMAR after resident care had been done and on completion of the task. A potential problem of not confirming that a task had been completed was mis-documentation of records and giving the wrong information to oncoming staff, resident injury, or medication error. It was the responsibility for the nursing administration, the ADON and the DON to make sure that all nurses are documenting properly in resident eMAR. Interview on 08/06/25 at 4:21 pm with ADON C reflected nurses documented in the eMAR after care had been given to the resident. It was a problem when you documented that care had been done when it had not been done because that was falsifying documentation. She said the negative effect of documenting care that was not received would be that the resident would not get the most proper or efficient care. She said it was the responsibility of everyone to make sure that the residents' care was documented accurately. Interview on 08/06/25 at 4:58 pm with the DON reflected it was important that nurses did not document care that a resident did not receive. It was not good nursing care or quality of care to document care that you did not give to a resident. The negative effect of documenting care was given when it was not given was that it could affect MD orders and could have a long-range effect for the care and treatment of the resident. The DON said it was the responsibility of nursing management, the ADON and the DON, to make sure that nurses had properly documented treatments given.

Based on observation, interview, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, that the facility maintained medical records on each resident that were accurately documented for one of five residents (Resident #1) reviewed for medical records.The facility failed to accurately document Resident #1's application of her orthopedic device and dialysis wound dressing removal.This failure could place residents at risk of not identifying or receiving care, for unassessed changes in conditions and improper documentation of treatments.Findings Include:Review of Resident #1's face sheet dated 08/06/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependance on renal dialysis (occurs when a person's kidneys are no longer able to adequately filter waste and excess fluid from the blood, necessitating regular dialysis treatments to sustain life), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and unspecified psychosis not due to a substance or known ( indicates a psychotic disorder where the cause is not clearly identified as being due to substance use or a medical condition).Review of Resident #1's care plan revised on 04/03/25 reflected Resident #1 needed dialysis related to renal failure.Review of Resident #1's Resident Assessment and Care Screening MDS dated [DATE] reflected a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident #1's face sheet dated 08/06/25 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependance on renal dialysis (occurs when a person's kidneys are no longer able to adequately filter waste and excess fluid from the blood, necessitating regular dialysis treatments to sustain life), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and unspecified psychosis not due to a substance or known ( indicates a psychotic disorder where the cause is not clearly identified as being due to substance use or a medical condition).Review of Resident #1's care plan revised on 04/03/25 reflected Resident #1 needed dialysis related to renal failure.Review of Resident #1's Resident Assessment and Care Screening MDS dated [DATE] reflected a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident #1's order dated 05/22/23, no discontinued date, reflected Resident #1 was to wear resting hand splint on left hand don (to put on, specifically clothing or equipment) after breakfast and doff (to take off, specifically clothing or equipment) after lunch as tolerated and skin checks by nursing pre and post wear and report any changes immediately every day and evening shift.Review of Resident #1's eMAR dated 08/06/25 documented by LVN B for Resident #1 to wear resting hand splint on left hand don (to put on, specifically clothing or equipment) after breakfast and doff (to take off, specifically clothing or equipment) after lunch as tolerated and skin checks by nursing pre and post wear and report any changes immediately every day and evening shift reflected hand splint applied to left hand. Observation on 08/06/25 at 12:10 pm with LVN B of Resident #1's left hand reflected no hand splint.Review of Resident #1's order dated 04/09/24 reflected remove dressing from AV Fistula (an abnormal connection between an artery and a vein) site left arm post dialysis the following day of Resident #1's dialysis. Record review of Resident #1's progress note by LVN A dated Wednesday 06/09/25 reflected Resident returned from dialysis via EMS, Resident did not receive dialysis due to family not showing up. Resident stable and in good spirits. Record review of Resident #1's eMAR dated Thursday 06/10/25 documented by LVN A reflected dressing was removed from AV Fistula (an abnormal connection between an artery and a vein) site left arm post dialysis.Record review of Resident #1's progress note by LVN A dated Thursday 07/07/25 reflected Notified by EMS transporters that resident was refusing to go with them to be transported to dialysis. Spoke with resident, she stated she was tired and would not go to dialysis today.Record review of Resident #1's eMAR dated Friday 07/08/25 documented by LVN A reflected dressing was removed from AV Fistula (an abnormal connection between an artery and a vein) site left arm post dialysis.Record review Resident #1's progress note by the DON dated Monday 07/11/25 reflected Resident unable to dialyze, returned to facility. Notified daughter and MD, resident in stable condition.Record review of Resident #1's eMAR dated Wednesday 07/12/25 documented by LVN A reflected dressing was removed from AV Fistula (an abnormal connection between an artery and a vein) site left arm post dialysis.Interview on 08/06/25 at 12:38 pm with LVN B reflected facility policy was that nurses documented in the eMAR that a treatment had been administered after it had been administered. She stated she did not put Resident #1's resting hand splint on her left hand but documented that she had done so. LVN B said usually the aides were good and knew when to put on resident orthopedic devices. She said she charted it was on, but it was off, and she should have made sure it was on. She said it was her responsibility to make sure that Resident #1's orthopedic hand splint was on Resident #1 because obviously it was not. She said it was her responsibility to make sure it was charted correctly. She said charting something for a resident that had been done, when it had not been done was not good nursing practice. She said if Resident #1's hand splint was not applied, Resident #1 could suffer a hand contracture. Interview on 08/06/25 at 2:11 pm with LVN A reflected that Resident #1 had an order for her dressing to be removed from her AV Fistula site left arm post dialysis on every evening shift the day after Resident #1 received dialysis. He said he would remove the bandage from Resident #1's arm if it was not actively bleeding. He stated that if Resident #1 did not go to dialysis, she would not have the bandage and there would be no reason to document the removal of the bandage. He agreed that he documented that he removed the bandage on 06/09/25, 07/08/25, and 07/12/25, when she had not received dialysis the day prior. He said that it was a problem because he charted something that did not happen and that was not good nursing practice. He said in the eMAR there are a bunch of different click offs and he might have just clicked off that he administered the treatment. He said that if you do not administer a procedure, you do not chart that you have administered the procedure. He said it was the responsibility of the nurse to document accurately and a negative effect of not charting properly was that you would not know what treatment the resident received. Interview on 08/06/25 at 4:21 pm with the ADON reflected nurses document in the eMAR after resident care had been done and on completion of the task. A potential problem of not confirming that a task had been completed was mis-documentation of records and giving the wrong information to oncoming staff, resident injury, or medication error. It was the responsibility for the nursing administration, the ADON and the DON to make sure that all nurses are documenting properly in resident eMAR. Interview on 08/06/25 at 4:21 pm with ADON C reflected nurses documented in the eMAR after care had been given to the resident. It was a problem when you documented that care had been done when it had not been done because that was falsifying documentation. She said the negative effect of documenting care that was not received would be that the resident would not get the most proper or efficient care. She said it was the responsibility of everyone to make sure that the residents' care was documented accurately. Interview on 08/06/25 at 4:58 pm with the DON reflected it was important that nurses did not document care that a resident did not receive. It was not good nursing care or quality of care to document care that you did not give to a resident. The negative effect of documenting care was given when it was not given was that it could affect MD orders and could have a long-range effect for the care and treatment of the resident. The DON said it was the responsibility of nursing management, the ADON and the DON, to make sure that nurses had properly documented treatments given.

Based on interview and record review, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after events to the State Survey Agency for 1 (Resident #1) of 4 residents reviewed for injury of unknown origin. The facility failed to report to HHSC when Resident #1 was found with a head laceration of unknown origin requiring staples on [DATE]. This failure placed residents at risk of abuse and neglect.Findings included:Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia. It also reflected he was on hospice and expired on [DATE]. Review of the quarterly MDS for Resident #1 dated [DATE] reflected a BIMS score of 00, indicating severe cognitive impairment. It reflected he had physical and verbal behavior symptoms four to six days out of the seven-day assessment period. It also reflected he had fallen once with and once without injury since admission. Review of the care plan for Resident #1 dated [DATE] reflected the following: The resident is Moderate risk for falls r/t Confusion, Unaware of safety needs, Wandering. Review of progress notes for Resident #1 dated [DATE] at 9:15 PM and documented by RN A reflected the following: CNA found resident sleeping in bed in next room. Had 3.5 by 1/2cm laceration on back of head which had been bleeding. Resident unable to verbalize how he got the injury. Blood was also found on floor by nightstand of other bed in room. Resident would not stand to move back to his room so was placed in wheelchair to move him. Notified MD who ordered send to ER, called on call nurse then on call [nurse practitioner] who said OK to send. Called DON then EMS. Notified RP of findings and plan. She questioned how he keeps falling and why he isn't being watched. Told her he is being watched and had been sleeping in own bed approximately 30 to 60 minutes prior. Requested to be notified when he returns. She called back few minutes later questioning about what room he had been in and color of female. Explained to her there were 2 females in room, the white one by door was in her bed, and he was sleeping in bed by window which was empty. Due to resident medical condition, she was unable to tell anything about incident. Review of an incident report dated [DATE] and completed by RN A included the text of the above progress note and the following: Injuries Observed at time of incident- No injuries observed at time of incident. Injuries Observed Post-Incident- No injuries observed post incident.Notifications: nurse practitioner, DON, MD, and RP. Review of ER records for Resident #1 dated [DATE] reflected the following: Scalp laceration. The four staples need to be removed in 7 days. OK to give Tylenol 1000 mgs every six hours as needed for pain. CT Brain and CT-C Spine negative for intracranial bleed and fracture. Review of progress notes for Resident #1 dated [DATE] at 1:19 AM reflected the following: Resident returned to the facility @ 0100 (1:00 AM). He is stable. No bleeding from the laceration back of the head. Staples to be removed in 7 days. Tylenol 1000 mg prescribed PRN for pain. All parties notified of his return to the facility. Review of assessments for Resident #1 reflected neurological checks performed for 72 hours after returning from the hospital on [DATE]. Review of the HHSC database on [DATE] reflected a facility-reported incident called in on [DATE] in which Resident #1 presented with a scalp laceration of unknown origin on [DATE] and received one staple. There was no facility reported incident for the scalp laceration of unknown origin discovered on [DATE] which required four staples. During an interview on [DATE] at 12:30 PM, a FM for Resident #1 stated she had received a call from the facility notifying her that Resident #1 had been found in another resident's (empty) bed with a laceration to his head and had been taken to the ER, where he had received staples to his head laceration. An attempt was made to interview RN A on [DATE] at 1:00 PM. A voicemail was left but no return call had occurred as of [DATE]. During an interview on [DATE] at 1:05 PM, CNA B stated she had worked a double that day and had been in rounds all afternoon. She stated she had just done a round and seen Resident #1 in his room less than an hour before, and then she did some documentation at the nurse's station and then came back down to do another round and found Resident #1 in another resident's empty bed with a big cut on his head. She stated she reported to the nurse on duty and Resident #1 went to the hospital. She stated she was off work by the time Resident #1 came back, but she found out he did get staples. She stated he was hard to predict, and they had to put eyes on him once per hour. She stated he might sit still in his room for a couple hours and then suddenly, he would be ready to walk. CNA B stated he refused to be accompanied or to use any mobility equipment, and they tried everything to keep him from walking unassisted, but he would curse and sometimes even physically assault the aides when they tried to assist him. During an interview on [DATE] at 2:44 PM, the ADM who stated she was the abuse coordinator and was responsible for implementing the abuse prevention system in the facility. She stated she remembered the surveyor was present on [DATE] and investigated a facility self-reported incident about Resident #1 presenting with a head laceration of unknown origin. She stated she was not aware that another injury had occurred the night after the investigation exit. She stated a head laceration with four staples would definitely prompt her to report the incident to HHSC. She stated the family, and physician had been notified according to the incident report and there was evidence of neurological assessments and after-fall monitoring in the progress notes as well as a nurse practitioner visit on [DATE]. She stated the process that should occur was for the ADONs to pull the incident list the Monday after a weekend, which would have been [DATE]. They would then discuss it at the morning meeting and determine what other steps, including reporting to HHSC, would be required. She stated she did not see how not reporting to HHSC could have affected the resident, as the facility followed their own protocol otherwise. During an interview on [DATE] 3:10 PM, the DON who stated she was brand new to the facility and had no knowledge of the events of [DATE] regarding Resident #1. During an interview on [DATE] at 3:27 PM, the ADON who stated she had responsibility for two halls of residents in the facility, and Resident #1's hall was not one of them. She stated when Resident #1 presented with the head laceration on [DATE], the previous assistant director of nursing was still in that position. The ADON who stated she was not aware of that event and would not have pulled a report the Monday after the injury due to not being responsible for Resident #1's hall. During an interview on [DATE] at 3:09 PM, the ADM who stated it was possible the incident did not get reviewed during morning meeting because the nurse who completed it had not documented an injury beyond the progress note narrative that was included. Review of facility policy dated [DATE] and titled Abuse Prohibition Policy reflected the following: The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary, corrective actions, depending on the results of the investigation. The abuse coordinator will report all allegations of abuse, neglect with serious, bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. Coordinator will report all other allegations on neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure DD A and [NAME] C were practicing food contamination prevention while preparing foods. The facility failed to ensure dietary employees were preventing cross-contamination of harmful substances to food by cloth towels. The facility failed to ensure the commercial ice machine was cleaned on a routine basis to prevent the development of slime or soil residues. The facility failed to ensure the ensure the commercial countertop water and ice dispenser machine was cleaned on a routine basis to prevent the development of slime or soil residues. The facility failed to ensure equipment food contact surfaces were cleaned where they are not exposed to splash, dust, or contamination. These failures could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Findings included: Observation on 4/28/2025 at 9:23 AM during the initial kitchen tour revealed a stainless-steel stockpot filled with cooked mashed potatoes for resident consumption sitting on top of the prepping counter near a red sanitation bucket with used cleaning towels and water with sanitation chemicals. The commercial ice machine's interior lid and exterior frame was dirty and had brown and white residue buildup. The commercial countertop water and ice dispenser machine in the dining room was dirty and had brown and white residue buildup with small white particles in the drainage area. Observation on 4/29/2025 at 9:35 AM revealed [NAME] C preparing lunch and using the cleaning towels from the red sanitation bucket. She lifted the towels out of the sanitation water bucket to wipe down the food preparation counters. The cleaning towel dropped into the red sanitation bucket causing splashes around the bucket where puree of foods was occurring. In an interview on 4/29/2025 at 9:35 AM [NAME] C stated she is constantly wiping her work area down to maintain a sanitized work area. She stated she likes to clean as she goes. [NAME] C stated the red sanitizer buckets with cleaning towels are replaced with clean water and sanitizer during each shift. She stated each kitchen staff is assigned a workstation for the day and they are responsible for keeping it cleaned. Observation on 4/29/2025 at 9:35 AM revealed DD B lifting the commercial ice machine lid and searching for a leak reported to him. DD B stated to DD A he would determine where the water leak was coming from , but he would return later to complete the task. Observation on 4/29/2025 at 9:58 AM revealed a red sanitation bucket with used cleaning towels and water with sanitation chemicals sitting on top of the prepping counter within proximity of food preparation counters and within proximity of stacked clean dishes and insulated plate covers used for resident meals. The commercial ice machine's interior lid and interior frame securing lid was dirty and had brown dirt and brown slime buildup. The exterior of the commercial ice machine had a white buildup around the lower part of the machine. The commercial countertop water and ice dispenser machine in the dining room was dirty and had brown dirt and white buildup with small white particles in the drainage area. Observation on 4/30/2025 at 11:57 AM revealed the commercial ice machine's interior lid and interior frame was dirty and had buildup of brown dirt, brown slime, brown sludge with slimy texture and discoloration The exterior of the commercial ice machine had a white buildup around the lower part of the machine. The commercial countertop water and ice dispenser machine in the dining room was dirty and had brown and white buildup with small white particles in the drainage area. In an interview on 4/30/2025 at 11:49 AM DD A stated she is responsible for the day-to-day operations of the facilities' kitchen. She stated all the counters, food prep machines, dishes, refrigerators, floors the commercial ice machine, and commercial countertop water and ice dispenser machine are tasks assigned daily to staff for cleaning. She stated dietary staff are responsible for keeping their work areas clean by using the cleaning towels from the red sanitizer buckets and wiping down and washing all equipment used to prepare food. She stated that all equipment and surfaces are cleaned daily, and a cleaning log of each area cleaned is logged after completion. She stated she deep cleans the commercial ice machine monthly, but she does not keep a log of this specific task. DD A stated the commercial ice machine filters are replaced by maintenance quarterly. She stated any large repairs required in the kitchen are repaired by DD B. DD A stated she does her best to clean the ice machines daily to keep from developing mildew and growing slime. She does believe the brown dirt and buildup surrounding the lid of the machine is an issue and if it leaked into the ice the residents can become sick. DD A stated she notified DD B that the company who services the ice machine would need to provide a deep cleaning. She stated she has mentioned it in the morning meetings for the last six months and she was not sure if it was on the schedule. She stated the ice machine is working fine, but it is old, it has a leak DD B was looking at yesterday. She stated the company could replace the ice machine all together as it is extremely old, but not sure why it has not been replaced. DD A stated the ADM is aware of the ice machine as she at times will help serve ice with beverages and will scoop out ice from the machine. She has also been present in the morning meetings when she has addressed the concern. DD A stated the process to place a work order for repairs is to verbally address in morning meetings with administration staff and to verbally notify the maintenance staff who in turns will add to his workload. DD A stated the red sanitizer bucket on top of the preparation area near the stove and oven is always kept in this location of the kitchen as it is constantly used and there is no other place or room to move it to. She stated all other red sanitizer buckets are located underneath the counter spaces throughout the kitchen. DD A stated she did not see the sanitizer bucket in the prep area as a concern. She stated that the cleaning water is changed during each shift. DD A stated if the cleaning water from the sanitizer bucket were to spill or splash onto food that residents consume can be harmful to their health, but stated she and the other cooks will be cautious to avoid this from happening. In an interview on 4/30/2025 at 12:07 PM DD B stated he is responsible for making all minor repairs in the facility. He stated for more challenging repairs or outside of his skill set he will contact an outside contractor. He stated the only issues with the commercial ice machine in the kitchen is that it only makes 20 lbs. of ice, a small leak was recently identified, and he does notice light mildew, grime, and rust . He stated the grime and mildew can be removed with cleaning. This also includes the commercial countertop water and ice dispenser machine in the dining room. He stated if he were to observe large amounts of mildew, grime, and rust in either ice machine he would contract for a deep cleaning. He stated work is performed every six months. DD B stated he noticed a concern with the ice machine door/lid sticking and not opening easily. He stated he has not looked over thoroughly and has not repaired recently. He stated a leak near the ice machine was conveyed to him. He stated he recently was notified in about the ice machine lid sticking during the morning meeting but does not recall if the brown grime and brown dust layered on the interior of the machine has been mentioned. DD B stated if the ice machine is not repaired and cleaned properly it could make the residents sick. He stated he may have overlooked the ice machine as he has a heavy workload, and work orders have doubled up on him, and he has been late to morning meetings and may have not received this information verbally. He stated verbal workorders received from dietary staff are entered into the facility maintenance software, so he is aware of his workload. Surveyor requested workorders and invoices for last two commercial ice machine service requests. DD B stated he does not receive the invoices for this work and the business office may have. Surveyor requested that he reach out and request invoices through his business office. Surveyor did not receive invoices from facility. In an interview on 4/30/2025 at 12:15 PM KA D stated the dietary staff are tasked daily with wiping down kitchen equipment, washing dishes, and cleaning all kitchen surfaces before the next shift. She stated a daily log of cleaning is completed by DD A when the task has been completed. Tasks are assigned differently each day. She stated all red cleaning sanitizer buckets are changed out during each shift and are kept in low areas away from clean dishes and food consumed by residents. She stated she is not sure why there is one red sanitizer bucket left on top of the cooking prep surfaces near the stove and warming tables. She stated she is not a cook, and she does not enter the area near the stove. She stated all other buckets are located underneath the counters in a safe area away from clean dishes and food. She stated if chemicals from spillage or splashes of the red sanitizer buckets were to fall onto clean dishes or food it can be harmful to residents and their health and cause a serious illness. In an interview on 4/30/2025 at 12:26 PM ADM stated kitchen operations are managed by the DD A. She stated the dietary staff are responsible for cleaning all kitchen equipment and machines daily. She stated the DD A is responsible for notifying management staff or DD B of any kitchen equipment not functioning properly. She stated the DD B is responsible for maintaining all kitchen equipment including the commercial ice machine and commercial countertop water and ice dispenser machine. The ADM stated if the DD B is unable to repair a facility machine, he then takes the necessary steps to secure an outside contractor specializing in the repair needed. The ADM stated the process for requesting kitchen equipment and other facility repairs is to notify DD B verbally. She stated this is usually done in morning meetings with directors of each department. She stated if she received a verbal repair request during the morning meeting, she would enter a workorder in the facility's maintenance software and DD B will use this as a guide to work on open facility repair concerns. This maintenance system allows DD B to check off repairs he has completed and provide notification tor management that a repair is in pending status and reason, or order is requiring approval for further work. The ADM stated she is unsure why the sanitizer buckets with cleaning towels would be sitting on top of prepping tables near clean dishes and food being prepared for resident consumption. When shown pictures of the dirty ice machines and sanitizer buckets near cooked food ADM stated it was a concern and not following facility policies. The ADM stated this practice can affect the residents in a negative way and cause illness. Record Review of Policy and Procedure: Kitchen and Equipment Cleaning and Sanitation Policy, dated 12.2020 reflected: The kitchen and dining service equipment and food contact surfaces shall be maintained in a clean and sanitized condition. Dining Services staff shall be trained on cleaning and sanitizing processes. The Dietary Manager shall provide cleaning assignments to indicate the time and task to be completed by dining services staff. The Dietary Manager is responsible to ensure that cleaning assignments have been timely completed. Adequate equipment and supplies will be available for proper cleaning and/or sanitizing of dishes, equipment, work surfaces, and floors. Equipment food contact surfaces and utensils shall be clean to sight and touch. Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Record Review of Frequency of Cleaning: Kitchen and Equipment Cleaning and Sanitation Policy, dated 12.2020 reflected: Equipment food contact surfaces and utensils shall be cleaned: Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to prevent accumulation of soil residues. Clean equipment, utensils and single-service and single use articles shall be stored: Where they are not exposed to splash, dust, or contamination. Record Review of 3-304.14 Wiping Clothes, Use Limitation: FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022 reflected: Soiled wiping cloths, especially when moist, can become breeding grounds for pathogens that could be transferred to food. Any wiping cloths that are not dry (except those used once and then laundered) must be stored in a sanitizer solution of adequate concentration between uses. Record Review of 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022 reflected: The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate. Record Review of 4-602.11 Equipment Food-Contact Surfaces and Utensils: FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022 reflected: Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to dispose of expired milk located in the kitchen's reach in refrigerator. 2. The facility failed to label and date all food items located in the reach in refrigerator, walk in refrigerator, and dry storage room. 3. The facility failed to properly store all food items to prevent contamination or spoilage. 4. The facility failed to sanitize the blender and thermometer during food preparation and temperature checks. 5. The facility failed to maintain a clean microwave, toaster, fryer, and clean the oven drip pans. 6. The facility failed to ensure dietary staff wore hairnets and beard guards while in the kitchen. 7. The facility failed to ensure dietary staff followed proper handwashing and glove use. 8. The facility failed to ensure industrial size trash cans used for food remnants/ debris in the kitchen had lids. These failures could place residents at risk for food contamination and foodborne illness. Findings Included : During the initial tour of the kitchen on [DATE] at 09:00 AM the following was observed: 1. The reach in refrigerator contained 1 gallon of chocolate milk that expired on [DATE], and a tray containing a plastic cup of an unknown fluid. The plastic cup was not covered and neither the tray or cup were labeled or dated. 2. A plastic cup of sugar was observed near the prep station used to fill smaller individual plastic sugar cups. The plastic cup of sugar had a metal spoon with clumped sugar stuck to the spoon from mixing other fluids. 3. The walk-in refrigerator contained separate metal containers of chicken patties, spinach, pineapples, and gravy that were not properly labeled or dated. 4. The walk-in freezer contained a bag of home-style fries that was not labeled or dated and the fries were exposed to air. 5. The dry storage room contained a tray with two individual-serving bowls of cereal. Neither the tray or bowls were labeled or dated and were not properly sealed exposing contents to air. 6. The dry storage room contained 2 boxes of instant food thickener, 1 box of white rice, and a bag of marshmallows not properly sealed and all items exposed to air. 7. The dry storage room contained 1 bottle of ketchup that had been opened and used, not refrigerated and the bottle reflected, refrigerate after opening. 8. The kitchen microwave, toaster , fryer, and oven drip pans were visibly soiled. The drip pans had a thick layer of burnt food and grease; the fryer had dried stuck on grease and food particles that covered the outside; the microwave appeared to have splattered dried food on the inner back and top; and the fryer had crumbs on the inside and on top and what appeared to be dried food stuck to the exterior. 9. The food temperature logs were observed to have missing temperatures recorded for dinner temperatures on 04 /,d+[DATE] and breakfast on [DATE]. 10. The bottom food prep counter shelf contained a plastic bin of individual serve bags filled with cornbread. The plastic bin was not labeled or dated, and the bags were not properly sealed which exposed the contents to air. 11. The industrial size 32-gallon trash can near the steam table food preparation area was filled with trash such as food remnants/ debris did not have a lid. In an interview on [DATE] at 09:25 AM with Dietary aide D, she stated it is their responsibility to check the refrigerators for expired items daily and discard anything expired. She said all stored items should have had the received or prepared date and she believed they should have been discarded after a week from the prepared date. In an interview on [DATE] at 09:28 AM with the Cook, she stated that she was swamped this morning and did not have time to log any of the breakfast temperatures, but that she knows they are supposed to be logged right away after ensuring food is at a safe temperature . The [NAME] said that dietary staff typically clean the oven drip pans every day to every other day but she did not know when they were last cleaned. In an observation on [DATE] at 11:38 AM in a kitchen follow up revealed, Dietary aide D was observed handing the [NAME] a thermometer. The [NAME] then placed the thermometer in the regular texture chicken alfredo pasta without sanitizing the probe. In an observation on [DATE] at 11:52 AM the [NAME] was observed in the preparation of 3 separate pureed meals which included corn with broth, puree chicken alfredo pasta, and pureed bread. The [NAME] did not sanitize the blender in between each pureed item, and only rinsed it with plain water in a two-compartment sink. The C ook also failed to change her gloves or wash her hands in between touching soiled kitchen equipment and utensils and then returning to the food preparation . In an observation on [DATE] at 12:06 PM revealed Dietary aide E failed to properly sanitize the blender before using it to make a fruit salad puree. The blender was not placed in the dishwasher before use, or washed in the 3 compartment sink with soap and water and sanitized. In an observation on [DATE] at 12:08 PM the [NAME] was observed sanitizing the thermometer used to take food temperatures in a small bucket of liquid dish sanitizer that was also being used by Dietary aide F to dip a cloth that was used to clean the prep table counter tops. In an observation on [DATE] at 01:04 PM in the dining room during lunch service, Dietary Aide G was observed entering the kitchen during meal tray preparation and assembly area without a hairnet or beard guard despite nursing staff being heard telling him to put them on before entering the kitchen. Dietary Aide G had hair long enough to go past his ears and hair on his chin approximately half an inch long. In an interview and observation on [DATE] at 01:30 PM with Dietary aide G in the dining room, he stated that he believed hairnets should be worn prior to entering the kitchen but he was not sure what the facility's policy was on them. He said a negative outcome to not wearing hairnets or proper hair restraints was hair could fall into the food. Dietary Aide G was then observed returning to the kitchen with no beard guard. In an interview on [DATE] at 02:57 PM with the Interim DM she stated it was her expectation that all food items are properly labeled with the open or prepared date and the use by date. She stated it was her expectation that any leftovers have a use by date of 3 days (including the date it was labeled) and be discarded after. She stated all food items should be sealed properly and not exposed to air. The Interim DM said if cereal is poured into a bowl, the bowl or tray should have the date it was poured and the date it will be used by. She said the bowls should be sealed airtight. The Interim DM said it was her expectation that the blender be properly sanitized in between every pureed item by being ran through the dishwasher because that was the best way of ensuring it was clean. She said the proper way of sanitizing thermometer probes is by using alcohol wipes before and in between each food item checked for temperature. The Interim DM said it was her expectation that the kitchen be maintained in sanitary condition and that sanitation rounds are made at the beginning and end of each shift to ensure the kitchen including appliances, and fryers etc. are cleaned. She said drip pans are to be checked and cleaned after each use of the stovetop. The Interim DM said that hairnets and beard guards (as needed) are part of the uniform and should be worn before you step in the kitchen. The Interim DM said anytime gloves are used you must wash your hands, and hands are supposed to be washed before putting on new gloves on. She said if gloves become contaminated such as if taking out the trash, touching dirty dishes, or raw meat they should be changed, and hands should be washed. The Interim DM said trash cans are to have lids to prevent contamination and pests. She said a negative outcome to no hair or beard guard is hair is a hazard and could get into the food and she said a negative outcome to items not being properly labeled, dated, or sealed could cause a resident to get a foodborne illness and get sick and they also wouldn't know when to throw items out. Record review of the facility's Sanitation policy revised ,d+[DATE] revealed: The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean free from litter and rubbish and protected from rodents, roaches flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from brakes, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. All equipment, food, contact services, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized, using hot water and or chemical sanitizing solutions. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways: Contact for at least 30 seconds with an iodine solution (at approved concentration); Contact with QAC (at approved concentration) per manufacturers instruction; Contact for least 10 seconds with a chlorine (at approved concentration); or Immersion for 30 seconds in hot (at least 171 F) water. Between uses cloths and towels, used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty. Manual washing and sanitizing will employ a three-step process for washing, rinsing, and sanitizing; Scrape food particles and wash using hot water and detergent; Rinse with hot water to remove soap residue; and Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of: Chlorine 50 ppm for 10 seconds; Iodine 12.5 ppm for 30 seconds; or Ammonium compound 150 to 200 ppm for time designated by manufacturer. Fixed equipment: 1. Fixed equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions. 2. Staff members will be trained in the cleaning and maintenance of all equipment. 3. Food contact equipment will be cleaned and sanitized after every use. 4. Non-food contact equipment will be clean and free of debris. The food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility's Food Receiving and Storage policy revised [DATE] revealed: Food shall be received and stored in a manner that complies with safe food handling practices. Food services or other designated staff will maintain clean food storage areas at all times. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in- first out system. All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Beverages must be dated when opened and discarded after 24 hours. Other open containers must be dated and sealed or covered during storage. Record review of the facility's Food Preparation and Service policy revised [DATE] revealed: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Appropriate measures are used to prevent cross-contamination. These include: Cleaning and sanitizing work surfaces, including cutting boards and food-contact equipment between uses, following food code guidelines. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness Food thermometers used to check food temperatures are clean, sanitized, and calibrated for accuracy. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. Food and nutrition services staff wear hair restraints (hairnet, hat, beard restraint, etc.) so that hair does not contact food.

Based on observation, interviews, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals for 1 of 1 resident (Resident #38) reviewed for pharmacy services and procedures in that: The facility failed to ensure medication administered to a resident was taken and not left in the room. This failure could place residents at risk of not receiving their physician ordered medications resulting in a decreased quality of life. Findings include: Record review of Resident #38's face sheet dated 04/11/24 revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of unspecified dementia-unspecified severity-without behavioral disturbance-psychotic disturbance-mood disturbance-and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life.), constipation-unspecified (infrequent, irregular, or difficult evacuation of the bowels), major depressive disorder-recurrent-unspecified (persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and generalized muscle weakness (reduction in the power exerted by the muscles resulting in the inability to perform a given task on the first attempt). Record review of Resident #38's MDS assessment dated [DATE] reflected a BIMS score not assessed (BIMS is used to evaluate aspects of cognition in the elderly). The MDS assessment revealed active diagnoses for anxiety disorder and depression. The MDS assessment reflected Resident #38 was currently taking an antidepressant. Record Review of Resident #38's care plan last revised 06/22/22 revealed the resident uses antidepressant medication Phenelzine Sulfate r/t depression with a goal of the resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date and interventions of: Administer antidepressant medications as ordered by physician. Monitor/ document side effects and effectiveness Q-Shift. Monitor/ document/ report PRN adverse reactions to antidepressant therapy; change in behavior/mood/cognition; hallucinations/ delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability; continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. loss, n/v, dry mouth, dry eyes, date initiated 11/21/2019, revision 06/22/22. Record review of Resident #38's clinical physician's orders reflected an active order of Phenelzine Sulfate Tablet 15 MG, give 1 tablet by mouth four times a day for depression related to major depressive disorder, recurrent, moderate. The order reflected a start date of 05/27/22 at 07:05 AM, medication class antidepressants. In an observation and interview on 04/09/24 at 11:15 AM revealed in Resident #38's room a small, round, orange tablet with the markings PD270 lying on Resident #38's bed. Resident #38 stated he believed that was a medication for depression, but he did not remember how it got there. At the time, LVN A entered the room and stated she did not know what medication the pill was, but that the medication aide would know and that the medication aides were supposed to watch the residents take all their medications before leaving the room. LVN A stated a potential negative outcome to leaving the medication behind and not making sure residents take it could result in a missed dose to help their conditions or the possibility of an overdose if the resident were to find the medication later and take it close to their next scheduled dose. LVN A was observed reviewing Resident #38's medication orders and MAR and said it was a medication prescribed to Resident #38 for depression; and stated the last dose administered on 04/09/24 was by Medication Aide C. Record review of Resident #38's MAR reflected Phenelzine Sulfate Tablet 15 MG was marked as being administered by Medication Aide C 04/09/24 at 07:00 AM and 11:00 AM, and by Medication Aide B on 04/08/24 at 04:00 PM and 07:00 PM. In an interview on 04/10/24 at 02:30 PM with Medication Aide C, she stated she was familiar with Resident #38's medication and the small orange pill he takes is for his depression. Medication Aide C stated Resident #38 gets the Phenelzine Sulfate tablet 4 times a day. She said she catches Resident #38 in the morning on his way to get coffee and will administer his medication to him there (hall or dining room) and ensures he takes it before walking away. Medication Aide C said that a negative outcome to leaving medication in the residents' room is there is the potential for another resident to find it and take a medication they are not prescribed. In an interview on 04/10/24 at 02:42 PM via phone call to Medication Aide B, she stated that she normally provides the Phenelzine Sulfate to Resident #38 in his room, but she said she will hand him the medication cup which Resident #38 will dump in his hand and then take them one by one. Medication Aide B said that was done in her presence and she will not leave until all medications are taken. Medication Aide B said she was not sure how the medication was left behind in Resident #38s room, and she said a negative outcome to leaving medication behind is another resident could get ahold of the medication. In an interview on 04/11/24 at 12:26 PM with the DON, she said it was her expectation that all staff administering medications follow all the rights of administration. The DON said staff should provide education to the residents on their medications and should be staying with the residents and watching them take the medication. The DON said she was aware of the pill found in Resident #38's bed and that she wrote the incident as a medication error and notified Resident #38's physician. The DON said that a negative outcome to leaving medication behind unattended is the resident won't get the prescribed treatment or another resident could come and take the medication when it's not prescribed to them. In an interview on 04/11/24 at 12:50 PM with the Administrator, she said it was her expectation for staff that are administering medication to be following all the rights of medication administration. She said a negative outcome to leaving medication behind unattended is the resident could not get the medication which could lead to negative consequences if the medication is not consumed that has been ordered. Record review of Administering Medications policy last revised 04/2019 revealed: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interviews and record review the facility failed to have an assessment that accurately reflected the status for 1 of 3 Residents (Resident #92) reviewed for assessment accuracy in that: Resident #92's discharge MDS dated [DATE] reflected he was discharged to Short Term General Hospital (acute hospital) when he was discharged home. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Findings include: Record review of Resident #92's face sheet dated 04/11/24 revealed a [AGE] year-old male admitted on [DATE] with no diagnosis information listed. The face sheet reflected a length of stay of 4 days, with a discharge date of [DATE]. Record review of Resident #92's discharge MDS assessment dated [DATE] revealed section A2105 discharge status was Short-Term General Hospital. The MDS assessment reflected section A was completed by MDS Coordinator and signed 04/03/24. Record review of Resident #92's interdisciplinary summary dated 04/02/24 reflected a discharge date of [DATE] at 05:00 PM and notes that reflected, admitted from home for respite care stay under services of [hospice provider]. Minimal assistance was required with ADL care, dc home with [family member] . In an interview on 04/10/24 at 12:52 PM with Resident #92's family member, she stated Resident #92 was discharged home. She said he was at the facility very briefly because the family wanted to get a break from his care but was later picked up by family and taken home and not ever discharged to the hospital. In an interview and observation on 04/10/24 at 12:59 PM with the MDS Coordinator, she stated Resident #92 was admitted to the facility for respite stay and that the family came in and picked him up to go home at discharge. The MDS Coordinator stated she was the one who competed the discharge MDS. She was observed reviewing Resident #92's discharge MDS and stated she would have to do a modification to correct it. The MDS Coordinator stated there was no negative outcomes to a discharge MDS assessment being incorrect . In an interview on 04/11/24 at 12:26 PM with the DON, she stated it was the responsibility of the MDS Coordinator to complete the MDS and the DON's responsibility to verify completion. The DON stated that a potential negative outcome to an inaccurate MDS assessment would be it could affect billing, but that depending on which section is incorrect it could affect other care areas. The DON said she remembered Resident #92 and that he was discharged home with family. In an interview on 04/11/24 at 12:50 PM with the Administrator, she stated the MDS was completed by an interdisciplinary team and that the MDS Coordinator is to verify it for accuracy and the DON is responsible for verifying its completion. The Administrator said a potential negative outcome to an inaccurate MDS assessment is it could affect billing and payments, or the resident may not receive their needed services depending on what section is incorrect. Record review of the facility MDS Coding Policy last revised 01/04/2023 revealed: affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Record review of the CMS RAI Manual last revised 10/20/23 revealed: 5.5 MDS Correction Policy Once completed, edited, and accepted into iQIES, providers may not change a previously completed MDS assessment as the resident's status changes during the course of the resident's stay-the MDS must be accurate as of the ARD. Minor changes in the resident's status should be noted in the resident's record (e.g., in progress notes), in accordance with standards of clinical practice and documentation. Such monitoring and documentation is a part of the provider's responsibility to provide necessary care and services. A significant change in the resident's status warrants a new comprehensive assessment (see Chapter 2 for details). It is important to remember that the electronic record submitted to and accepted into iQIES is the legal assessment. Corrections made to the electronic record after iQIES acceptance or to the paper copy maintained in the medical record are not recognized as proper corrections. It is the responsibility of the provider to ensure that any corrections made to a record are submitted to iQIES in accordance with the MDS Correction Policy. Several processes have been put into place to assure that the MDS data are accurate both at the provider and in iQIES.

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 4 residents (Resident #53) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #53 to the appropriate, State-designated authority when she was diagnosed schizoaffective disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings included: Record review of Resident #53's face sheet dated 04/11/24 revealed a [AGE] year-old female admitted on [DATE] with a diagnoses of type 2 diabetes mellitus without complications (condition resulting from insufficient production of insulin causing high blood sugar), schizoaffective disorder bipolar type (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) with onset date of 05/04/22, erythema intertrigo (inflammatory skin condition), and hyperlipidemia unspecified (abnormally high levels of any or all lipids or lipoproteins in the blood). Record review of Resident #53's MDS assessment dated [DATE] reflected a BIMS score of 15 suggesting cognition was intact. The MDS also reflect an active diagnosis of schizophrenia. Record review of Resident #53's PASARR Level 1 screening dated 03/05/21 reflected section c is there evidence or an indicator this is an individual that has a mental illness? was marked no. No additional PASARR screenings were found in Resident #53's records. In an interview on 04/10/24 at 03:45 PM with the MDS Coordinator she stated she had just turned in HHS form 1012 Mental Illness/Dementia Resident Review for Resident #53 on 04/10/24. The MDS Coordinator said that when Resident #53 first came in she did not trigger for a level 2 PASARR. She said an audit was conducted the week of 03/31/24 which is how the event was found. The MDS Coordinator said that audits are attempted every 6 months and she did not know why it wasn't caught sooner. She said that after the 1012 was submitted was when they would know if the resident in question would qualify for a level 2 assessment. The MDS Coordinator said that typically a diagnosis of a Mental Illness at admission would trigger them for a level 2 assessment or if they were to develop one later the added diagnosis would have a level 2 assessment triggered. The MDS Coordinator said that by going that long without the PASARR level 2 assessment the negative outcome is the resident could have missed out on additional mental health services. In an interview on 04/11/24 at 12:26 PM with the DON she stated was the MDS Coordinators responsibility to complete a PASARR assessment and ensure accuracy. The DON said that she was not savvy on PASARRs, but she believed that a new PASARR assessment should be completed within 3 months of a new Mental Illness diagnosis or change that would require one. The DON said that it was her expectation that PASARRs are verified for accuracy and if the plan of care changes that they reassess. The DON said that a potential negative outcome to a PASARR level 2 not being completed was the potential for residents to miss needed treatment or services which would result in a decline of their health because they are not properly assessed or diagnosed . She stated the resident's quality of life could decline and that staff as a team should be ensuring assessments are being completed accurately. In an interview on 04/11/24 at 12:50 PM with the Administrator she stated it was the MDS Coordinator's responsibility to verify when a PASARR level 2 is needed. The Administrator stated it was her expectation that PASARR assessments are accurate and that PASARR level 2's are completed as soon as being identified as being needed. She said that a negative outcome to not having a timely PASARR level 2 completed would mean the resident could be missing out on getting necessary services to treat the mental illness. Record review of the PASRR Policy and Procedure last revised 07/18/18 revealed: [facility] uses the most current version of PASRR rules, TAC Title 40, Part 1 Chapter 19, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services and IDT meetings.

Based on interview and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 1 of 4 residents (Resident #36) reviewed for PASARR coordination, in that: A PASARR Level I was completed inaccurately for Resident #36 who had an active mental health diagnosis on admission. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings Included: Record review of Resident #36's face sheet revealed a [AGE] year old female admitted on [DATE] with a diagnosis of Variant Creutzfeld-[NAME] Disease (commonly referred to as mad cow disease or human mad cow disease is a rare and fatal prion (infectious protein particle) disease that affects the brain caused by abnormal prion proteins that accumulate in the brain leading to progressive damage), anxiety disorder-unspecified (a group of mental illnesses that cause constant fear and worry), psychotic disorder with delusions due to known physiological condition with onset dated 06/20/2019, and anorexia (eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight, and a distorted perception of weight). Record review of Resident #36's MDS assessment dated [DATE] reflected a BIMS assessment was not completed (used to evaluate aspects of cognition in the elderly). Section I reflected Resident #36 had an active diagnosis of psychotic disorder (other than schizophrenia). Record review of PASRR Level 1 Screening completed 06/20/2019 revealed section c stated, Is there evidence or an indicator this is an individual that has a Mental Illness? Which was answered no. In an interview on 04/10/24 at 03:45 PM with the MDS Coordinator she stated she had just turned in HHS form 1012 Mental Illness/Dementia Resident Review for Resident #36 on 04/10/24. The MDS Coordinator said that when Resident #36 first came in she did not trigger for a level 2 PASARR, she said an audit was conducted the week of 03/31/24 which is how this event was found. The MDS Coordinator said that audits are attempted every 6 months and she did not know why this wasn't caught sooner. She said that after the 1012 is submitted is when they would know if the resident in question would qualify for a level 2 assessment. The MDS Coordinator said that typically a diagnosis of a Mental Illness at admission would trigger them for a level 2 assessment or if they were to develop one later the added diagnosis would have a level 2 assessment triggered. The MDS Coordinator said that by going this long without the PASARR level 2 assessment the negative outcome is the resident could have missed out on additional mental health services. In an interview on 04/11/24 at 12:26 PM with the DON, she stated it was the MDS Coordinators responsibility to complete a PASARR assessment and ensure accuracy. The DON said that she was not savvy on PASARRs, but she believed that a new PASARR assessment should be completed within 3 months of a new Mental Illness diagnosis or change that would require one. The DON said that it was her expectation that PASARRs are verified for accuracy and if the plan of care changes that they reassess. The DON said that a potential negative outcome to a PASARR level 2 not being completed is the potential for residents to miss needed treatment or services which would result in a decline of their health because they are not properly assessed or diagnosed . She stated the residents quality of life could decline and that staff as a team should be ensuring assessments are being completed accurately. In an interview on 04/11/24 at 12:50 PM with the Administrator she stated it was the MDS Coordinators responsibility to verify when a PASARR level 2 is needed. The Administrator stated it was her expectation that PASARR assessments are accurate and that PASARR level 2's are completed as soon as being identified as being needed. She said that a negative outcome to not having a timely PASARR level 2 completed would mean the resident could be missing out on getting necessary services to treat the mental illness. Record review of the PASRR Policy and Procedure last revised 07/18/18 revealed: [facility] uses the most current version of PASRR rules, TAC Title 40, Part 1 Chapter 19, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services and IDT meetings.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #4) reviewed for respiratory care. The facility failed to ensure Resident #4's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #4's oxygen treatment and tubing changes were documented on the respiratory MAR. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #4's face sheet dated 04/11/24 revealed a [AGE] year-old female admitted on [DATE] with a diagnoses of panlobular emphysema (disease of the lungs in which the air sacs in the lungs are permanently damaged), chronic obstructive pulmonary disease- unspecified (chronic inflammatory lung disease that causes obstructed airflow from the lungs), generalized muscle weakness, insomnia-unspecified (sleep disorder where people have trouble falling asleep or staying asleep), and hyperlipidemia-unspecified (abnormally high levels of any or all lipids or lipoproteins in the blood). Record review of Resident #4's MDS assessment dated [DATE] reflected a BIMS of 15 suggesting cognition was intact . Record review of Resident #4's care plan last revised 05/09/22 reflected the resident has COPD r/t smoking with intervention of oxygen setting: O2 via NC @ 2L. Record review of Resident #4's clinical physician's orders reflected an active order for oxygen that reflected, O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3 LPM to keep O2 sats >92% with order start date of 10/16/23 at 03:00 PM. Record review of Resident #4's respiratory MAR revealed there were no previous recorded documentation or orders of oxygen tubing changes . The Respiratory MAR reflected change nebulizer treatment tubing Q week on Sunday, every night shift every Sunday with a start date of 04/14/24 and change, label/date O2 tubing weekly on Sunday with a start date of 04/14/24. In an observation and interview on 04/10/24 at 09:22 AM in Resident #4's room, she was observed with the nasal cannula at her nose receiving oxygen. Neither the oxygen tubing to the nasal cannula or the humidifier bottle were dated. Resident #4 said she did not remember exactly when the last time it was changed, but she thinks it may have been on Sunday 04/07/24. In an observation on 04/11/24 at 09:55 AM in Residents #4's room, the humidifier bottle and oxygen tubing were observed not labeled/dated and the nasal cannula was observed lying on the floor , uncovered, under Resident #4's wheelchair. In an interview and observation on 04/11/24 at 10:05 AM with LVN A, she stated oxygen tubing was to be changed every Sunday along with the humidifier bottle. She said there was supposed to be a date on both the humidifier bottle and the tubing to identify when it was changed . LVN A said that when the residents are not using the oxygen the tubing is supposed to be stored in a bag that keeps it sealed . LVN A said that a negative outcome to a resident whose cannula is on the ground could lead to an infection from bacteria if they were to pick it up and put the cannula back up to their face. LVN A was observed changing the humidifier bottle and tubing and dating the new items. LVN A was observed asking Resident #4 if she wanted to use her oxygen to which Resident #4 responded no. LVN A did not have a storage bag with her and was unable to properly store it. She was observed wrapping the tubing around her hand and then placing it in the handle of the oxygen concentrator. In an interview and observation on 04/11/24 at 12:26 PM with the DON, she stated it was her expectation that when oxygen is not being used by a resident that the tubing is stored appropriately in a bag. The DON said the tubing and humidifier bottle should be changed weekly and both should be dated. The DON said that a potential negative outcome to residents from tubing/nasal cannula on the floor would be a potential for infection. The DON was observed looking up the respiratory MAR and said she could not find dates of when the tubing was last changed. The DON said it appeared nobody was documenting when the tubing was being changed for Resident #4's oxygen therapy. The DON said she could see new orders starting on 04/11/24 possibly entered from LVN A who was interviewed earlier to change and document the oxygen tubing. In an interview on 04/11/24 at 12:50 PM with the Administrator she said it was her expectation that the oxygen tubing is stored in a plastic bag and that should be dated. She said a potential negative outcome to oxygen tubing on the flood is a risk for infection if the resident were to use it after. Record review of the Oxygen Administration policy last revised 02/2023 revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician order or facility protocol for oxygen administration. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of treatment. 5. The reason for PRN administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why the intervention was taken. 9. The signature and title of the person recording the data. Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safely for 1 of 1 kitchens reviewed for food storage and sanitation, in that: 1. The facility failed to ensure food and beverages in refrigerator unit #1 were covered, labeled, and dated. 2. The facility failed to ensure food in the dry food storage room were labeled and dated. These deficient practices could place residents at risk of foodborne illness. Findings included: An observation of the kitchen's refrigerator unit #1 on 01/24/24 at 10:16 a.m. revealed one 2/8 empty gallon of milk with no shelf and open date, one 7/8 empty gallon of milk without a cap and with no shelf and open date, one 6/8 empty gallon of milk with no shelf and open date, four full gallons of milk that were sealed and with no shelf date, one 1/2 empty quart of high calorie and protein nutritional drink with no shelf and open date, four sandwiches that were individually wrapped in plastic wrap with no shelf date, and eight cups of milk with each having a plastic cover and with no shelf date. All gallons of milk had a best by date of 01/25/24. An observation of the kitchen's dry food storage room on 01/24/24 at 10:16 a.m. revealed an open container of mashed potato granules that was covered with foil on top and with no shelf or open date. The mashed potato granules container had a best by date of 10/05/24. During an interview on 01/24/24 at 10:53 a.m., DA A revealed she worked at the facility for seven years. DA A also revealed she was trained on dietary services and in-serviced by the DM and nurses often. DA A did not know how often she was in-serviced. DA A revealed the DAs were responsible for labeling and dating food and beverages stored in the refrigerators and dry food storage room daily and as soon as the facility received new inventory. DA A also revealed the DM was responsible for verifying that food and beverages stored in the refrigerators and dry food storage room were labeled and dated daily and as soon as the facility received new inventory. DA A did not know who stored the food and beverages in Refrigerator unit #1 and the dry food storage room without a shelf and open date. DA A was not sure if residents' health could be at risk if they consumed food and beverages that were opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 11:17 a.m., DA B revealed he worked at the facility for six months. DA B also revealed he was trained on dietary services and in-serviced by the DM every two weeks. DA B revealed the DAs were responsible for labeling and dating food and beverages stored in the refrigerators and dry food storage room daily. DA B explained any open food or beverages were labeled and dated. DA B revealed the DM was responsible for verifying that food and beverages stored in the refrigerators and dry food storage room were labeled and dated. DA B did not know how often the DM verified that food and beverages were labeled and dated. DA B also did not know who stored food and beverages in Refrigerator unit #1 and the dry food storage room without a label and date. DA B explained he was responsible for restocking and labeling the gallons of milk in Refrigerator unit #1. DA B did not know who was responsible for labeling and dating the gallons of milk in Refrigerator unit #1. DA B explained DA A labeled and dated food and beverages in Refrigerator unit #1 and the dry food storage room. DA B revealed residents were at risk of becoming sick if they consumed milk from a gallon that was opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 2:54 p.m., DA C revealed she worked at the facility for six months. DA C also revealed she was trained on dietary services and in-serviced by the DM every two weeks. DA C revealed all kitchen staff, which comprised of DAs, cooks and the DM, were responsible for labeling and dating food and beverages whenever the facility received new inventory and whenever food or a beverage was opened. DA C also revealed the DM was responsible for verifying that food and beverages were labeled and dated. During an interview on 01/24/24 at 3:04 p.m., DA D revealed she worked at the facility for one year. DA D also revealed she was trained on dietary services and in-serviced by the DM every two months. DA D revealed the DAs were responsible for labeling and dating food and beverages whenever they were opened. DA D also revealed the DM was responsible for verifying that food and beverages were labeled and dated. DA D revealed residents' health could be at risk if they consumed food and beverages that were opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 3:30 p.m., the DM revealed she worked at the facility for one year. The DM also revealed the DON, ADM, and ADON trained and in-serviced her dietary staff on dietary services. The DM revealed the DAs were responsible for storing, sealing, labeling, and dating food and beverages. The DM explained the cooks were responsible for labeling and dating the opened and left over food from meal service. The DM further explained she was responsible for verifying food and beverages were labeled and dated when she started her work shift, after breakfast, after lunch, and after dinner meal service. The DM explained she visually checked the dry food storage room, refrigerators and freezers to make sure food and beverages were labeled and dated. The DM revealed residents' health could be negatively impacted if they consumed food and beverages that were opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 3:54 p.m., The DON revealed residents could become sick if they consumed food and beverages that were opened and not labeled with a shelf and open date. An attempt to interview Cook A was made on 01/24/24 at 4:21 p.m. by telephone. The surveyor left a voicemail and call back number. Record review of the Dietary Aide position description, undated, reflected the following job responsibilities: -Report missing/illegible labels to your supervisor Record review of the Cook position description, undated, reflected the following job responsibilities: -Report missing/illegible labels to the Director of Food Services. Record review of the Dietary Department Director position description, undated, reflected the following job responsibilities: -Directs and manages all facility dietary functions and personnel -Assures that proper storage is available, and that handling of food and supplies complies with federal guidelines Record review of the Dietary Department's daily cleaning schedule, from 01/10/24 through 01/24/24, reflected DA A and the DM signed off on verifying that food was labeled and dated daily. Record review of the facility's in-services given to dietary staff from October 2023 through January 2024 reflected no documented evidence the staff were not trained on food storage and labeling. Record review of the facility's food receiving and storage policy and procedure, dated October 2022, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). Such foods will be rotated using a 'first in - first out' system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. A. The facility failed to ensure the floors in the walk-in freezer and walk-in refrigerator was free of ice and water. B. The facility failed to properly store and label food in the facility's walk- in refrigerator and walk-in freezer. C. The facility failed to ensure Dietary Aide I and Dietary Cook J properly sanitized hands between tasks. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: A. Observation on 03/14/2023 between 9:05 AM - 9:30 AM revealed small chunks of ice and water on the floor in the walk-in refrigerator and the walk- in freezer. The floor was very slippery and was difficult to walk. There was a small thin layer of ice on the floor in the walk-in freezer and did could not see the ice until walked on the section of the floor where the ice was located. In an interview on 03/14/2023 at 9:10 AM the Dietary Manager stated one of her staff left the freezer slightly opened and there was ice around the door. She stated she had to knock off the ice to close the walk-in freezer door. She stated she checked all the food on 03/14/2023 in the freezer and the temperature of the freezer and there were no issues of any foods defrosted . She stated all foods were frozen and had not begun to defrost. She stated she checked everything in the freezer. She also stated it was an accident hazard with the water and ice on the floors in the walk-in refrigerator and walk-in freezer. She also stated someone had potential to fall and hurt themselves and she stated it was difficult to walk in the freezer and refrigerator. She stated she had the maintenance supervisor to look at the refrigerator and freezer to ensure it was in proper working order and he did not find any issues. B. Observation on 03/14/2023 of the walk-in refrigerator between 9:05 AM - 9:30 AM revealed a half box of uncooked sausage and three boxes of stacked carton of eggs stored on the wet floor. One half-opened transparent plastic bag with variety of cheese not labeled or dated. Observation on 03/14/2023 of the walk-in freezer between 9:05- 9:30 AM revealed a box of frozen bread stored on the floor. There were three damp packages of pie shells stored next to the fan. A slightly damp box of cookie dough stored next to pipes covered in duct tape. Observation on 03/14/2023 of the food prep table in the kitchen between 9:05 AM - 9:30 AM revealed a pan of approximately 15 individually cellophane leftover wrapped rolls not labeled or dated. An opened transparent plastic bag of leftover cereal not labeled or dated. An open transparent plastic bag of uncooked grits not labeled or dated. C. Observation on 03/14/2023 at 10:20 AM revealed Dietary Aide I removed her gloves after placing approximately ten trays of bowls of spice cake on the meal tray cart. She exited the kitchen area and entered the dry storage area. When she was walking to the dry storage area, her middle finger, fore finger, and ring finger touched her shirt, and she moved portion of her hair found under the hair net. She pulled parchment paper from the box in the dry storage area and returned to the kitchen. She began to place the parchment paper on top of the bowls of spice cakes found on the trays. Dietary Aide I's middle finger and ring finger on her right hand touched approximately ten spice cakes. Dietary Aide I did not sanitize or wash hands after she removed her gloves. In an interview on 03/14/2023 at 10:30 AM Dietary Aide I stated she did remove her gloves after she placed the trays with bowls of cake on the meal cart. She stated she did not wash or sanitize her hands after she removed her gloves. She stated she did touch her clothes and part of her hair. She also stated she did go into the dry storage area due to needed parchment paper to place over the trays of cake. She stated her fingers did touch some of the cake when she tried to place the paper over the cake. She stated there was a possibility with her touching the cake without washing or sanitizing her hands she may have contaminated the cake. She also stated she had been in serviced on hand sanitizing when in the kitchen. She stated she did not know what may happen if a resident ate contaminated food. She later stated a resident may become ill with a stomach virus. Observation on 03/14/2023 at 10:40 AM revealed Dietary Cook J was wearing gloves when she placed her right hand inside the oven mitt and touched the outside of the oven mitt. She touched her shirt and touched the oven door when she removed pureed food from the oven. She also touched the top drawer of a small plastic container located in the kitchen with office supplies and the thermometer stored in the top drawer. The top drawer had brownish substance on it and was not clean. Dietary Cook J did not remove her gloves during these tasks. She removed her gloves and began to sanitize the thermometer. Dietary Cook J opened the top of the garbage can with both hands and she began to take temperature of the pureed food on the steam table. She touched inside of the pureed meat container with her middle finger and ring finger on her right hand. Dietary Cook J did not wash or sanitize her hands or donned new gloves. In an interview on 03/14/2023 at 10:50 AM Dietary Cook J stated she did not wash or sanitize her hands when she removed her gloves. She stated she did not place new gloves on her hands when she was taking temperature of the pureed meat. She stated she was expected to wash or sanitize hands after she touched: the garbage can, the drawer in the small plastic organizer, inside of oven mitts, outside of oven mitts and her clothes. She stated it was a possibility she could contaminate the food from her unclean hands. She stated if she did have something on her hands and it was transferred to the food a resident may become ill and need to go to hospital with stomach problems. She stated she had been in serviced on kitchen hand hygiene. She also stated she was expected to sanitize hands after she removed her gloves and before placing new gloves on her hands. She stated if she was not wearing gloves, she was to sanitize hands immediately if her hands touched anything contaminated. In an interview on 03/15/2023 at 3:00 PM the Dietary Manager stated all staff was expected to wash their hands after removing their gloves. She stated there was an expectation of all dietary staff to wash their hands in between tasks. She also stated she was not sure when the oven mitts had been washed and they would be considered not sanitized. She also stated the small three drawer plastic container was dirty and the dietary cook was expected to wash her hands after she touched the plastic container, and the lid of the garbage can. She stated this was unacceptable. She also stated the staff had potential of cross contaminating the food served to the residents when they do not wash hands or wear gloves according to guidelines. She stated all foods were to be labeled and dated no matter where the foods were being stored. She also stated if foods were not labeled or dated it was difficult to determine when the left-over food was used. She stated a resident had potential of becoming very sick with stomach viruses and would require hospitalization . She stated it was serious when staff did not wash or sanitize their hands. In an interview on 03/15/2023 at 3:30 PM the Maintenance Supervisor stated he checked the refrigerator and freezer in the kitchen and there was nothing needed to be repaired. He stated the ice and water was from the door of the walk-in freezer was slightly left opened and caused ice to surround the door. He stated the water was from the ice melting. He stated the walk-in freezer and refrigerator was in good working order. In an interview on 03/16/2023 at 12:45 PM the Administrator stated all staff in the kitchen were to wash their hands after removing gloves, between tasks and after touching anything contaminated. She stated there was a potential of a resident becoming physically ill if the staff hands touched residents' food prior to serving the meals. She stated all left-over food, or any food was to be labeled and dated. She stated if residents ate undated left-over foods there was a possibility for the resident to become ill. She also stated the boxes of food was not to be stored on the floor anywhere in the kitchen including the walk-in refrigerator and freezer. She stated boxes or containers of food were not appropriate to store next to the fan or pipes in the refrigerator or freezer. She also stated the ice and water on the floors in the refrigerator and freezer was expected to be clean immediately to prevent someone from falling. She stated it was Dietary Manager's responsibility to monitor all aspects of the kitchen especially hand sanitation. The Administrator did not specify what type of illness a resident could obtain if they ate contaminated food. Review of Food Receiving and Storage Policy dated 10/2022 revealed foods shall be received and stored in manner that complies with safe food handling practices. Food Services, or other designated staff, will always maintain clean food storage areas. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Review of Refrigerators and Freezers Policy dated 10/2022 revealed this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will see food expiration guidelines. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of undated Handwashing Policy revealed food service personnel shall wash hands: 1. Whenever hands are obviously soiled. 2. After working with unclean equipment, work surfaces, clothing, wash cloths, etc. 3. Before preparing or handling food. 4. Before and after removing gloves (note: gloves can cause contamination. Gloves should be changed often). 5. Whenever in doubt. 6. Upon completion of duty.

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 9 residents reviewed for resident's rights. (Resident #72) The facility failed to ensure Resident #72 was provided the assistance she needed with her meal which resulted in Resident #72 eating her meal with her hands. This deficient practice placed residents at risk, who require assistance with activities of daily living, for psychosocial harm due to a diminished quality of life. Findings included: Review of Resident #72's Face Sheet dated 03/15/2023 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnosis: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (Hemiplegia and hemiparesis are related conditions that cause weakness or paralysis on one side of the body), Aphasia (A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.) and Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.) Review of Resident #72's Quarterly MDS dated [DATE] reflected Resident #72 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #72 was further assessed to require supervision with one-person physical assist with eating. Review of Resident #72's Comprehensive Care Plan reflected a focus area dated 02/09/2023 I have an ADL self-care performance deficit related to hemiplegia with contracture . Interventions included .assist with meals as needed. Set up meal tray, open beverages, cut foods, provide assistance as needed .Provide finger foods when the resident has difficulty using utensils . Further review of Resident #72's Care Plan reflected a focus are dated 02/09/2023 Dietary concern . interventions include provide adaptive equipment as recommended in self-feeding .Resident eats with hands, finger foods are provided as needed . Review of Resident #72's Consolidated Physician orders reflected a diet order dated 11/07/2022 Mechanical soft texture, thin consistency, divided plate with all meals. Observation and interview on 03/14/2023 at 12:15 PM revealed Resident #72 being fed lunch by LVN A. Resident #72 was observed to not have fluids with her lunch. LVN A stated resident was not on fluid restrictions but if they gave her fluids before she ate, she would not eat her meal. LVN A further stated that if Resident #72 was not assisted with her meals she would eat with her fingers. Observation on 03/15/2023 at 12:25 PM revealed Resident #72 in the locked unit dining room with her lunch. Resident #72 was provided mechanical soft food on a divided plate. Resident #72 was not being provided assistance with eating and was using her fingers and hands to eat her meal. Resident #72 was scooping large amounts of food into her hands and licking it off her fingers and palm. In an interview on 03/15/2023 at 12:45 PM CNA H stated they were short of help on the locked unit for feeding assist. She stated the ADON usually came down to assist but did not come down today. In an interview on 03/15/2023 at 1:00 PM the ADON stated she was not able to go assist with feeding on the locked unit since they were shorthanded in other areas of the facility, and she was passing medication. In an interview on 03/16/2023 at 9:41 AM LVN A stated the kitchen never sends Resident #72 finger foods. She stated that if you don't assist Resident #72, she will eat with her fingers. When LVN A was asked if they had enough staff to feed the residents, she stated they really had to hustle a lot and stated they are short often with feeding assistance. In an interview on 03/16/2023 at 11:24 AM the Administrator stated if a resident needs assist with feeding that staff should be available to assist the resident and the resident should not have to eat with their hands. In an interview on 03/16/2023 at 11:33 AM the DON stated the locked unit should have enough staff to ensure all residents are provided feeding assist. She stated the ADON should have gone down to the locked unit to assist with feeding. The DON stated it was a dignity issue to have residents eat with their hands. Review of the facility's policy Resident Rights dated 02/2021 reflected Employees shall treat all residents with kindness, respect, and dignity .These rights include the resident's right to: a dignified, existence .equal access to quality care .

Based on, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (Resident #1) of one resident reviewed for behavioral health services. -The facility did not assess Resident #1 after a change in behavior in which Resident #1 refused to leave her room and stopped attending activities after she reported being traumatized by isolation in another room for COVID-19. -The facility did not assess Resident #1 for mental health needs after Resident #1 exhibited signs of psychosocial harm from her experience in COVID-19 isolation as demonstrated by a significant change in her behavior following COVID-19 isolation This failure could place residents with adjustment difficulty and/or mental/psychological disorders at risk for not receiving appropriate care and interventions. Findings included: Record review of Resident #1's face sheet, dated 02/09/2022, revealed Resident #1 to be a [AGE] year old female admitted to the facility 09/11/2021 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS assessment, dated 12/15/2021, revealed Resident #1 to have BIMS of 15 to indicate intact cognitive response. Resident #1 had a 0 score for Mood Interview to indicate Resident #1 was not experiencing symptoms of a mood disorder and had a 0 score for behavioral symptoms including wandering, aggressiveness, delusions, hallucinations or other disruptive behavioral symptoms. Resident #1 was independent for activities of daily living and required supervision only for walking in her room and corridor. Resident #1 was fully continent, ambulatory with a medical device and required no assistance with eating. Record review of Resident #1's Care Plan, dated 11/22/2021, revealed Resident #1 is independent for meeting emotional, intellectual, physical, and social needs; with a goal of, The resident will attend/participate in activities of choice five times a week by next review date. Interventions included the activity calendar would be posted in the residents' room; inviting the resident to scheduled activities; the resident would be invited to participate daily; thanking the resident for attendance at activity functions and the resident preferred the following TV channels: catholic church. The care plan further revealed, The resident has a behavior problem. She tends to be bossy and attempt to instruct residents on what to do. She 'preaches' to them telling them they must pray. She also interferes in other resident's care; and had a goal of, the resident will have no evidence of bossy behavior or interfering patterns by review date. Interventions for this area included: If reasonable, discuss the resident's behavior, explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed and provide a program of activities that is of interest and accommodates resident's status. In an interview on 02/09/2022 at 9:34 AM, RP A stated she was the medical power of attorney for Resident #1. She stated Resident #1 called her on 01/10/2022 while in isolation after testing positive for COVID-19 and was very upset. She stated Resident #1 was moved to different room and her clothes and personal items were not moved with her. She stated Resident #1 reported to her on 01/10/2022 that she did not have clean clothes, underwear, deodorant, and a toothbrush for the first four days of isolation. She stated Resident #1 did not have her notebooks that she liked to write in or her Bible. She stated Resident #1 did not like to watch TV but enjoyed writing and keeping a journal. She stated she called the facility and had to complain to the staff so Resident #1 would be brought her personal items. She stated Resident #1 then called her upset about not having toilet paper and the bathroom sink not working in her room. She stated she called the SW on 01/11/2022 and then they added Resident #1 to the phone call. She said during the phone call the SW yelled at her stating Resident #1 was a chronic liar and mentally ill. She stated Resident #1 became even more upset about the SW's attitude and they ended the phone call. She stated she spoke with Resident #1 later and Resident #1 was extremely upset. She stated she spoke with the ADMIN on 01/11/2022 and the ADMIN was able to have the items Resident #1 requested delivered to her room. She stated Resident #1 continued to be upset throughout the rest of the isolation period and then returned to her regular room on 01/18/2022. She stated Resident #1 now refused to leave her room at all and attends no activities. She stated before the negative experience in isolation, Resident #1 was very social and attended multiple activities every week. She stated Resident #1 would walk the hallways and exercise and now did not step outside her room. She stated Resident #1 feared catching COVID-19 again and having to be isolated. She stated Resident #1 was not afraid of COVID-19 as she only had mild symptoms but was afraid of having to be isolated again away from her familiar environment and personal belongings. She stated Resident #1 told her the SW was creepy and would have nothing more to do with him. She stated they attempted to have Resident #1 transferred to another facility, but Resident #1 was declined because of it being reported she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 02/09/2022 at 10:20 AM, Resident #1 stated she did not leave her room at all. She stated she ate all her meals in her room and did not attend activities anymore. She stated she did not want to catch COVID-19 again and have to be isolated. She stated being in isolation was a horrible experience and if the facility were to try to test her again, she would refuse so that there was no chance she could be forced to be put into isolation. She stated after she tested positive, the DON made her move to the isolation room. She stated she did not have sheets and a blanket on her bed until 10:30 PM that night. She stated she did not receive clean clothes and underwear until day six in isolation. She stated she and her roommate had to sleep in the same clothes they were wearing when they moved into the isolation room. She stated she had to beg them to bring her Bible and her writing notebooks. She said in the bathroom in the isolation room, there was a plumbing part and wiring pieces. She stated the faucet to the sink was not working and would spray all over the bathroom and floor when they would use it. She stated the facility fixed the faucet on day six. She stated she felt like a prisoner in a third world country. She said she felt very depressed during isolation and never wanted to return. She stated she had a three-way phone call with RP A and SW. She said the SW would only speak to RP A and then began yelling at RP A. She said the SW called her a liar and mentally ill on the phone call. She said she thought the SW was creepy and scary and she no longer wanted to speak with him regarding any matters. She said she wanted to move to a different facility, but RP A told her the other facility said no because she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she watched Mass on her tablet on Sundays and would ask other residents if they would like to watch with her. She stated she had asked if other residents would like to pray with her and if they said no, she would stop. She stated since isolation, she did not have any contact with other residents except her roommate. She stated the Activity Director tried to get her to attend some activities and she told her no. She stated she used to attend almost all of the activities and would help other residents if needed, but since isolation she had not attended any activities. She stated she was a coach and physical education teacher before she retired, and she used to walk the hallways for exercise. She stated it was 165 steps from the end of her hallway to the end of the opposite hallway and she would walk it several times per day to stay fit. She stated she no longer walked the hallway and she tried to do some exercise independently in her room. She said no one from the facility has been in to talk with about her change in routine and that she did not leave her room anymore. In an interview on 02/09/2022 at 10:55 AM, LVN B stated Resident #1 did not leave her room anymore. She stated they used to have to redirect her because she would be in other residents' rooms or trying to assist with caring for a resident, but now Resident #1 stayed to herself. She stated Resident #1 did not want to catch COVID-19 again and that was why she was self-isolating. She stated she did not assess her and was not aware of other staff members assessing Resident #1 for this change in behavior. She stated she thought since it was the resident's choice to self-isolate due to COVID-19, it was not concerning and did not require an assessment. She stated this was a big change in Resident #1's behavior compared to what her behavior was prior to COVID-19 isolation. She said Resident #1 was social with other residents and at activities and was no longer out and about in the facility. She said Resident #1 no longer attended activities or socialized with other residents. In an interview on 02/09/2022 at 11:15 AM, CNA C stated she cared for Resident #1 prior to COVID-19 isolation, during COVID-19 isolation and after COVID-19 isolation. She stated Resident #1 was almost never in her room prior to COVID-19 isolation and would be up talking to other residents and notifying them of other residents' needs. She stated staff would have to re-direct her frequently to not interfere with other residents care and to not go into other residents rooms. She stated Resident #1 was easily redirected and did not become upset or agitated when redirected. She stated Resident #1 was independent and did not require assistance with ADL's. She stated Resident #1 seemed bored prior to isolation because Resident #1 was always looking for something to do. She stated Resident #1 was upset in COVID-19 isolation because she wanted her belongings brought to the new room. She stated they tried to explain that they could not bring all of her belongings because they would have to be disinfected before returning to her normal room. She stated every day while Resident #1 was in isolation she would have a new list of things she wanted from her room and they would do their best to get it to her. She stated the staff member caring for COVID-19 positive residents would not go in other parts of the facility so another staff member would go get the items and leave the items at the doors to the COVID-19 unit. She stated Resident #1 would become agitated when her belongings were not brought immediately. She stated since Resident #1 returned to her normal room, she did not leave her room for activities or meals. She stated Resident #1 told her it was because she was afraid of catching COVID-19 and having to return to the isolation room. She stated that was a big change in Resident #1's behavior compared with how social she was prior to COVID-19 isolation. In an interview on 02/09/2022 at 1:31 PM, the SW stated he had not spoken with Resident #1 since she moved back to her normal room from COVID-19 isolation on 01/18/2022. He stated Resident #1 had many complaints while in COVID-19 isolation and he had a phone call with RP A and Resident #1 on 01/11/2022. He stated RP A was reporting concerns about Resident #1's care and lack of supplies while in COVID-19 isolation. He stated he was trying to tell RP A that Resident #1 had everything she needed and that possibly Resident #1 was not being truthful and asked RP A if she considered whether Resident #1 could be lying. He stated prior to COVID-19 isolation, Resident #1 was bored and constantly wandering the facility. He stated Resident #1 would complain about everything including a battery being out in the clock in the dining room. He stated now Resident #1 remained in her room because Resident #1 was afraid of COVID-19. He stated Resident #1 did not seem to have a pleasant experience in COVID-19 isolation and did not want to return. He stated her roommate in COVID-19 isolation complained about how much Resident #1 complained while they were together. He stated he had not completed a psychosocial assessment or any other assessment regarding Resident #1's mental health since the COVID-19 isolation period. He stated he had avoided speaking with Resident #1 since the phone call with RP A and Resident #1, when Resident #1 was in COVID-19 isolation. He stated he felt they were both avoiding each other since the phone call. He denied yelling at Resident #1 and RP A on the phone call. He stated he was not aware of any other staff assessing Resident #1's change in behavior following isolation for COVID-19. In an interview on 02/09/2022 at 1:49 PM, the ADMIN stated Resident #1 did not leave her room since COVID-19 isolation and thought it was because Resident #1 was afraid of COVID-19. She stated she was not aware of Resident #1 being assessed for a change in behavior. She stated Resident #1 was self-isolating per her choice and they were not concerned. She stated Resident #1 did have many complaints while in COVID-19 isolation that they attempted to solve as much as possible until Resident #1 returned to her normal room. She stated she was not aware of the phone call in which the SW allegedly called Resident #1 a liar and mentally ill. She stated a complaint was not made to her regarding the phone call by Resident #1 or RP A. She stated she was not aware the SW was avoiding contact with Resident #1. She stated she knew RP A had them send records to another facility but was not told Resident #1 was declined. She stated she thought Resident #1 decided to stay with them. She said Resident #1 had not exhibited elopement or exit seeking behaviors while at their facility. She said Resident #1 was admitted to the facility because of a wandering behavior while living with RP A. She stated Resident #1 was originally on the locked unit, but Resident #1 needed more interaction with more cognitively intact residents so they moved her off the locked unit. She stated Resident #1 had not attempted to leave the facility but would frequently wander the hallways. She stated they had to re-direct her from other residents' rooms or when she attempted to care for other residents. She stated Resident #1 was easily redirected without issue. She stated they did not have a facility policy regarding psychosocial assessment following a major change in behavior or psychosocial effect of a change on a resident. In an interview on 02/09/2022 at 2:31 PM, the ACT DIR stated Resident #1 would come to all of the activities prior to her isolation for COVID-19. She stated she considered Resident #1 to be like an assistant because Resident #1 would help her with setting up activities, helping other residents and cleaning up. She said Resident #1 was not bothersome and did not seem to annoy other residents when she helped them, for example with their bingo card. She said she had not received any complaints from other residents regarding Resident #1. She said she tried to persuade Resident #1 to start coming to activities again since COVID-19 isolation and Resident #1 refused to attend activities. She stated Resident #1 used to come out and play guitar for the other residents but did not do that anymore. She said Resident #1 did not come to activities anymore because Resident #1 was afraid of COVID-19. Record review of Resident #1 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's nursing progress notes, dated 01/07/2022 at 12:58 PM, revealed Routine Covid testing provided, resident results were POSITIVE. At this time resident remains alert no distress/discomfort noted. Resident transferred with belonging and meds. Record review of Resident #1's nursing progress note, dated 01/08/2022 at 4:30 AM, revealed COVID Swab sample Positive on 1-7-2022 using Abbott Covid Card Collection system. Resident moved to hot zone. Record review of Resident #1's nursing progress note, dated 01/08/2022, revealed, Resident remains on quarantine for positive covid test .alert and oriented, calm, cooperative with no complaints of pain or discomfort at this time Record review of Resident #1's nursing progress notes, dated 01/11/2022, revealed, Resident has been on cell phone all day talking to family. Multiple lists have been sent out of things resident requesting. Resident claimed she has not been receiving her medications. Admin aware. Will continue to monitor. There were no additional progress notes in the period reviewed of 01/01/2022 - 02/09/2022 regarding Resident #1 not leaving her room or not attending activities since Resident #1 returned from COVID-19 isolation on 01/18/2022. In an interview on 02/09/2022 at 3:11 PM, LVN D stated she is the MDS Nurse and there was not a significant change assessment completed on Resident #1. She stated Resident #1 was choosing to self-isolate and there was not a change in more than one care area. She stated Resident#1 stopped coming out of her room by choice. She did not think this should have been assessed for mood issues such as depression related to isolation or severe anxiety over COVID-19. She said there was not an assessment completed for psychosocial effect of COVID-19 isolation on Resident #1. She stated no other residents were having issues after isolation. In a follow-up interview on 02/09/2022 at 4:00 PM, the ADMIN stated Resident #1 should have been assessed for psychosocial emotional effect of COVID-19 and a significant change assessment was initiated today, 02/09/2022 by the MDS Nurse, LVN D. Record review of RAI assessment tool, dated October 2019, revealed a significant change assessment will be completed when a resident has a significant change as defined by A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.

Based on observations, interview, record review, and review of the facility's policy, the facility failed to have safeguards in place to ensure residents' medications were not misappropriated for one of one sampled resident reviewed for misappropriation of property (Resident (R) 16). The facility employed the Assistant Director of Nursing (ADON) even after becoming aware that the ADON could not have access or administer any narcotic mediations per the Texas Peer Assistance Program for Nurses (TPAPN). The facility failed to ensure the nurse did not have access to R16's narcotic medications. This failure to prevent potential misappropriation of medications has the potential for R16 and other residents in the facility to be at risk for not having their prescribed medication available to manage or respond to the symptoms for which the controlled medication was ordered. The facility's failures had the potential to affect all residents who were ordered narcotic medications. This put all residents who were ordered narcotic medications at risk for serious harm. On 03/16/21, the facility's ADON misappropriated three vials of R16's physician ordered narcotic medication of [MEDICATION(S)] (an antianxiety medication used to treat [CONDITION(S)] type activity). After the misappropriation, the facility failed to prevent other possible misappropriation of resident medication. LVN 2 notified the former Director of Nursing (DON) of the incident. Additionally, a narcotic count of R17's medications on 05/27/21, revealed two different medications did not reconcile ([MEDICATION(S)] concentrate and [MEDICATION(S)]) and the facility could not explain or account for the deficits. R17's Controlled Drug Record for the [MEDICATION(S)] revealed the resident should have had 12.5 Milliliters (ML) left in the container; however, the Director of Nursing (DON) confirmed the bottled only contained 12.0 ML. R17's Controlled Drug Record for the [MEDICATION(S)] revealed the resident should have had 29.50 ML left; however, the DON confirmed the bottle only contained 28.75 ML. Interview with the DON revealed she could not explain the discrepancies in the Controlled Drug Records and the medication on hand. Even though the facility's abuse policy indicated the facility would respond by Quality Assurance/Improvement Committee analyzing what changes may to the facility's procedures may be needed, the facility failed to effectively ensure this was completed. Also, review of the facility's investigation completed by the Administrator and former DON revealed facility failed to identify and report that R16's medication had been misappropriated to the State Agency (SA). The facility reported to the SA that no residents were involved. The Administrator stated that the [MEDICATION(S)] was taken from the Emergency Drug Kit (EDK); however, LVN 2 reported the medications were R16's. It was determined the Immediate Jeopardy began on 02/10/21 when the facility became aware of the ADON's restrictions of being able to have access to narcotics. Even though the facility had become aware of the risk this placed on the facility's vulnerable population, the facility failed to educate other nursing staff to ensure access to the resident's narcotic medications was not given to the ADON. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation on 05/27/21. On 05/27/21 at 9:30 PM, the facility's Administrator was notified and issued an Immediate Jeopardy at F602, Free from Misappropriation/Exploitation. The removal plan for the Immediate Jeopardy was validated on 05/29/21 through interviews and record reviews. Review of the facility's policy revealed the policy was updated to include misappropriation of medication. Record reviews and interviews revealed all facility licensed nurses and certified medication aides had been in-serviced on nurses who were on TPAPN restrictions, not giving narcotic keys to anyone, and misappropriation of resident medications. The facility was notified that the Immediate Jeopardy was removed on 05/29/21 at 11:40 AM. After the immediacy was removed, the noncompliance remained at a lower scope and severity level of no actual harm, with a potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Review of the facility's abuse prohibition policy, reviewed 10/08/20, revealed Intent: This protocol was intended to assist in prevention of abuse, neglect, and misappropriation of property .1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected .misappropriation of property .3. The facility will designate a qualified staff member to oversee the abuse prohibition program .Definitions: Abuse means the willful infliction of injury, withholding or misappropriating property or money .Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 2. The Abuse Coordinator will report such allegations to the state agency in accordance with state law. 5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. 6. Procedure for the investigation will include, but is not limited to the following: Notification to the attending physician and family .Identification of the person alleged to have been abuse and type of alleged abuse .measures to prevent repeat incidents .Reporting/Response: .4. The facility Quality Assurance/Improvement committee will analyze all occurrences to determine what change or changes are needed, if any, to the facility's policy and procedures to prevent further occurrences . Review of Intake completed by the SA revealed .Contacted the reporter [facility] at 10:16 AM on 03/17/21 to obtain additional information .No Residents involved . Review of the facility's investigation revealed the investigation contained a document titled, Provider Investigation Report, dated 03/24/21 and signed by the facility's administrator. Review of the report revealed for the description of the allegation, the administrator documented DON called in reference to missing [MEDICATION(S)] and RN [former ADON's name] acting abnormal, with slurred speech and staggering. Continued review of the report revealed for the incident category drug diversion was selected; however, abuse and/or exploitation was not selected which indicated the Administrator failed to identify and/or report the actual allegation of misappropriation of resident medications. Further review of report revealed the Administrator determined the investigative findings as Inconclusive. Continued review of the facility's investigation by the Administrator did not reference the [MEDICATION(S)] medication belonging to R16 including the prescription label information. Review of the facility's investigation also revealed a total of only three staff members' statements related to the incident and did not contain any documented evidence of any audits that were completed, review of any medications the former ADON may have completed during her normal shift, and no documented evidence the former ADON was interviewed or requested to write a statement. Review of the facility's undated Quality Assurance Improvement Plan, revealed Area of Concern: Drug Diversion .Problem: Concerns about Showers. Immediate solution: 1. Nurse Suspended Immediately. 2. Police notified. 3. Pharmacy notified. 5. MD [medical director] notified. 6. Narcotics Audit completed immediately and reconciled. 7. In-serviced all staff immediately .Target Completion Date 03/16/21. Follow Up Daily. Long Term Solution: Complete education with for all nurse employees on drug counts .Target Completion Date on going. DON to perform counts in tandem twice daily times 1 week .Random drug audits by DON to ensure education is satisfactory times 1 month and ongoing as needed .Interdisciplinary Process. Facility Admin [Administrator] to follow corporate process and report and discrepancies to QAPI . Review of R16's undated Admission Record, located in the resident's electronic medical record (EMR) under the profile tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R16's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R16's Controlled Drug Record, dated 01/11/21, provided by the DON, revealed the facility received 15 vials of [MEDICATION(S)] ([MEDICATION(S)]) 2MG/ML, for R16 on 01/11/21. Continued review of the Controlled Drug Record revealed on 03/16/21, the former DON documented Correct Count 12 . Review of the facility's untitled and undated document completed by the facility's former DON located in the facility's investigation revealed On March 16, 2021, around 10:30 PM, I received a call from facility charge nurse [ Licensed Vocational Nurse (LVN)2] regarding the Assistant Director of Nursing, [ADON's name] absurd behavior. She [LVN2] further said that she was having slurred speech, difficulty in walking. Charge Nurse [LVN2] and Certified Medication [Aide] [CMA3] noted blood stain on her hands. CMA and nurse found blood stain on the paper towels in the can in the female restroom and a needle cap on the paper towel holder .The charge nurse reported that 3 vials of [MEDICATION(S)] were empty .Upon arriving in the facility, I observe [ADON's name] standing by the nurse's station with sleepy looking eyes .The charge nurse showed me the 3 vials of [MEDICATION(S)] that were opened and nothing in it. 2 vials the top had a tape and blue caps were not intact. 1 vial was open, empty with no blue cap on it. These vials were handed to the female police officer .Restraining order placed . Interview on 05/27/21 at 11:58 AM with LVN2 revealed the evening of the incident the ADON (who was her supervisor) came up to her during the 2:00 PM to 10:00 PM shift and told her that she needed the narcotic keys to check expiration dates. LVN2 stated she gave the medication room keys to the ADON and finished completing her task. Continued interview revealed as she was walking back to the nurses' station, the ADON was coming out of the medication room (where the refrigerated narcotics are kept) and the ADON handed her the keys back. LVN2 stated later on while she was completing medication pass, the ADON came and started talking to her about covering her (the LVN's) shifts while she was on vacation. The LVN stated the ADON left the hall and then returned a short time later and started repeating the same conversation except for this time, her speech was slurred, and she had blood on her hand. The ADON again left the hall. The LVN stated when she finished her medication pass, she walked past the ADON's office and seen her slumped over her desk and thought she was asleep. The LVN stated CMA3 came out of the restroom and reported that there was blood in the restroom. The LVN stated she approached the ADON and asked it was her blood. The ADON stated to the LVN, No, I usually do mine over the sink. The LVN stated to the ADON you say that like its normal. The LVN stated at that time, she took CMA3 with her to the medication room where she discovered three empty vials of [MEDICATION(S)] that was prescribed to R16. The LVN stated she called the former DON and reported this. The former DON told her the ADON was not to have the narcotic keys and to call the Administrator which she did. The LVN stated it did not take the administrator long to get to the facility and the administrator took over from there. Interview on 05/27/21 at 1:42 PM with the former DON revealed she was called by LVN2 on the evening of 05/16/21 who reported how the former ADON was acting and that there were the empty vials of [MEDICATION(S)] in the refrigerator. The former DON informed LVN2 to contact the Administrator and that she was on her way. The former DON stated when she arrived at the facility, she seen that there were three empty vials of [MEDICATION(S)] that belonged to R16. The former DON stated the police officer asked her to come with her to gather evidence which were a 10-cc syringe wrapping, alcohol pads, and the empty vials. The former DON stated she corrected R16's narcotic count sheet to reflect the three diverted vials and then completed a narcotic count for all medication carts in the facility. The former DON stated she did this the next day and week also but did not document this, she just went behind the nurses after they counted. The former DON stated she contacted R16's family and informed them that the resident's injectable [MEDICATION(S)] had been discontinued; however, she did not notify the resident's family that the resident's medication had been misappropriated. Follow-up interview with the former DON on 05/27/21 at 2:57 PM revealed the former ADON was to have a chaperone during her shift. The former DON revealed the former ADON was only allowed to access medication of narcotics with a chaperone present. The former DON stated the former ADON could still carry medication cart keys and narcotic keys, she just could not pull them or administer them. The former DON stated other facility nurses were aware that she had to have another nurse to give narcotic medications; however, she verbally told the nurses and there was no documentation that this occurred. The former DON found out of the former ADON's restriction during the former ADON's orientation, and this was not disclosed by the former ADON during the interview process. Follow-up interview with LVN2 on 05/27/21 at 5:05 PM, revealed she had never been educated that the ADON could not administer narcotics. The LVN also stated had she known this, she would never have given her the keys to the narcotic medications. LVN2 stated that the former ADON had left and then returned to the building. LVN2 stated when she asked the former ADON why she was back, the ADON told her that she went to get something to eat, and she had to come back to do some work. Review of the facility provided employee list revealed the ADON's hire date was 02/10/21. Review of the ADON's personnel file revealed a document titled Texas Peer Assistance Program for Nurses [TPAPN], dated 02/10/21. The document revealed .To Whom It May Concern, I am writing regarding the above TPAPN participant [ADON's name] signed her TPAPN Participation Agreement on 04/29/20 and has projected discharge date of [DATE]. Thus far, she has demonstrated compliance with all aspects of her monitoring and presents with positive attitude regarding recovery and safe nursing practice .Practice Restrictions. Practice restrictions are put in place to help ensure safe nursing practice. As part of her agreement, [ADON's name] has agreed NOT TO: 1. Access, administer, count, or waste any controlled substances .Prior to employment, please contact the case manager below to confirm monitoring requirements and restrictions . Review of the former ADON's Authorization and Release to conduct background investigations, revealed the form was completed by the former ADON on 04/09/20. The form revealed Have you ever been sanctioned, disciplined, debarred and/or excluded by a duly authorized regulatory agency or are there current restrictions or limits on your license(s) or certification(s)? This was answered No. Continued review of the form revealed the former DON dated the form 02/04/21. The form was electronically completed and electronically signed by the former ADON on 04/09/20 at 16:19:05, which indicated the ADON was not required to complete an updated form prior to her hire. Interview on 05/27/21 at 2:30 PM with the Co-Medical Director revealed he was not aware of the former ADON's restriction until after the incident. The Co-Medical Director stated he would prefer that nurses that were hired have a clean slate meaning no restrictions. Continued interview with the Co-Medical Director revealed it was his expectation the facility would have maybe completed an audit of controlled substances every so often after the drug diversion incident. Interview on 05/27/21 at 2:40 PM with the facility's Pharmacy Consultant revealed the facility's former DON notified her that there was possible drug diversion. Continued interview revealed the Pharmacy Consultant asked the facility if they wanted her to come and complete an audit or an investigation; however, the former DON stated she did not need to because the police had already been notified. The Pharmacy Consultant stated normally after drug diversion, she would go to a facility and complete and audit/investigation. Interview on 05/27/21 at 3:22 PM with the current DON revealed no audits of narcotics were currently being completed regularly. Interview on 05/27/21 at 3:37 PM with the local Police Department when a copy of the police report was requested, revealed it had already been sent to the District Attorney's office and a copy could not be released now. Interview on 05/27/21 at 5:54 PM with the Administrator revealed she was unsure of when she became aware that the former ADON had restrictions. The Administrator also stated to her understanding the former ADON was to have another nurse on duty the same time as her and could not access and administer narcotics. The Administrator stated the facility was not aware of the restrictions until after she [ former ADON] was hired. The Administrator further stated after the former DON spoke with the TPAPN case manager it was decided to allow the former ADON to work because the case manager informed the former DON, she [case manager] could modify whatever was needed for the former ADON to remain employed. The Administrator stated she [administrator] was the Abuse Coordinator. The Administrator stated this investigation was a team effort, but she allowed the former DON to spearhead the investigation. The Administrator stated that she felt like this was a thorough investigation. The Administrator stated the facility's determination of the investigation was inconclusive because the former ADON did not admit to taking the medication and no one ever saw her take the mediation. The Administrator stated the medication [[MEDICATION(S)]] that was on hand, had never been used by the resident. The Administrator confirmed the [MEDICATION(S)] was prescribed to R16; however, the resident had never received the medication. When asked if misappropriation of R16's mediation occurred, the administrator reported drug diversion occurred and would not answer specifically if this was misappropriation. The Administrator stated that when she reported to the State Agency that no residents were involved, she thinks she was meaning no resident was administered any medications. After reviewing the former ADON's background authorization form, specifically regarding question about restrictions, the Administrator stated the former ADON should have marked yes. When asked if a more current form should have been completed, she stated she did not know how the facility's system pulls the form up. The Administrator stated it would have been her expectation the former DON would have educated the staff about the former ADON not having access to narcotics. The Administrator stated she was not aware of any audits of narcotic medication counts that have been completed since the incident. The Administrator stated if the pharmacy consultant offered to come to the facility to complete an audit and investigation, it was her expectation the former DON would have approved and said yes. The Administrator stated in regard to the deficits of the current liquid narcotic medications, that it was like only 0.50 and a little bit. When asked what safeguards had been put in place since the 03/16/21 incident, the Administrator stated there had been in-services completed. When asked if it was possible for a resident's medication to be misappropriated, she stated yes.

Based on interview, record reviews, review of the facility's investigations, and review of the facility's policy, the facility failed to ensure all residents were free from abuse for two of six sampled residents reviewed for abuse and neglect (Resident (R) 4 and R10). R4 sustained actual harm of a fractured rib after the resident was physically abused by R9. Additionally, R10 was victim to verbal and emotional abuse from a facility employee. Findings include: Review of the facility's policy titled, Abuse Prohibition Policy, revised 10/08/20 revealed .This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment .1. The facility will prohibit .abuse .Abuse means the willful infliction of injury .with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, kicking, shoving, pinching .Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation .Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents .Abuse Prohibition Program: .The facility will attempt to screen for potentially abusive residents via the admission process .Prevention: 5. Residents identified as exhibiting abusive behaviors will be reviewed and have their treatment plans modified as appropriate .4. Protection: .4. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. Resident to Resident Incidents: .6. The interdisciplinary team will make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following: Immediate discharge from the facility due to potential for harm to other residents. Can the behavior be controlled by location monitoring? Need for referral to a psychologist/psychiatrist .11. The victim will be seen by Social Services to determine further psychological support needed as well as follow up with physician/family . Review of the facility's policy titled Resident Rights, revised December 2016, revealed .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .c. be free from abuse, neglect, misappropriation of property, and exploitation . 1. Review of R9's Admission Record, located in the resident's closed Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R9's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/25/20, located in the resident's closed EMR revealed the facility assessed the resident to be independent with all ADLs, to have no balance concerns during transitions and walking, to have no functional limitations in Range of Motion, and required no mobility devises. Continued review of the MDS revealed a BIMS should have been conducted; however, this was not completed for the resident. Review of R9's Brief Interview for Mental Status (BIMS) assessment, dated 03/26/20, located in the resident's closed EMR under the evaluations tab revealed the facility assessed the resident to have a BIMS score of six out of 15 which indicated the resident was severely cognitively impaired. Review of R9's Progress Notes, located in the resident's closed EMR under the progress notes tab revealed nursing note, dated 03/30/20, revealed, Resident with aggressive behaviors, drawing back fist threatening to hit Certified Nurse Aide (CNA) .I addressed his behavior, and he drew back with fist . Review of R9's untitled Physician's Progress Notes, dated 04/09/20, located in the resident's closed EMR under the miscellaneous tab, revealed .Staff reports increased behaviors, combativeness, and elopement attempts . Review of R9's Comprehensive Care Plan located in the resident's closed EMR under the care plan tab revealed a focus initiated on 10/04/19 of The resident has a behavior problem. The resident is combative towards staff. Review of R4's Admission Record, located in the resident's EMR revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's quarterly MDS with an ARD of 03/14/20 revealed the resident was assessed to be independent with all ADLs, to have no balance concerns during transitions and walking, to have no functional limitations in Range of Motion, and required no mobility devices. The facility assessed the resident to not have had any falls preadmission or postadmission. The facility assessed the resident to have not exhibited any behaviors towards others or not towards others; however, the resident was assessed to exhibit wandering behaviors. Continued review revealed the facility assessed the resident to have a BIMS score of three out of 15 which indicated severe cognitive impairment. Review of R4's radiology report titled, Patient Report, dated 04/27/20, revealed .Impressions: Indication: Trauma. Left rib series 3 views. Findings: There are findings compatible with a mildly displace acute fracture involving the left lateral ninth rib . Review of the State Agency form titled, Provider Investigation Report, dated 04/27/20, completed by the Administrator revealed, .Incident Category .Abuse [selected] .Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s) [R4's name] .interviewable [selected] .[R9's name] .interviewable [selected] .Description of the Allegation. [R4's name] reported to [Licensed Vocational Nurse (LVN) 1's name] that day before yesterday, [R9's name] had hit him several times and that he had lost his balance and fallen. Resident complained of a possible broken rib. Injury/Adverse effect? Yes [selected]. Description of Injury. Small quarter size blueish discoloration to left posterior flank and mildly displaced acute fracture involving the left lateral ninth rib .Provider Response. [R9's name] was immediately placed on 1:1 supervision .Provider Action Taken Post-Investigation. [R9's name] was discharged home with the family at family request .signed by the administrator. Review of LVN1's handwritten statement, dated 04/27/20, located in the facility's investigation, revealed R4 approached the nurse and complained of pain to his left side and verbalized that he though he may have had a broken rib. Continued review of the statement revealed .Bruise noted to left side. He continued to explain to me that the resident that wears plaid had punched him a couple to [sic] times day before yesterday. Accused resident eats occasionally at table c? [with] [R4's name] . Review of R4's undated statement, located in the facility's investigation revealed On Saturday at lunch time but before the food was in dining room, I was sitting at table and they guy that walks around all the time c? [with] plaid pants came up to table. He started saying stuff to me and after that he started hitting me. [Asked, where did he hit you?] In the chest. I got up and hit back at him. He kept hitting me and I fell . I hit the table with my head when I fell . [Asked, how were you laying on the floor?] With my face down. [Asked, did he keep hitting you?] Yes in the head. Then he disappeared after that and nobody acknowledged any of it. [Asked, how did you get off the floor?] He helped me up. [stated to resident: So after he hit you he helped you up?] I fell and couldn't get up. No he didn't help me get up. He turned me so I could sit there and was able to get up. [Asked: So how did you get off floor?] I just got up. I had to sit awhile because I was hurt. I thought it was ok but it keeps hurting. [Asked: Where do you hurt?] here (pointed to lower left abdominal quadrant.) Here (he pointed to left side of forehead). Here (pointed back to lower left abdominal quadrant); but stated that my ribs are broke, they hurt. It hurts so bad when I stand my neck hurts. [Asked: Did you tell anyone?] Told woman that brought medicine I was hurting. Told someone who brought food didn't know if I could eat because I hurt . Review of R9's undated statement, located in the facility's investigation revealed [Asked: Did you get into a scuffle with [R4's name]?] He said I may have broken a rib. [Asked: When did this happen?] Thursday or Friday. [Asked: Where were yall [sic] at?] Were [sic] he always sits at for meals. [Asked: When was this?] We were fixing to eat lunch. [Asked: Were there anyone else around?] Everybody was sitting around tables. [Asked: Was there any staff around?] No. [Asked: What happened?] We just didn't get along at time [sic]. I really don't know. [Asked: What made you hit him?] He [R4] said don't put your hands on me. I hit him a couple times in his should [sic], chest, (pointed to left side). He might have pushed me first. [Asked: did he fall?] Yes. [Asked: How did [sic] get back up?] He got up by his self. [Asked: anything else happen?] No I just walked over here (point to door to dining room) went to my room. Review of the Administrator's untitled investigation summary, dated 05/04/20, revealed On Monday 04/27/20, [R4's name] approached [LVN1's name] and complained of pain to the left side. He verbalized that he believes that he may have a broken rib. Resident did present with a small quarter size blueish discoloration to the left posterior flank [between the ribs and the hip]. Resident went on to say that the resident that wears plaid pants had hit him a couple of times two days ago and that he had fallen. [R4's name] reported to [former ADON's name] that the other resident had walked up to him in the dining room and started saying stuff to him and hit him. When asked where was he hit, the resident reported in the chest. Resident reported he got back up and hit back. He then reported that the other resident hit him again and he fell .When [R9's name] was questioned about the incident, and if he had gotten into a scuffle, resident reported yes I did. [R9's name] reported that the two just didn't get along at the time and he really don't know what happened. He reported that he hit him in his shoulder, chest, and pointed to his left side . [R9's name] did report that [R4's name] had fallen . [R4's name] was ordered x-rays .x-rays did reveal a mildly displaced acute fracture involving the left lateral ninth rib . Review of R9's nursing Progress Notes, dated 04/27/20, located in the resident's EMR under the progress notes tab, revealed [Attending Physician (AP) 2's name] on unit. Discharge discussed. Resident may discharge home with son. Continued review of nursing progress notes dated 04/27/20, revealed Resident daughter in law at facility for discharge . Review of R9's nursing Progress Notes, dated 04/28/20, revealed resident assessed. No new skin issues noted. After investigation an incident with another resident it was discovered that this resident [R9] had struck out at the other resident. After speaking to this resident [R9] he did admit to striking out at the resident [R4] .Resident has the habit of putting his hand on your shoulder when taking [sic] to someone. Educated resident on not touching someone when talking to them and also keeping hands to self in general. Also educated resident on it not being appropriate to strike out at anyone for any reason. Resident placed on 1:1 .Family has decided to discharge resident from facility and take him home . Interview on 05/25/21 at 5:15 PM with the Administrator revealed she believes there was a resident-to-resident altercation; however, she did not believe abuse occurred due to the fact that both residents were cognitively impaired, and she could not determine if there was a willful intention. Continued interview with the Administrator on 05/28/21 at 4:29 PM revealed she completed the investigation, and she did not confirm abuse. The Administrator did not determine during the investigation how this was not witnessed by staff. 2. Review of R10's undated Admission Record, located in the resident's EMR under the profile tab revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's significant change in status MDS with an ARD of 10/06/20, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was fully cognitively intact. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two persons for bed mobility and toilet use. The resident's MDS also revealed the facility assessed R10 to require extensive assistance of one person for transfers (how resident moves between surfaces), dressing and was totally dependent on one staff person for bathing. Review of R10's most recent quarterly MDS with an ARD of 02/26/21, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated the resident was fully cognitively intact. Review of Intake, specifically the details of the allegation revealed .Incident occurred on 11/15/2020 during the 6:00 PM to 2:00 AM shift. The resident reported that CNA [CNA16's Name] told her, I guess you need your butt wiped again, when answering the call light, and she was delayed in providing timely care and was rude to the resident . Review of CNA16's Disciplinary Action Record, dated 11/16/20, provided to the State Agency as part of the facility's investigation, revealed CNA16 was suspended after an allegation of abuse. Continued review of the disciplinary action record revealed .Facts Regarding Incident .: resident [R10] stated several occurrences of rude disrespectful verbal interaction c? [with] associate [CNA16] resulting in anxiety, reluctance to ask for necessary care, violation of infection control policy, delayed in complete response from associate regarding care/tasks . Review of CNA16's typed [email] statement revealed On Sunday November 5, [sic] 2020 I [CNA16's Name] work [sic] the right side of hall .I changed her because she had a bowel movement. So 5 min [minutes] late she turned the light on again at that time I was on my way to another resident room to change them. So I asked the resident if he give me a second so I checked on her [R10]. She stated I need brief [sic] change so I asked can she give me a second I was assisting someone I was just stopping to see what she needed. So I went back to the resident when I finished her light was on again. I went to her room and said yes [R10's name] she said I [R10] need a brief changed and I said [R10's name] I told you I was coming back I remembered I didn't forget (I [CNA16] giggled) while talking to her as I was taking her brief off she become angry that her bowel was constantly looking that way .so 5 mins [minutes] later she turned it [call light] on I went to help her she said a brief change so (in a joking way not rude) I said again [R10's name] she [R10] said it's not my fault . Review of an undated and untiled investigation summary located in the facility's investigation file revealed . [R10's Name] reported to the DON [former DON2] on Monday 11-16-20 that [CNA16's name] on 11-15-20 stated to her I guess you need your butt wiped again, and was rude when answering her call light. [CNA16's name] reported that she was assigned to resident and had answered [R10's Name] call light several times due to her having diarrhea that weekend. [CNA16's name] reported that she did not intend for [R10's name] to take it the way that she did and that she was only joking with her . Interview on 05/26/20 at 2:00 PM with R10 revealed she reported CNA16 to the DON and she was told that the CNA would not be assigned to her anymore. Continued interview with R10 revealed on 11/15/20 she had many episodes of incontinence from diarrhea that day and CNA16 had changed her each time. R10 stated she pushed her call light and CNA16 came in and stated to her I'm changing your butt again. R10 stated she remembers this because she [R10] would never talk or use words like that. R10 stated that CNA16 made the comment, walked out of the room, but came back a few minutes later and changed her. Further interview with R10 revealed she had another incontinent episode after that; however, she waited as long as she could before she pushed the call light to be assisted again. When asked how long she waited after the incontinence episode before she pushed her call light, R10 stated approximately 10 minutes. R10 stated thankfully, another CNA came and answered her call light instead of CNA16. Continued interview with R10 revealed when a different CNA answered her call light and changed her, she requested for the CNA to tell the nurse supervisor (former DON2) that she wanted to speak to her. R10 stated at that time she reported CNA10. When asked how this incident made her feel, R10 stated she felt humiliated and shameful like she had done something wrong. R10 also stated she was in disgust that she was paying all this money to be taken care of and had to lay in diarrhea and not want to push her call light. Continued interview with R10 revealed after she reported CNA16 she was petrified that the CNA was going to come in the back door [resident's room is located by the door] and hurt her. The resident stated she expressed these concerns to the social worker, and they assured her that she was safe. Interview on 05/26/21 at 1:24 PM with the Social Service Director (SSD) revealed during the time of R10's allegation, he did speak to the resident. The SSD stated the resident did express fear of people being able to come in the back door; however, he did not remember the resident mention anyone specific. Continued interview with the SSD revealed he told R10 that he would see about getting the code changed. The SSD stated the resident felt better and was not scared after the conversation. Further interview with the SSD revealed related to the allegation, he thought it was the CNA's sense of humor and she did not mean to offend anyone. Continued interview on 05/27/21 at 10:32 AM with R10 revealed when asked if she felt what CNA16 said to her was abuse, she stated maybe a word or two. Interview on 05/28/21 at 4:29 PM with the Administrator revealed she was the person who was responsible for and who completed the investigation. The Administrator stated the outcome of the investigation was unfounded based on the resident's interview and the staff's interview. The Administrator also stated they (facility) did not feel that abuse occurred. Continued interview with the Administrator revealed she interviewed R10 herself and R10 did state she became anxious at that time [incident]; however, the resident did not feel abused even though the CNA's approach was not appropriate. The Administrator stated CNA10 stated her intentions were not ill willed and that she was joking with R10 when she said again to the resident. The Administrator further stated CNA16 was allowed to come back to work because this allegation was unfounded. When asked if the former DON2 should have been interview or a statement obtained from her since the resident reported the allegation to her, the administrator stated former DON2 verbally reported to her [Administrator] that R10 needed to speak to her in reference to CNA16. When asked should the DON's statement been included in the investigations, the Administrator avoided the question and repeated the previous answer. Review of the facility's investigation revealed no documented evidence an interview was conducted with R10 even though the Administrator stated she interviewed R10.

Based on record review and interview the facility failed to ensure the resident was free from abuse, neglect, and exploitation for one (1) of one (5) residents reviewed for neglect (Resident #3). 1.) The facility did not obtain Resident #3's [MEDICATION NAME] prescription refill before the facility ran out of pain medicine and; 2.) Resident #3 did not receive her scheduled [MEDICATION NAME] 30 mg one (1) tablet twice a day as ordered by the physician for two (2) and a half days for a total of five (5) doses (06/10/2017 - 06/12/2017). This failure affected Resident #3 by causing her to experience pain, diarrhea and withdrawal symptoms and could affect 17 other residents on pain management programs by not having the medications on hand according to physician's orders [REDACTED]. Findings Included: Review of Resident #3's Face Sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses' including; Hypertension and [MEDICAL CONDITION]. Review of Resident #3's 30 day MDS dated [DATE] reflected a Brief Interview for Mental Status score of 15 indicating no cognitive loss. Resident #3 was assessed as having no mood or behavior indicators and was assessed as requiring limited assistance or supervision only for her Activities of Daily Living. Resident #3 was assessed as receiving routine pain medication and having no pain and did not need as needed pain pills for breakthrough pain during the assessment period from 05/20/2017 to 05/27/2017. Review of Resident #3's Care Plan dated 05/10/2017 reflected constant pain in her back and all over her body with a [DIAGNOSES REDACTED]. Intervention included; Administer pain medication as ordered. Review of Resident #3's Physician order [REDACTED]. Medications included; [MEDICATION NAME] 30 mg one by mouth twice a day starting on 05/09/2017. In an interview on 06/13/2017 at 8:40 AM Resident #3 stated she had pain from cracked vertebrate and the facility ran out of her [MEDICATION NAME] on Friday night 06/09/2017 and therefore she did not have [MEDICATION NAME] for Saturday, Sunday or Monday until Monday night 06/12/17 at 8:00 PM. Resident #3 stated the facility told her they didn't have a refill order for her [MEDICATION NAME] because the pain doctor wasn't at his clinic on Friday 06/09/2017 when they attempted to obtain a refill script. Resident #3 stated the facility staff should have known to reorder the medicine two or three days before she ran out on Friday. Review of Resident #3's [MEDICATION NAME] Extended Release 30 mg tablets count sheet reflected she received one as ordered on [DATE] at 8:00 PM. Resident #3 missed doses on 06/10/2017 and 06/11/2017 at 8:00 AM and 9:00 PM and on 06/12/2017 at 8:00 AM due to the medication was not available. In an interview on 06/13/2017 at 2:00 PM LVN R stated on Friday 06/09/2017 Resident #3 was running out of her [MEDICATION NAME] and LVN R informed the DON the facility needed a new controlled narcotic refill prescription and the DON told her to get one. LVN R told the NP for Resident #3 she needed a new controlled narcotic refill prescription for Resident #3 and the NP reminded LVN R the Pain Doctor was in charge of the controlled narcotic refill prescription and to call him. LVN R called the Pain Doctor's office and was told he was off on Fridays and would not be back until Monday. LVN R stated she did not go back and tell the DON or the NP who worked for Resident #3's Medical Doctor (who was also the Medical Director for the facility) she was not able to get the prescription and Resident #3 would be out of the [MEDICATION NAME] Friday night - 06/09/2017. In an interview on 06/13/2017 at 2:40 PM RN J stated she checked the carts daily for medication availability. She stated she told the Medication Aide on Thursday, 06/08/2017 to order the medications. RN J stated she heard the Medication Aide tell the DON on that day that Resident #3 needed her [MEDICATION NAME] refilled. RN J stated she knew the plan was for the DON to talk to the Nurse Practitioner on Friday, 06/09/2017. In an interview on 06/13/2017 at 2:40 PM LVN R stated there would not be a medication error form to notify Administration Resident #3 did not receive her scheduled [MEDICATION NAME] for five missed doses because she had written an order to place the drug on Hold. LVN R stated it was facility practice to write a hold order when medications weren't available. LVN R stated she talked to the NP about needing the prescription but she did not tell her she wanted a hold order. LVN R stated she did not call a doctor to write the order to hold the medication. In an interview on 06/13/2017 at 3:44 PM LVN B stated Resident #3's [MEDICATION NAME] came to the facility on Monday 06/12/2017 between 3:00 and 4:00 PM. LVN B stated around 7:00 PM Resident #3 asked for her [MEDICATION NAME] and LVN B told her it was due at 9:00 PM so she would be receiving it at 8:00 PM. LVN B stated she gave Resident #3 her [MEDICATION NAME] at 8:00 PM on Monday night 06/12/2017. In an interview at 06/13/2017 at 3:00 PM the NP stated the facility should not have run out of Resident #3's [MEDICATION NAME] and they should have requested the refill for [MEDICATION NAME] seven days before she ran out so the Pain Doctor would have time to write and deliver the secured prescription for [MEDICATION NAME]. The NP stated diarrhea and extreme pain were indications that Resident #3 was having withdrawal symptoms from the [MEDICATION NAME]. In an interview on 06/13/2017 at 3:30 PM the Administrator stated she did not know Resident #3 was out of her [MEDICATION NAME] for the weekend and Monday or how it happened until surveyor intervention. She stated the facility was supposed to re-order the medications a week or so before they run out but she was not exactly sure when. The Administrator stated the staff had been in-serviced multiple times to be sure the facility had medications on hand as ordered. In an interview on 06/13/2017 at 4:13 PM the Administrator stated writing hold orders for medication was not facility policy. She stated the staff should have called the Medical Director for assistance and Resident #3 should not have been without her routine pain medicine. In a telephone interview on 06/13/2017 at 4:19 PM the DON stated she was told on Thursday, 06/08/2017 by LVN R Resident #3 was low on [MEDICATION NAME]. The DON stated the only question she asked was, Is she out? and the answer was no. The DON stated she told the NP and the NP wrote an order for [REDACTED]. The DON stated the staff should not have let Resident #3 go without her pain medicine. Review of the facility's policy entitled Medication Administration General Guidelines dated 2007 and revised 09/2010 reflected Medications are administered in accordance with written orders of the prescriber .If necessary, the nurse contacts the prescriber for clarification. The Policy also reflected Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of the policy for Abuse, Neglect dated 05/01/01 reflected: The facility will prohibit neglect. The facility will conduct an investigation of alleged or suspected neglect and provide notification of information to authorities. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Prevention: Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring. The facility will track all occurrences that could potentially constitute neglect. Review of the CMS form 672 reflected there were 18 residents on a pain management program.

Based on record review and interview the facility failed to ensure the facility developed and implemented written policies and procedures that prohibit and prevent abuse, neglect and exploitation and to investigate any such allegations and report it for one (1) of one (5) residents reviewed for neglect (Resident #3). 1.) The facility did not obtain Resident #3's [MEDICATION NAME] prescription refill before the facility ran out of pain medicine and; 2.) Resident #3 did not receive her scheduled [MEDICATION NAME] 30 mg one (1) tablet twice a day as ordered by the physician for two (2) and a half days for a total of five (5) doses (06/10/2017 - 06/12/2017). This failure affected Resident #3 by causing her to experience pain, diarrhea and withdrawal symptoms and could affect 17 other residents on pain management programs by not having the medications on hand according to physician's orders [REDACTED]. Findings Included: Review of the policy for Abuse, Neglect dated 05/01/01 reflected: The facility will prohibit neglect. The facility will conduct an investigation of alleged or suspected neglect and provide notification of information to authorities. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Prevention: Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring. The facility will track all occurrences that could potentially constitute neglect. Review of the facility's policy entitled Medication Administration General Guidelines dated 2007 and revised 09/2010 reflected Medications are administered in accordance with written orders of the prescriber .If necessary, the nurse contacts the prescriber for clarification. The Policy also reflected Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of Resident #3's Face Sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses' including; Hypertension and [MEDICAL CONDITION]. Review of Resident #3's 30 day MDS dated [DATE] reflected a Brief Interview for Mental Status score of 15 indicating no cognitive loss. Resident #3 was assessed as having no mood or behavior indicators and was assessed as requiring limited assistance or supervision only for her Activities of Daily Living. Resident #3 was assessed as receiving routine pain medication and having no pain and did not need as needed pain pills for breakthrough pain during the assessment period from 05/20/2017 to 05/27/2017. Review of Resident #3's Care Plan dated 05/10/2017 reflected constant pain in her back and all over her body with a [DIAGNOSES REDACTED]. Intervention included; Administer pain medication as ordered. Review of Resident #3's Physician order [REDACTED]. Medications included; [MEDICATION NAME] 30 mg one by mouth twice a day starting on 05/09/2017. In an interview on 06/13/2017 at 8:40 AM Resident #3 stated she had pain from cracked vertebrate and the facility ran out of her [MEDICATION NAME] on Friday night 06/09/2017 and therefore she did not have [MEDICATION NAME] for Saturday, Sunday or Monday until Monday night 06/12/17 at 8:00 PM. Resident #3 stated the facility told her they didn't have a refill order for her [MEDICATION NAME] because the pain doctor wasn't at his clinic on Friday 06/09/2017 when they attempted to obtain a refill script. Resident #3 stated the facility staff should have known to reorder the medicine two or three days before she ran out on Friday. Review of Resident #3's [MEDICATION NAME] Extended Release 30 mg tablets count sheet reflected she received one as ordered on [DATE] at 8:00 PM. Resident #3 missed doses on 06/10/2017 and 06/11/2017 at 8:00 AM and 9:00 PM and on 06/12/2017 at 8:00 AM due to the medication was not available. In an interview on 06/13/2017 at 2:00 PM LVN R stated on Friday 06/09/2017 Resident #3 was running out of her [MEDICATION NAME] and LVN R informed the DON the facility needed a new controlled narcotic refill prescription and the DON told her to get one. LVN R told the NP for Resident #3 she needed a new controlled narcotic refill prescription for Resident #3 and the NP reminded LVN R the Pain Doctor was in charge of the controlled narcotic refill prescription and to call him. LVN R called the Pain Doctor's office and was told he was off on Fridays and would not be back until Monday. LVN R stated she did not go back and tell the DON or the NP who worked for Resident #3's Medical Doctor (who was also the Medical Director for the facility) she was not able to get the prescription and Resident #3 would be out of the [MEDICATION NAME] Friday night - 06/09/2017. In an interview on 06/13/2017 at 2:40 PM RN J stated she checked the carts daily for medication availability. She stated she told the Medication Aide on Thursday, 06/08/2017 to order the medications. RN J stated she heard the Medication Aide tell the DON on that day that Resident #3 needed her [MEDICATION NAME] refilled. RN J stated she knew the plan was for the DON to talk to the Nurse Practitioner on Friday, 06/09/2017. In an interview on 06/13/2017 at 2:40 PM LVN R stated there would not be a medication error form to notify Administration Resident #3 did not receive her scheduled [MEDICATION NAME] for five missed doses because she had written an order to place the drug on Hold. LVN R stated it was facility practice to write a hold order when medications weren't available. LVN R stated she talked to the NP about needing the prescription but she did not tell her she wanted a hold order. LVN R stated she did not call a doctor to write the order to hold the medication. In an interview on 06/13/2017 at 3:44 PM LVN B stated Resident #3's [MEDICATION NAME] came to the facility on Monday 06/12/2017 between 3:00 and 4:00 PM. LVN B stated around 7:00 PM Resident #3 asked for her [MEDICATION NAME] and LVN B told her it was due at 9:00 PM so she would be receiving it at 8:00 PM. LVN B stated she gave Resident #3 her [MEDICATION NAME] at 8:00 PM on Monday night 06/12/2017. In an interview at 06/13/2017 at 3:00 PM the NP stated the facility should not have run out of Resident #3's [MEDICATION NAME] and they should have requested the refill for [MEDICATION NAME] seven days before she ran out so the Pain Doctor would have time to write and deliver the secured prescription for [MEDICATION NAME]. The NP stated diarrhea and extreme pain were indications that Resident #3 was having withdrawal symptoms from the [MEDICATION NAME]. In an interview on 06/13/2017 at 3:30 PM the Administrator stated she did not know Resident #3 was out of her [MEDICATION NAME] for the weekend and Monday or how it happened until surveyor intervention. She stated the facility was supposed to re-order the medications a week or so before they run out but she was not exactly sure when. The Administrator stated the staff had been in-serviced multiple times to be sure the facility had medications on hand as ordered. In an interview on 06/13/2017 at 4:13 PM the Administrator stated writing hold orders for medication was not facility policy. She stated the staff should have called the Medical Director for assistance and Resident #3 should not have been without her routine pain medicine. In a telephone interview on 06/13/2017 at 4:19 PM the DON stated she was told on Thursday, 06/08/2017 by LVN R Resident #3 was low on [MEDICATION NAME]. The DON stated the only question she asked was, Is she out? and the answer was no. The DON stated she told the NP and the NP wrote an order for [REDACTED]. The DON stated the staff should not have let Resident #3 go without her pain medicine. Review of the CMS form 672 reflected there were 18 residents on a pain management program.

Based on record review and interview the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (1) of one (1) reviewed for pharmacy services (Resident #3). 1.) The facility did not obtain Resident #3's Morphine prescription refill before the facility ran out of pain medicine and; 2.) Resident #3 did not receive her scheduled Morphine 30 mg one (1) tablet twice a day as ordered by the physician for two (2) and a half days for a total of five (5) doses (06/10/2017 - 06/12/2017). This failure affected Resident #3 by causing her to experience pain, diarrhea and withdrawal symptoms and could affect 17 other residents on pain management programs by not having the medications on hand according to physician's orders [REDACTED]. Findings Included: Review of Resident #3's Face Sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses' including; Hypertension and Chronic Obstructive Pulmonary Disease. Review of Resident #3's 30 day MDS dated [DATE] reflected a Brief Interview for Mental Status score of 15 indicating no cognitive loss. Resident #3 was assessed as having no mood or behavior indicators and was assessed as requiring limited assistance or supervision only for her Activities of Daily Living. Resident #3 was assessed as receiving routine pain medication and having no pain and did not need as needed pain pills for breakthrough pain during the assessment period from 05/20/2017 to 05/27/2017. Review of Resident #3's Care Plan dated 05/10/2017 reflected constant pain in her back and all over her body with a [DIAGNOSES REDACTED]. Intervention included; Administer pain medication as ordered. Review of Resident #3's Physician order [REDACTED]. Medications included; Morphine Sulphate 30 mg one by mouth twice a day starting on 05/09/2017. In an interview on 06/13/2017 at 8:40 AM Resident #3 stated she had pain from cracked vertebrate and the facility ran out of her Morphine on Friday night 06/09/2017 and therefore she did not have Morphine for Saturday, Sunday or Monday until Monday night 06/12/17 at 8:00 PM. Resident #3 stated the facility told her they didn't have a refill order for her Morphine because the pain doctor wasn't at his clinic on Friday 06/09/2017 when they attempted to obtain a refill script. Resident #3 stated the facility staff should have known to reorder the medicine two or three days before she ran out on Friday. Review of Resident #3's Morphine Sulfate Extended Release 30 mg tablets count sheet reflected she received one as ordered on [DATE] at 8:00 PM. Resident #3 missed doses on 06/10/2017 and 06/11/2017 at 8:00 AM and 9:00 PM and on 06/12/2017 at 8:00 AM due to the medication was not available. In an interview on 06/13/2017 at 2:00 PM LVN R stated on Friday 06/09/2017 Resident #3 was running out of her Morphine and LVN R informed the DON the facility needed a new controlled narcotic refill prescription and the DON told her to get one. LVN R told the NP for Resident #3 she needed a new controlled narcotic refill prescription for Resident #3 and the NP reminded LVN R the Pain Doctor was in charge of the controlled narcotic refill prescription and to call him. LVN R called the Pain Doctor's office and was told he was off on Fridays and would not be back until Monday. LVN R stated she did not go back and tell the DON or the NP who worked for Resident #3's Medical Doctor (who was also the Medical Director for the facility) she was not able to get the prescription and Resident #3 would be out of the Morphine Friday night - 06/10/2017. In an interview on 06/13/2017 at 2:40 PM RN J stated she checked the carts daily for medication availability. She stated she told the Medication Aide on Thursday, 06/08/2017 to order the medications. RN J stated she heard the Medication Aide tell the DON on that day that Resident #3 needed her Morphine refilled. RN J stated she knew the plan was for the DON to talk to the Nurse Practitioner on Friday, 06/09/2017. In an interview on 06/13/2017 at 2:40 PM LVN R stated there would not be a medication error form to notify Administration Resident #3 did not receive her scheduled Morphine for five missed doses because she had written an order to place the drug on Hold. LVN R stated it was facility practice to write a hold order when medications weren't available. LVN R stated she talked to the NP about needing the prescription but she did not tell her she wanted a hold order. LVN R stated she did not call a doctor to write the order to hold the medication. In an interview on 06/13/2017 at 3:44 PM LVN B stated Resident #3's Morphine came to the facility on Monday 06/12/2017 between 3:00 and 4:00 PM. LVN B stated around 7:00 PM Resident #3 asked for her Morphine and LVN B told her it was due at 9:00 PM so she would be receiving it at 8:00 PM. LVN B stated she gave Resident #3 her Morphine at 8:00 PM on Monday night 06/12/2017. In an interview at 06/13/2017 at 3:00 PM the NP stated the facility should not have run out of Resident #3's Morphine and they should have requested the refill for Morphine seven days before she ran out so the Pain Doctor would have time to write and deliver the secured prescription for Morphine. The NP stated diarrhea and extreme pain were indications that Resident #3 was having withdrawal symptoms from the Morphine. In an interview on 06/13/2017 at 3:30 PM the Administrator stated she did not know Resident #3 was out of her Morphine for the weekend and Monday or how it happened until surveyor intervention. She stated the facility was supposed to re-order the medications a week or so before they run out but she was not exactly sure when. The Administrator stated the staff had been in-serviced multiple times to be sure the facility had medications on hand as ordered. In an interview on 06/13/2017 at 4:13 PM the Administrator stated writing hold orders for medication was not facility policy. She stated the staff should have called the Medical Director for assistance and Resident #3 should not have been without her routine pain medicine. In a telephone interview on 06/13/2017 at 4:19 PM the DON stated she was told on Thursday, 06/08/2017 by LVN R Resident #3 was low on Morphine. The DON stated the only question she asked was, Is she out? and the answer was no. The DON stated she told the NP and the NP wrote an order for [REDACTED]. The DON stated the staff should not have let Resident #3 go without her pain medicine. Review of the facility's policy entitled Medication Administration General Guidelines dated 2007 and revised 09/2010 reflected Medications are administered in accordance with written orders of the prescriber .If necessary, the nurse contacts the prescriber for clarification. The Policy also reflected Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of the CMS form 672 reflected there were 18 residents on a pain management program.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (2) of six (6) residents (Resident #1 and #5) when: The facility failed to administer physician ordered Coumadin to Resident #1. Resident #1 was not administered the Coumadin on Mondays, Wednesdays, or Fridays by RN A when Resident #1 went to Dialysis. Resident #1 was sent to the hospital on [DATE], and diagnosed with [REDACTED]. The facility failed to administer physician ordered Coumadin to Resident #5. Resident #5 was not administered the Coumadin for six (6) days in December 2016. This resulted in an Immediate Jeopardy (IJ) on 02/17/2017. While the IJ was removed on 02/18/2017, the facility remained out of compliance at a severity level of actual harm harm that is not immediate jeopardy with a scope of pattern that is not IJ. This deficient practice affected Resident #1 and Resident #5 and placed 10 residents prescribed anticoagulant therapy at risk for Pulmonary Embolisms, blood clots, and possible death. Findings include: Review of the Face Sheet for Resident #1 dated 11/22/2016, reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Care Plan for Resident #1 dated 12/20/2016, reflected he was prescribed an Anticoagulant and staff were to administer the medication as ordered, perform lab work as ordered to monitor therapeutic levels, and notify the physician of any abnormal results. He also needed Dialysis treatments and staff were to communicate with the Dialysis center and monitor lab values as ordered. Review of the 60-day MDS Assessment for Resident #1 dated 02/06/2017, reflected a BIMS score of 14 indicated cognitively intact. He had an Active [DIAGNOSES REDACTED]. He also received an Anticoagulant for four (4) of seven (7) days. He was also received Dialysis while he was a resident. Review of the Physician order [REDACTED]. Review of Resident #1's admission orders [REDACTED]. Review of the Treatment Administration Record (TAR) for Resident #1 dated February 2017, reflected Coumadin 3 mg tablet one per mouth every day at 5:00 PM with an order date and start date of 12/12/2016. The TAR reflected the circled initials of RN A on 02/01/2017, 02/03/2017, 02/06/2017, and 02/08/2017. There were no explanations of the circled initials for the Coumadin, but RN A gave the reason for not administering a Duoneb on 02/01/2017 at 3:00 PM as Resident #1 was at Dialysis on Monday, Wednesday, and Friday. There were no initials for 02/09/2017 and 02/10/2017 on the Coumadin order-indicated the medication was not given. Review of the TAR for Resident #1 dated January 2017, reflected Coumadin 3 mg tablet one per mouth every day at 5:00 PM with an order and start date of 12/12/2016 had circled initials of RN A on 01/02/2017, 01/04/2017, 01/06/2017, 01/11/2017, 01/13/2017, 01/16/2017, 01/18/2017, 01/20/2017, 01/23/2017, 01/25/2017, 01/27/2017, and 01/30/2017. The TAR reflected the explanation of the circled initials on 01/02/2017 only was out to dialysis on M, W, F (Monday, Wednesday, Friday). Review of the TAR for Resident #1 dated December 2016, reflected Coumadin 3 mg one per mouth at 5:00 PM (hand written) The order had circled initials of RN A on 12/14/2016, 12/16/2016, 12/19/2016, 12/21/2016, 12/23/2016, 12/26/2016, and 12/28/2016. There was an explanation for the circled initials of Res (Resident) has dialysis on M, W, F and leaves at 2:15p and doesn't return til 8p. The TAR had no initials for 12/24/2016, 12/25/2016, 12/29/2016, 12/30/2016, or 12/31/2016. Review of the History and Physical Report from the hospital for Resident #1 dated 02/12/2017, reflected he was short of breath. The medications listed for him included Coumadin (warfarin) 5 mg a day. The Report reflected he had swollen legs. The lab findings reflected his Coumadin level was below therapeutic levels. The [DIAGNOSES REDACTED]. Review of the Progress Note from the hospital for Resident #1 dated 02/16/2017, reflected .Patient was diagnosed with [REDACTED]. Review of the Consultant Pharmacist Report dated 12/21/2016 reflected Resident #1 had No irregularities noted. The Report reflected The medications have been reviewed and no changes are recommended at this time for this resident. In an interview on 02/17/2017 at 11:35 AM, Resident #1's spouse (also a Resident at the facility) stated Resident #1 was not getting his evening time medications from RN A on Mondays, Wednesdays, or Fridays because he was at dialysis. She stated she talked to ADON who told her (Resident #1's spouse) she (ADON) would find out what should be done. Resident #1's spouse stated ADON said it was okay for Resident #1 to miss the Coumadin medication on his dialysis days. Resident #1's spouse stated she questioned the response from ADON, but she continued to assure Resident #1's spouse it would be okay. Resident #1's spouse stated Resident #1 went to the hospital on Sunday (02/12/2017) for shortness of breath around 12:30 PM. She stated Resident #1 had blood clots in both of his legs and his lung. In an interview on 02/17/2017 at 5:04 PM, RN A stated she was not giving Resident #1 his Coumadin on his dialysis days because he was gone at 5:00 PM. She stated Resident #1 left on Monday, Wednesday, and Friday around 2:00 PM and returned around 8:30 PM. She stated she worked at the facility from 2:00 PM to 10:00 PM every Monday through Friday. She stated she did not notify the physician or the DON about the doses of Coumadin she was not giving on Monday, Wednesday, or Friday. She stated she should have called to inform the physician of the missed doses, but she was not sure if the Coumadin could be given at a different time. In an interview on 02/17/2017 at 5:21 PM, the on-call physician stated he did not know Resident #1 and he could not give any information because the hospital did not allow the physicians to follow their residents at the hospital, they had their own doctors. He stated the physicians were alerted when their residents were in the hospital and when they return. He stated they sometimes received notes from the hospital to review. He also stated the physician for Resident #1 was not available at this time. In an interview on 02/17/2017 at 5:52 PM, Resident #1's spouse called the hospital while this surveyor was in the room. The nurse from the hospital confirmed the [DIAGNOSES REDACTED]. Resident #1 was also on the phone and stated he had not been receiving the Coumadin when he went to dialysis. Resident #1's spouse stated he also was not getting the levels checked by lab work. Review of medical records for Resident #1, reflected no lab orders or results since 12/12/16 to the investigation date of 02/17/17. In an interview on 02/17/2017 at 6:10 PM, DON stated she received the paperwork from the hospital (Progress Note dated 02/16/2017) and she confirmed Resident #1 had a Pulmonary Embolism. DON stated she was not aware Resident #1 was not receiving the ordered Coumadin on his dialysis days. DON stated the facility standard was for residents on Coumadin to have monthly lab draws for PT/INR unless the physician ordered something weekly. In an interview on 02/17/2017 at 6:15 PM, Administrator stated she was not made aware Resident #1 was not receiving his ordered Coumadin. Administrator stated RN A was suspended on 02/11/2017 and had not returned. In an interview on 02/17/2017 at 7:00 PM, ADON stated at first she was not aware of Resident #1 not getting his Coumadin. Then ADON stated she had discussed the medication Coumadin with Resident #1 and his wife Resident #8. ADON stated she was aware he was not getting the Coumadin on dialysis days. She stated she was taking with a NP at the facility about Coumadin and the NP mentioned it was okay to not get the Coumadin on days a resident goes to dialysis because the medications are washed out. ADON stated she did not call Resident #1's physician to notify him of the situation. She stated after looking at the MARs and TARs she was aware of the situation since 12/20/2016. She stated she also did not alert DON. Review of the Face Sheet of Resident #5 dated 02/18/201,7 reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS Assessment for Resident #5 dated 01/23/2017 reflected a BIMS score of 10 indicated moderate cognitive impairment. She had active [DIAGNOSES REDACTED]. She also received anticoagulant therapy medications for all 7 days of the assessment period. Review of the Care Plan for Resident #5 dated 09/28/2016 reflected she was on anticoagulant therapy and staff would encourage safety awareness to prevent injury, monitor for bleeding, perform labs as indicated, and notify Physician of any abnormal findings. Review of the Physician order [REDACTED]. Review of the TAR for Resident #5 dated December 2016 reflected a hand written order for Coumadin 2 mg one tablet every day. The order started on 12/21/2016 but was not given on 12/21/2016, 12/22/2016, 12/23/2016, 12/26/2016, 12/27/2016, or 12/29/2016. In an interview on 02/17/2017 at 7:42 PM Administrator and DON stated they were not aware of the omissions of Coumadin for Resident #5. Review of the facility's policy entitled Medication Administration General Guidelines dated 2007 and revised 09/2010 reflected Medications are administered in accordance with written orders of the prescriber .If necessary, the nurse contacts the prescriber for clarification. The Policy also reflected Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR indicated [REDACTED].,tags, colored plastic strips, or paper clips). After completing the medication pass, the nurse returns to the missed resident to administer the medication. The policy reflected under Documentation: .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time .), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. The facility Administrator, DON, and Corporate Clinical Specialist (on phone) were advised on 02/17/2017 at 7:42 PM that an IJ had been identified due to failures listed in the above evidence. On 02/18/2017 at 9:19 AM the Administrator provided surveyor with a written Plan of Removal that was accepted on 02/18/2017 at 12:47 PM and reflected: Concern: On February 17, 2017, facility administration was made aware of an immediate jeopardy concerning resident #1 not receiving Coumadin on his dialysis days and the presence of omissions on the Medication Administration Record [REDACTED] Resident Specific Actions: Resident #1 is presently in the hospital. The facility was unable to contact the residents attending physician regarding the missed doses of Coumadin for resident #1 and the documentation omissions for resident #5, therefore the on call physician who is also the Medical Director was contacted, February 17, 2017, and informed of the missed doses and the concerns voiced by agency. Actions Taken to Identify Other Residents with the potential to be effected by this practice: Medication Administration Records for the last 3 months reviewed for all residents receiving anti-coagulant therapy to ensure all doses have been given per physician orders. Review revealed 30 documentation omissions for resident #1. Omissions for resident #1 were omitted by 2 employees. RN #1(A) is no longer employed by the facility and RN #2 (ADON) was counseled on February 18, 2017. The on call physician for Resident #1 was notified. Review also revealed 8 documentation omissions for Resident #5. Omissions for resident #5 were omitted by 3 Licensed Nurses. RN#1 (A) is no longer employed at the facility. LVN #1 and LVN #2 were counseled regarding the omissions. The on call physician for Resident #5 was notified. Systematic Changes: All in-services below were initiated on 2-17-2017 and will be completed on 2-18-2017. No nursing employee will be allowed to work their scheduled shift until they have received in-servicing on the topics identified below. All In-services will be completed by the Director of Nursing or Designee. An In-service with Licensed Nurses, entitled, Missed Dose Protocol for Nurses, was initiated on February 17, 2017. The in-service stated that, anytime a medication is not given the doctor must be notified and the NP can only be notified if they are the NP for that physician. An In-service was initiated with the Medication Aides on February 17, 2017, entitled, Missed Dose Protocol for CMA's. The in-service stated that anytime there is a medication issue or a medication not given, the nurse must be notified. An In-service was initiated with the Licensed Nurses, entitled, Ensuring Proper Drug Regimens for Dialysis Residents. The in-service informed staff that if dialysis times conflicts with scheduled medication administration times, then the physician needs to be contacted to make appropriate administration time adjustments. On February 17, 2017, the facility's Medical Director provided education to nurse practitioner regarding Coumadin withholding for dialysis residents. A disciplinary action was completed with the ADON for failure to notify MD and the DON of dialysis time conflicting with scheduled time of Coumadin administration. Expectations for ADON outlined in disciplinary action. DON or designee will review MAR's daily to ensure proper administration procedures are followed and no omissions are present. If any missed doses are identified they will follow up to ensure that the MD has been notified. Monitoring and Quality Assurance: Nursing administration will review MAR'S daily to validate medication administration as per order. And if any missed doses are identified they will follow up to ensure MD has been notified. Nursing Administration will review labs for residents on anti-coagulants to ensure labs are completed. Nursing Administration followed up with physician to ensure PT/INR ordered monthly at a minimum for residents on Coumadin Therapy. Nursing Administration will audit medication administration records for resident's receiving dialysis twice a week to ensure they are receiving medications as ordered. The results of audits, observations, and reviews will be reviewed by the Regional Clinical Specialist and or designee and shared with the QA team monthly to ensure continued compliance. Any issues identified will be addressed as the QA team deems necessary. IJ Removal Completion Date: February 18, 2017 The Surveyor monitored the current plan of removal from 02/17/17 - 02/18/17 as follows: Review of the records of five (5) other residents (Residents #4, #5, #6, #7, and #8 on anticoagulants and findings were listed above for Resident #5. No other concerns found for the other listed residents. Observation on 02/18/2017 at 10:49 AM revealed the DON provided an in-service for the nursing staff on Medication Administration, Omissions, and Notification to the Physician. The DON provided the in-service and sign-in sheets. Interviews on 02/18/2017 at 12:42 PM through 1:16 PM with RN B, LVN D, and MA H; they stated understanding of the in-service provided. Review of the In-Services entitled Ensure Proper Drug Regime for the Dialysis Residents, Missed Dose Protocol for Nurses, Missed Medications/Dose Protocol for CMAs dated 02/17/2017 reflected the staff were trained on these topics/policies and over 70 percent of the nurses and medication aides were trained. The Administrator was notified on 02/18/2017 at 1:56 PM that the IJ was removed, however, the facility remained out of compliance at a Severity level of Harm at a Scope of Pattern that is not IJ due to the facility required time to train all staff and monitor their Plan of Removal. The facility provided a list of ten (10) residents in the facility that were prescribed anticoagulants.

Based on observation, interview, and record review, the facility failed to provide the resident the right to be free from neglect for one (1) of eight (8) residents (Resident #1) reviewed for abuse, neglect, and misappropriation of property. The facility failed to administer physician ordered [MEDICATION NAME] to Resident #1. Resident #1 was not administered the [MEDICATION NAME] on Mondays, Wednesdays, or Fridays by RN A, when Resident #1 went to [MEDICAL TREATMENT]. RN A did not consult the physician about not administering the [MEDICATION NAME]. ADON did not consult the physician when she was aware of the omissions on 12/20/2016. The Administrator and DON were also not consulted. Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. This resulted in an Immediate Jeopardy (IJ) on 02/17/2017. While the IJ was removed on 02/18/2017, the facility remained out of compliance at a Severity Level of Actual Harm that is not Immediate Jeopardy with a Scope of Pattern that is not IJ. This deficient practice affected Resident #1 and placed ten (10) residents prescribed anticoagulant therapy at risk for [MEDICAL CONDITION] Embolisms, blood clots, and possible death. Findings include: Review of the Face Sheet for Resident #1 dated 11/22/2016, reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Care Plan for Resident #1 dated 12/20/2016, reflected he was prescribed an Anticoagulant and staff were to administer the medication as ordered, perform lab work as ordered to monitor therapeutic levels, and notify the physician of any abnormal results. He also needed [MEDICAL TREATMENT] treatments and staff were to communicate with the [MEDICAL TREATMENT] center and monitor lab values as ordered. Review of the 60-day MDS Assessment for Resident #1 dated 02/06/2017, reflected a BIMS score of 14 indicated cognitively intact. He had an Active [DIAGNOSES REDACTED]. He also received an Anticoagulant for four (4) of seven (7) days. He also received [MEDICAL TREATMENT], while he was a resident. Review of the Physician order [REDACTED]. Review of Resident #1's admission orders [REDACTED]. Review of the Treatment Administration Record (TAR) for Resident #1 dated February 2017, reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM with an order date and start date of 12/12/2016. The TAR reflected the circled initials of RN A on 02/01/2017, 02/03/2017, 02/06/2017, and 02/08/2017. There were no explanations of the circled initials for the [MEDICATION NAME], but RN A gave the reason for not administering a [MEDICATION NAME] on 02/01/2017 at 3:00 PM as Resident #1 was at [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. There were no initials for 02/09/2017 and 02/10/2017 on the [MEDICATION NAME] order-indicated the medication was not given. Review of the TAR for Resident #1 dated January 2017, reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM. with an order and start date of 12/12/2016 had circled initials of RN A on 01/02/2017, 01/04/2017, 01/06/2017, 01/11/2017, 01/13/2017, 01/16/2017, 01/18/2017, 01/20/2017, 01/23/2017, 01/25/2017, 01/27/2017, and 01/30/2017. The TAR reflected the explanation of the circled initials on 01/02/2017 only was out to [MEDICAL TREATMENT] on M, W, F (Monday, Wednesday, Friday). Review of the TAR for Resident #1 dated December 2016, reflected [MEDICATION NAME] 3 mg one per mouth at 5:00 PM (hand written). The order had circled initials of RN A on 12/14/2016, 12/16/2016, 12/19/2016, 12/21/2016, 12/23/2016, 12/26/2016, and 12/28/2016. There was an explanation for the circled initials of Res (Resident) has [MEDICAL TREATMENT] on M, W, F and leaves at 2:15p and doesn't return til 8p. The TAR had no initials for 12/24/2016, 12/25/2016, 12/29/2016, 12/30/2016, or 12/31/2016. Resident #1 was at the hospital from 11/30/2016-12/12/2016. Review of the History and Physical Report from the hospital for Resident #1 dated 02/12/2017, reflected he was short of breath. The medications listed for him included [MEDICATION NAME] ([MEDICATION NAME]) 5 mg a day. The Report reflected he had swollen legs. The lab findings reflected his [MEDICATION NAME] level was below therapeutic levels. The [DIAGNOSES REDACTED]. Review of the Progress Note from the hospital for Resident #1 dated 02/16/2017, reflected .Patient was diagnosed with [REDACTED]. In an interview on 02/17/2017 at 11:35 AM, Resident #1's spouse (also a Resident at the facility) stated Resident #1 was not getting his evening time medications from RN A on Mondays, Wednesdays, or Fridays because he was at [MEDICAL TREATMENT]. She stated she talked to ADON who told her (Resident #1's spouse) she (ADON) would find out what should be done. Resident #1's spouse stated ADON said it was okay for Resident #1 to miss the [MEDICATION NAME] medication on his [MEDICAL TREATMENT] days. Resident #1's spouse stated she questioned the response from ADON, but she continued to assure Resident #1's spouse it would be okay. Resident #1's spouse stated Resident #1 went to the hospital on Sunday (02/12/2017) for shortness of breath around 12:30 PM. She stated Resident #1 had blood clots in both of his legs and his lung. In an interview on 02/17/2017 at 5:04 PM, RN A stated she was not giving Resident #1 his [MEDICATION NAME] on his [MEDICAL TREATMENT] days because he was gone at 5:00 PM. She stated Resident #1 left on Monday, Wednesday, and Friday around 2:00 PM and returned around 8:30 PM. She stated she worked at the facility from 2:00 PM to 10:00 PM every Monday through Friday. She stated she did not notify the physician or the DON about the doses of [MEDICATION NAME] she was not giving on Monday, Wednesday, or Friday. She stated she should have called to inform the physician of the missed doses, but she was not sure if the [MEDICATION NAME] could be given at a different time. In an interview on 02/17/2017 at 5:21 PM, the on-call physician stated he did not know Resident #1 and he could not give any information because the hospital did not allow the physicians to follow their residents at the hospital, they had their own doctors. He stated the physicians were alerted when their residents were in the hospital and when they return. He stated they sometimes received notes from the hospital to review. He also stated the physician for Resident #1 was not available at this time. In an interview on 02/17/2017 at 5:52 PM, Resident #1's spouse called the hospital while this surveyor was in the room. The nurse from the hospital confirmed the [DIAGNOSES REDACTED]. Resident #1 was also on the phone and stated he had not been receiving the [MEDICATION NAME] when he went to [MEDICAL TREATMENT]. Resident #1's spouse stated he also was not getting the levels checked by lab work. Review of Medial Records for Resident #1, revealed no lab orders or results since 12/12/16 to the investigation date of 02/17/17. In an interview on 02/17/2017 at 6:10 PM, DON stated she received the paperwork from the hospital (Progress Note dated 02/16/2017 listed above) and she confirmed Resident #1 had a [MEDICAL CONDITION] Embolism. DON stated she was not aware Resident #1 was not receiving the ordered [MEDICATION NAME] on his [MEDICAL TREATMENT] days. DON stated the facility standard was for residents on [MEDICATION NAME] to have monthly lab draws for [MEDICATION NAME] levels unless the physician ordered something different. In an interview on 02/17/2017 at 6:15 PM, Administrator stated she was not made aware Resident #1 was not receiving his ordered [MEDICATION NAME]. Administrator stated RN A was suspended on 02/11/2017 and had not returned. In an interview on 02/17/2017 at 7:00 PM, ADON stated at first she was not aware of Resident #1 not getting his [MEDICATION NAME]. Then ADON stated she had discussed the medication [MEDICATION NAME] with Resident #1 and his wife (also a Resident at the facility). ADON stated she was aware he was not getting the [MEDICATION NAME] on [MEDICAL TREATMENT] days. She stated she was talking with a NP at the facility about [MEDICATION NAME] and the NP mentioned it was okay to not get the [MEDICATION NAME] on days a resident goes to [MEDICAL TREATMENT] because the medications are washed out. ADON stated she did not call Resident #1's physician to notify him of the situation. She stated after looking at the MARs and TARs she was aware of the situation since 12/20/2016. She stated she also did not alert DON. Review of the Face Sheet of Resident #5 dated 02/18/2017 reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS Assessment for Resident #5 dated 01/23/2017 reflected a BIMS score of 10 indicated moderate cognitive impairment. She had active [DIAGNOSES REDACTED]. She also received anticoagulant therapy medications for all 7 days of the assessment period. Review of the Care Plan for Resident #5 dated 09/28/2016 reflected she was on anticoagulant therapy and staff would encourage safety awareness to prevent injury, monitor for bleeding, perform labs as indicated, and notify Physician of any abnormal findings. Review of the Physician order [REDACTED]. Review of the TAR for Resident #5 dated December 2016 reflected a hand written order for [MEDICATION NAME] 2 mg one tablet every day. The order started on 12/21/2016 but was not given on 12/21/2016, 12/22/2016, 12/23/2016, 12/26/2016, 12/27/2016, or 12/29/2016. In an interview on 02/17/2017 at 7:42 PM Administrator and DON stated they were not aware of the omissions of [MEDICATION NAME] for Resident #5. Review of the facility's policy entitled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/2001 reflected Each resident has the right to be free from .neglect . The policy included the definition of neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy reflected under Identification 1. Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Administrator or DON and investigated immediately. The policy reflected under Reporting/Response 1. Any employee who becomes aware of an allegation of .neglect .shall report the incident to a supervisor, DON or Administrator immediately. Failure to do so will result in disciplinary action, up to and including termination .The facility will report to the state board of nursing .any substantiated allegation. The facility Administrator, DON, and Corporate Clinical Specialist (on phone) were advised on 02/17/2017 at 7:42 PM that an IJ had been identified due to failures listed in the above evidence. On 02/18/2017 at 9:19 AM the Administrator provided surveyor with a written Plan of Removal that was accepted on 02/18/2017 at 12:47 PM and reflected: Concern: On February 17, 2017, facility administration was made aware of an immediate jeopardy concerning resident #1 not receiving [MEDICATION NAME] on his [MEDICAL TREATMENT] days and the presence of omissions on the Medication Administration Record [REDACTED] Resident Specific Actions: Resident #1 is presently in the hospital. The facility was unable to contact the residents attending physician regarding the missed doses of [MEDICATION NAME] for resident #1 and the documentation omissions for resident #5, therefore the on call physician who is also the Medical Director was contacted, February 17, 2017, and informed of the missed doses and the concerns voiced by agency. Actions Taken to Identify Other Residents with the potential to be effected by this practice: Medication Administration Records for the last 3 months reviewed for all residents receiving anti-coagulant therapy to ensure all doses have been given per physician orders. Review revealed 30 documentation omissions for resident #1. Omissions for resident #1 were omitted by 2 employees. RN #1(A) is no longer employed by the facility and RN #2 (ADON) was counseled on February 18, 2017. The on call physician for Resident #1 was notified. Review also revealed 8 documentation omissions for Resident #5. Omissions for resident #5 were omitted by 3 Licensed Nurses. RN#1 (A) is no longer employed at the facility. LVN #1 and LVN #2 were counseled regarding the omissions. The on call physician for Resident #5 was notified. Systematic Changes: All in-services below were initiated on 2-17-2017 and will be completed on 2-18-2017. No nursing employee will be allowed to work their scheduled shift until they have received in-servicing on the topics identified below. All In-services will be completed by the Director of Nursing or Designee. An In-service with Licensed Nurses, entitled, Missed Dose Protocol for Nurses, was initiated on February 17, 2017. The in-service stated that, anytime a medication is not given the doctor must be notified and the NP can only be notified if they are the NP for that physician. An In-service was initiated with the Medication Aides on February 17, 2017, entitled, Missed Dose Protocol for CMA's. The in-service stated that anytime there is a medication issue or a medication not given, the nurse must be notified. An In-service was initiated with the Licensed Nurses, entitled, Ensuring Proper Drug Regimens for [MEDICAL TREATMENT] Residents. The in-service informed staff that if [MEDICAL TREATMENT] times conflicts with scheduled medication administration times, then the physician needs to be contacted to make appropriate administration time adjustments. On February 17, 2017, the facility's Medical Director provided education to nurse practitioner regarding [MEDICATION NAME] withholding for [MEDICAL TREATMENT] residents. A disciplinary action was completed with the ADON for failure to notify MD and the DON of [MEDICAL TREATMENT] time conflicting with scheduled time of [MEDICATION NAME] administration. Expectations for ADON outlined in disciplinary action. DON or designee will review MAR's daily to ensure proper administration procedures are followed and no omissions are present. If any missed doses are identified they will follow up to ensure that the MD has been notified. Monitoring and Quality Assurance: Nursing administration will review MAR'S daily to validate medication administration as per order. And if any missed doses are identified they will follow up to ensure MD has been notified. Nursing Administration will review labs for residents on anti-coagulants to ensure labs are completed. Nursing Administration followed up with physician to ensure PT/INR ordered monthly at a minimum for residents on [MEDICATION NAME] Therapy. Nursing Administration will audit medication administration records for resident's receiving [MEDICAL TREATMENT] twice a week to ensure they are receiving medications as ordered. The results of audits, observations, and reviews will be reviewed by the Regional Clinical Specialist and or designee and shared with the QA team monthly to ensure continued compliance. Any issues identified will be addressed as the QA team deems necessary. IJ Removal Completion Date: February 18, 2017 The Surveyor monitored the current plan of removal on 02/17/17 - 02/18/17 as follows: Review of the records of five (5) other residents (Residents #4, #5, #6, #7, and #8 on anticoagulants and findings were listed above for Resident #5. No other concerns found for the other listed residents. Observation on 02/18/2017 at 10:49 AM revealed the DON provided an in-service for the nursing staff on Medication Administration, Omissions, and Notification to the Physician. The DON provided the in-service and sign-in sheets. Interviews on 02/18/2017 at 12:42 PM through 1:16 PM with a RN B, LVN D, and MA H; they stated understanding of the in-service provided. Review of the In-Services entitled Ensure Proper Drug Regime for the [MEDICAL TREATMENT] Residents, Missed Dose Protocol for Nurses, Missed Medications/Dose Protocol for CMAs dated 02/17/2017 reflected the staff were trained on these topics/policies and over 70 percent of the nurses and medication aides were trained. The Administrator was notified on 02/18/2017 at 1:56 PM that the IJ was removed, however, the facility remained out of compliance at a Severity level of Harm at a Scope of Pattern that is not IJ due to the facility required time to train all staff and monitor their Plan of Removal. The facility provided a list of ten (10) residents in the facility that was prescribed anticoagulants.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (1) of eight (8) residents reviewed for neglect. The facility failed to administer physician ordered [MEDICATION NAME] to Resident #1. Resident #1 was not administered the [MEDICATION NAME] on Mondays, Wednesdays, or Fridays by RN A, when Resident #1 went to [MEDICAL TREATMENT]. RN A did not consult the physician about not administering the [MEDICATION NAME]. ADON did not consult the physician when she was aware of the omissions on 12/20/2016. The Administrator and DON were also not consulted. Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. This resulted in an Immediate Jeopardy (IJ) on 02/17/2017. While the IJ was removed on 02/18/2017, the facility remained out of compliance at a Severity Level of Actual Harm that is not Immediate Jeopardy with a Scope of Pattern that is not IJ. This deficient practice affected Resident #1 and placed ten (10) residents prescribed anticoagulant therapy at risk for [MEDICAL CONDITION] Embolisms, blood clots, and possible death. Findings include: Review of the facility's policy entitled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/2001 reflected Each resident has the right to be free from .neglect . The policy included the definition of neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy reflected under Identification 1. Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Administrator or DON and investigated immediately. The policy reflected under Reporting/Response 1. Any employee who becomes aware of an allegation of .neglect .shall report the incident to a supervisor, DON or Administrator immediately. Failure to do so will result in disciplinary action, up to and including termination .The facility will report to the state board of nursing .any substantiated allegation. Review of the Face Sheet for Resident #1 dated 11/22/2016 reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Care Plan for Resident #1 dated 12/20/2016, reflected he was prescribed an Anticoagulant and staff were to administer the medication as ordered, perform lab work as ordered to monitor therapeutic levels, and notify the physician of any abnormal results. He also needed [MEDICAL TREATMENT] treatments and staff were to communicate with the [MEDICAL TREATMENT] center and monitor lab values as ordered. Review of the 60 day MDS Assessment for Resident #1 dated 02/06/2017 reflected a BIMS score of 14 indicated cognitively intact. He had an Active [DIAGNOSES REDACTED]. He also received an Anticoagulant for four (4) of seven (7) days. He also received [MEDICAL TREATMENT], while he was a resident. Review of the Physician order [REDACTED]. Review of Resident #1's admission orders [REDACTED]. Review of the Treatment Administration Record (TAR) for Resident #1 dated February 2017 reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM with an order date and start date of 12/12/2016. The TAR reflected the circled initials of RN A on 02/01/2017, 02/03/2017, 02/06/2017, and 02/08/2017. There were no explanations of the circled initials for the [MEDICATION NAME], but RN A gave the reason for not administering a [MEDICATION NAME] on 02/01/2017 at 3:00 PM as Resident #1 was at [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. There were no initials for 02/09/2017 and 02/10/2017 on the [MEDICATION NAME] order indicated the medication was not given. Review of the TAR for Resident #1 dated January 2017 reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM. with an order and start date of 12/12/2016 had circled initials of RN A on 01/02/2017, 01/04/2017, 01/06/2017, 01/11/2017, 01/13/2017, 01/16/2017, 01/18/2017, 01/20/2017, 01/23/2017, 01/25/2017, 01/27/2017, and 01/30/2017. The TAR reflected the explanation of the circled initials on 01/02/2017 only was out to [MEDICAL TREATMENT] on M, W, F (Monday, Wednesday, Friday). Review of the TAR for Resident #1 dated December 2016 reflected [MEDICATION NAME] 3 mg one per mouth at 5:00 PM (hand written) The order had circled initials of RN A on 12/14/2016, 12/16/2016, 12/19/2016, 12/21/2016, 12/23/2016, 12/26/2016, and 12/28/2016. There was an explanation for the circled initials of Res (Resident) has [MEDICAL TREATMENT] on M, W, F and leaves at 2:15p and doesn't return til 8p. The TAR had no initials for 12/24/2016, 12/25/2016, 12/29/2016, 12/30/2016, or 12/31/2016. Resident #1 was at the hospital from 11/30/2016 12/12/2016. Review of the History and Physical Report from the hospital for Resident #1 dated 02/12/2017 reflected he was short of breath. The medications listed for him included [MEDICATION NAME] ([MEDICATION NAME]) 5 mg a day. The Report reflected he had swollen legs. The lab findings reflected his [MEDICATION NAME] level was below therapeutic levels. The [DIAGNOSES REDACTED]. Review of the Progress Note from the hospital for Resident #1 dated 02/16/2017 reflected .Patient was diagnosed with [REDACTED]. In an interview on 02/17/2017 at 11:35 AM Resident #1's spouse (also a Resident at the facility) stated Resident #1 was not getting his evening time medications from RN A on Mondays, Wednesdays, or Fridays because he was at [MEDICAL TREATMENT]. She stated she talked to ADON who told her (Resident #1's spouse) she (ADON) would find out what should be done. Resident #1's spouse stated ADON said it was okay for Resident #1 to miss the [MEDICATION NAME] medication on his [MEDICAL TREATMENT] days. Resident #1's spouse stated she questioned the response from ADON, but she continued to assure Resident #1's spouse it would be okay. Resident #1's spouse stated Resident #1 went to the hospital on Sunday (02/12/2017) for shortness of breath around 12:30 PM. She stated Resident #1 had blood clots in both of his legs and his lung. In an interview on 02/17/2017 at 5:04 PM RN A stated she was not giving Resident #1 his [MEDICATION NAME] on his [MEDICAL TREATMENT] days because he was gone at 5:00 PM. She stated Resident #1 left on Monday, Wednesday, and Friday around 2:00 PM and returned around 8:30 PM. She stated she worked at the facility from 2:00 PM to 10:00 PM every Monday through Friday. She stated she did not notify the physician or the DON about the doses of [MEDICATION NAME] she was not giving on Monday, Wednesday, or Friday. She stated she should have called to inform the physician of the missed doses, but she was not sure if the [MEDICATION NAME] could be given at a different time. In an interview on 02/17/2017 at 5:21 PM the on call physician stated he did not know Resident #1 and he could not give any information because the hospital did not allow the physicians to follow their residents at the hospital, they had their own doctors. He stated the physicians were alerted when their residents were in the hospital and when they return. He stated they sometimes received notes from the hospital to review. He also stated the physician for Resident #1 was not available at this time. In an interview on 02/17/2017 at 5:52 PM Resident #1's spouse called the hospital while this surveyor was in the room. The nurse from the hospital confirmed the [DIAGNOSES REDACTED]. Resident #1 was also on the phone and stated he had not been receiving the [MEDICATION NAME] when he went to [MEDICAL TREATMENT]. Resident #1's spouse stated he also was not getting the levels checked by lab work. Review of Medial Records for Resident #1 revealed no lab orders or results since 12/12/16 to the investigation date of 02/17/17. In an interview on 02/17/2017 at 6:10 PM DON stated she received the paperwork from the hospital (Progress Note dated 02/16/2017 listed above) and she confirmed Resident #1 had a [MEDICAL CONDITION] Embolism. DON stated she was not aware Resident #1 was not receiving the ordered [MEDICATION NAME] on his [MEDICAL TREATMENT] days. DON stated the facility standard was for residents on [MEDICATION NAME] to have monthly lab draws for [MEDICATION NAME] levels unless the physician ordered something different. In an interview on 02/17/2017 at 6:15 PM Administrator stated she was not made aware Resident #1 was not receiving his ordered [MEDICATION NAME]. Administrator stated RN A was suspended on 02/11/2017 and had not returned. In an interview on 02/17/2017 at 7:00 PM ADON stated at first she was not aware of Resident #1 not getting his [MEDICATION NAME]. Then ADON stated she had discussed the medication [MEDICATION NAME] with Resident #1 and his wife (also a Resident at the facility). ADON stated she was aware he was not getting the [MEDICATION NAME] on [MEDICAL TREATMENT] days. She stated she was talking with a NP at the facility about [MEDICATION NAME] and the NP mentioned it was okay to not get the [MEDICATION NAME] on days a resident goes to [MEDICAL TREATMENT] because the medications are washed out. ADON stated she did not call Resident #1's physician to notify him of the situation. She stated after looking at the MARs and TARs she was aware of the situation since 12/20/2016. She stated she also did not alert DON. Review of the Face Sheet of Resident #5 dated 02/18/2017 reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS Assessment for Resident #5 dated 01/23/2017 reflected a BIMS score of 10 indicated moderate cognitive impairment. She had active [DIAGNOSES REDACTED]. She also received anticoagulant therapy medications for all 7 days of the assessment period. Review of the Care Plan for Resident #5 dated 09/28/2016 reflected she was on anticoagulant therapy and staff would encourage safety awareness to prevent injury, monitor for bleeding, perform labs as indicated, and notify Physician of any abnormal findings. Review of the Physician order [REDACTED]. Review of the TAR for Resident #5 dated December 2016 reflected a hand written order for [MEDICATION NAME] 2 mg one tablet every day. The order started on 12/21/2016 but was not given on 12/21/2016, 12/22/2016, 12/23/2016, 12/26/2016, 12/27/2016, or 12/29/2016. In an interview on 02/17/2017 at 7:42 PM Administrator and DON stated they were not aware of the omissions of [MEDICATION NAME] for Resident #5. The facility Administrator, DON, and Corporate Clinical Specialist (on phone) were advised on 02/17/2017 at 7:42 PM that an IJ had been identified due to failures listed in the above evidence. On 02/18/2017 at 9:19 AM the Administrator provided surveyor with a written Plan of Removal that was accepted on 02/18/2017 at 12:47 PM and reflected: Concern: On February 17, 2017, facility administration was made aware of an immediate jeopardy concerning resident #1 not receiving [MEDICATION NAME] on his [MEDICAL TREATMENT] days and the presence of omissions on the Medication Administration Record [REDACTED] Resident Specific Actions: Resident #1 is presently in the hospital. The facility was unable to contact the residents attending physician regarding the missed doses of [MEDICATION NAME] for resident #1 and the documentation omissions for resident #5, therefore the on call physician who is also the Medical Director was contacted, February 17, 2017, and informed of the missed doses and the concerns voiced by agency. Actions Taken to Identify Other Residents with the potential to be effected by this practice: Medication Administration Records for the last 3 months reviewed for all residents receiving anti coagulant therapy to ensure all doses have been given per physician orders. Review revealed 30 documentation omissions for resident #1. Omissions for resident #1 were omitted by 2 employees. RN #1(A) is no longer employed by the facility and RN #2 (ADON) was counseled on February 18, 2017. The on call physician for Resident #1 was notified. Review also revealed 8 documentation omissions for Resident #5. Omissions for resident #5 were omitted by 3 Licensed Nurses. RN#1 (A) is no longer employed at the facility. LVN #1 and LVN #2 were counseled regarding the omissions. The on call physician for Resident #5 was notified. Systematic Changes: All in services below were initiated on 2 17 2017 and will be completed on 2 18 2017. No nursing employee will be allowed to work their scheduled shift until they have received in servicing on the topics identified below. All In services will be completed by the Director of Nursing or Designee. An In service with Licensed Nurses, entitled, Missed Dose Protocol for Nurses, was initiated on February 17, 2017. The in service stated that, anytime a medication is not given the doctor must be notified and the NP can only be notified if they are the NP for that physician. An In service was initiated with the Medication Aides on February 17, 2017, entitled, Missed Dose Protocol for CMA's. The in service stated that anytime there is a medication issue or a medication not given, the nurse must be notified. An In service was initiated with the Licensed Nurses, entitled, Ensuring Proper Drug Regimens for [MEDICAL TREATMENT] Residents. The in service informed staff that if [MEDICAL TREATMENT] times conflicts with scheduled medication administration times, then the physician needs to be contacted to make appropriate administration time adjustments. On February 17, 2017, the facility's Medical Director provided education to nurse practitioner regarding [MEDICATION NAME] withholding for [MEDICAL TREATMENT] residents. A disciplinary action was completed with the ADON for failure to notify MD and the DON of [MEDICAL TREATMENT] time conflicting with scheduled time of [MEDICATION NAME] administration. Expectations for ADON outlined in disciplinary action. DON or designee will review MAR's daily to ensure proper administration procedures are followed and no omissions are present. If any missed doses are identified they will follow up to ensure that the MD has been notified. Monitoring and Quality Assurance: Nursing administration will review MAR'S daily to validate medication administration as per order. And if any missed doses are identified they will follow up to ensure MD has been notified. Nursing Administration will review labs for residents on anti coagulants to ensure labs are completed. Nursing Administration followed up with physician to ensure PT/INR ordered monthly at a minimum for residents on [MEDICATION NAME] Therapy. Nursing Administration will audit medication administration records for resident's receiving [MEDICAL TREATMENT] twice a week to ensure they are receiving medications as ordered. The results of audits, observations, and reviews will be reviewed by the Regional Clinical Specialist and or designee and shared with the QA team monthly to ensure continued compliance. Any issues identified will be addressed as the QA team deems necessary. IJ Removal Completion Date: February 18, 2017 The Surveyor monitored the current plan of removal on 02/17/17 02/18/17 as follows: Review of the records of five (5) other residents (Residents #4, #5, #6, #7, and #8 on anticoagulants and findings were listed above for Resident #5. No other concerns found for the other listed residents. Observation on 02/18/2017 at 10:49 AM revealed the DON provided an in service for the nursing staff on Medication Administration, Omissions, and Notification to the Physician. The DON provided the in service and sign in sheets. Interviews on 02/18/2017 at 12:42 PM through 1:16 PM with a RN B, LVN D, and MA H; they stated understanding of the in service provided. Review of the In Services entitled Ensure Proper Drug Regime for the [MEDICAL TREATMENT] Residents, Missed Dose Protocol for Nurses, Missed Medications/Dose Protocol for CMAs dated 02/17/2017 reflected the staff were trained on these topics/policies and over 70 percent of the nurses and medication aides were trained. The Administrator was notified on 02/18/2017 at 1:56 PM that the IJ was removed, however, the facility remained out of compliance at a Severity level of Harm at a Scope of Pattern that is not IJ due to the facility required time to train all staff and monitor their Plan of Removal. The facility provided a list of ten (10) residents in the facility that was prescribed anticoagulants.

Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication error when the staff failed to administer physician ordered medication to meet the needs of each resident for two (2) of six (6) residents (Resident #1 and Resident #5) reviewed for significant medication errors when: The facility failed to administer physician prescribed [MEDICATION NAME] (an anticoagulant) to Resident #1. Resident #1 was not administered the [MEDICATION NAME] on Mondays, Wednesdays, or Fridays by RN A when Resident #1 went to [MEDICAL TREATMENT]. RN A did not notify the physician about not administering the [MEDICATION NAME]. ADON did not notify the physician when she was aware of the omissions on 12/20/2016. The Administrator and DON were also not notified. Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. The facility failed to administer physician prescribed [MEDICATION NAME] to Resident #5. Resident #5 was not administered the [MEDICATION NAME] for six (6) days in December 2016. The physician, Administrator, and DON were not notified of the omissions. This resulted in an Immediate Jeopardy (IJ) on 02/17/2017. While the IJ was removed on 02/18/2017, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern that is not IJ. This deficient practice affected Resident #1 and Resident #5 and placed 10 residents prescribed anticoagulant therapy at risk for [MEDICAL CONDITION] Embolisms, blood clots, and possible death. Findings include: Review of the Face Sheet for Resident #1 dated 11/22/2016 reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Care Plan for Resident #1 dated 12/20/2016 reflected he was prescribed an Anticoagulant and staff were to administer the medication as ordered, perform lab work as ordered to monitor therapeutic levels, and notify the physician of any abnormal results. He also needed [MEDICAL TREATMENT] treatments and staff were to communicate with the [MEDICAL TREATMENT] center and monitor lab values as ordered. Review of the 60 day MDS Assessment for Resident #1 dated 02/06/2017 reflected a BIMS score of 14 indicated cognitively intact. He had an Active [DIAGNOSES REDACTED]. He also received an Anticoagulant for four (4) of seven (7) days. He was also received [MEDICAL TREATMENT] while he was a resident. Review of the Physician order [REDACTED]. Review of Resident #1's admission orders [REDACTED]. Review of the Treatment Administration Record (TAR) for Resident #1 dated February 2017 reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM with an order date and start date of 12/12/2016. The TAR reflected the circled initials of RN A on 02/01/2017, 02/03/2017, 02/06/2017, and 02/08/2017. There were no explanations of the circled initials for the [MEDICATION NAME], but RN A gave the reason for not administering a [MEDICATION NAME] on 02/01/2017 at 3:00 PM as Resident #1 was at [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. There were no initials for 02/09/2017 and 02/10/2017 on the [MEDICATION NAME] order indicated the medication was not given. Review of the TAR for Resident #1 dated January 2017 reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM with an order and start date of 12/12/2016 had circled initials of RN A on 01/02/2017, 01/04/2017, 01/06/2017, 01/11/2017, 01/13/2017, 01/16/2017, 01/18/2017, 01/20/2017, 01/23/2017, 01/25/2017, 01/27/2017, and 01/30/2017. The TAR reflected the explanation of the circled initials on 01/02/2017 only was out to [MEDICAL TREATMENT] on M, W, F (Monday, Wednesday, Friday). Review of the TAR for Resident #1 dated December 2016 reflected [MEDICATION NAME] 3 mg one per mouth at 5:00 PM (hand written) The order had circled initials of RN A on 12/14/2016, 12/16/2016, 12/19/2016, 12/21/2016, 12/23/2016, 12/26/2016, and 12/28/2016. There was an explanation for the circled initials of Res (Resident) has [MEDICAL TREATMENT] on M, W, F and leaves at 2:15p and doesn't return til 8p. The TAR had no initials for 12/24/2016, 12/25/2016, 12/29/2016, 12/30/2016, or 12/31/2016. Review of the History and Physical Report from the hospital for Resident #1 dated 02/12/2017 reflected he was short of breath. The medications listed for him included [MEDICATION NAME] ([MEDICATION NAME]) 5 mg a day. The Report reflected he had swollen legs. The lab findings reflected his [MEDICATION NAME] level was below therapeutic levels. The [DIAGNOSES REDACTED]. Review of the Progress Note from the hospital for Resident #1 dated 02/16/2017 reflected .Patient was diagnosed with [REDACTED]. In an interview on 02/17/2017 at 11:35 AM Resident #1's spouse (also a Resident at the facility) stated Resident #1 was not getting his evening time medications from RN A on Mondays, Wednesdays, or Fridays because he was at [MEDICAL TREATMENT]. She stated she talked to ADON who told her (Resident #1's spouse) she (ADON) would find out what should be done. Resident #1's spouse stated ADON said it was okay for Resident #1 to miss the [MEDICATION NAME] medication on his [MEDICAL TREATMENT] days. Resident #1's spouse stated she questioned the response from ADON, but she continued to assure Resident #1's spouse it would be okay. Resident #1's spouse stated Resident #1 went to the hospital on Sunday (02/12/2017) for shortness of breath around 12:30 PM. She stated Resident #1 had blood clots in both of his legs and his lung. In an interview on 02/17/2017 at 5:04 PM RN A stated she was not giving Resident #1 his [MEDICATION NAME] on his [MEDICAL TREATMENT] days because he was gone at 5:00 PM. She stated Resident #1 left on Monday, Wednesday, and Friday around 2:00 PM and returned around 8:30 PM. She stated she worked at the facility from 2:00 PM to 10:00 PM every Monday through Friday. She stated she did not notify the physician or the DON about the doses of [MEDICATION NAME] she was not giving on Monday, Wednesday, or Friday. She stated she should have called to inform the physician of the missed doses, but she was not sure if the [MEDICATION NAME] could be given at a different time. In an interview on 02/17/2017 at 5:21 pm the on call physician stated he did not know Resident #1 and he could not give any information because the hospital did not allow the physicians to follow their residents at the hospital, they had their own doctors. He stated the physicians were alerted when their residents were in the hospital and when they return. He stated they sometimes received notes from the hospital to review. He also stated the physician for Resident #1 was not available at this time. In an interview on 02/17/2017 at 5:52 PM Resident #1's spouse called the hospital while this surveyor was in the room. The nurse from the hospital confirmed the [DIAGNOSES REDACTED]. Resident #1 was also on the phone and stated he had not been receiving the [MEDICATION NAME] when he went to [MEDICAL TREATMENT]. Resident #1's spouse stated he also was not getting the levels checked by lab work. Review of Resident #1's Medical Records reflected no lab orders or results from 12/12/2016 through the review date of 02/17/17. In an interview on 02/17/2017 at 6:10 PM DON stated she received the paperwork from the hospital (Progress Note dated 02/16/2017) and she confirmed Resident #1 had a [MEDICAL CONDITION] Embolism. DON stated she was not aware Resident #1 was not receiving the ordered [MEDICATION NAME] on his [MEDICAL TREATMENT] days. DON stated the facility standard was for residents on [MEDICATION NAME] to have monthly lab draws for PT/INR unless the physician ordered something weekly. In an interview on 02/17/2017 at 6:15 PM Administrator stated she was not made aware Resident #1 was not receiving his ordered [MEDICATION NAME]. Administrator stated RN A was suspended on 02/11/2017 and had not returned. In an interview on 02/17/2017 at 7:00 PM ADON stated at first she was not aware of Resident #1 not getting his [MEDICATION NAME]. Then ADON stated she had discussed the medication [MEDICATION NAME] with Resident #1 and his wife Resident #8. ADON stated she was aware he was not getting the [MEDICATION NAME] on [MEDICAL TREATMENT] days. She stated she was taking with a NP at the facility about [MEDICATION NAME] and the NP mentioned it was okay to not get the [MEDICATION NAME] on days a resident goes to [MEDICAL TREATMENT] because the medications are washed out. ADON stated she did not call Resident #1's physician to notify him of the situation. She stated after looking at the MARs and TARs she was aware of the situation since 12/20/2016. She stated she also did not alert DON. Review of the Face Sheet of Resident #5 dated 02/18/2017 reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS Assessment for Resident #5 dated 01/23/2017 reflected a BIMS score of 10 indicated moderate cognitive impairment. She had active [DIAGNOSES REDACTED]. She also received anticoagulant therapy medications for all 7 days of the assessment period. Review of the Care Plan for Resident #5 dated 09/28/2016 reflected she was on anticoagulant therapy and staff would encourage safety awareness to prevent injury, monitor for bleeding, perform labs as indicated, and notify Physician of any abnormal findings. Review of the Physician order [REDACTED]. Review of the TAR for Resident #5 dated December 2016 reflected a hand written order for [MEDICATION NAME] 2 mg one tablet every day. The order started on 12/21/2016 but was not given on 12/21/2016, 12/22/2016, 12/23/2016, 12/26/2016, 12/27/2016, or 12/29/2016. In an interview on 02/17/2017 at 7:42 PM Administrator and DON stated they were not aware of the omissions of [MEDICATION NAME] for Resident #5. Review of the facility's policy entitled Medication Administration General Guidelines dated 2007 and revised 09/2010 reflected Medications are administered in accordance with written orders of the prescriber .If necessary, the nurse contacts the prescriber for clarification. The Policy also reflected Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR indicated [REDACTED].,tags, colored plastic strips, or paper clips). After completing the medication pass, the nurse returns to the missed resident to administer the medication. The policy reflected under Documentation: .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time .), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. The facility Administrator, DON, and Corporate Clinical Specialist (on phone) were advised on 02/17/2017 at 7:42 PM that an IJ had been identified due to failures listed in the above evidence. On 02/18/2017 at 9:19 AM the Administrator provided surveyor with a written Plan of Removal that was accepted on 02/18/2017 at 12:47 PM and reflected: Concern: On February 17, 2017, facility administration was made aware of an immediate jeopardy concerning resident #1 not receiving [MEDICATION NAME] on his [MEDICAL TREATMENT] days and the presence of omissions on the Medication Administration Record [REDACTED] Resident Specific Actions: Resident #1 is presently in the hospital. The facility was unable to contact the residents attending physician regarding the missed doses of [MEDICATION NAME] for resident #1 and the documentation omissions for resident #5, therefore the on call physician who is also the Medical Director was contacted, February 17, 2017, and informed of the missed doses and the concerns voiced by agency. Actions Taken to Identify Other Residents with the potential to be effected by this practice: Medication Administration Records for the last 3 months reviewed for all residents receiving anti coagulant therapy to ensure all doses have been given per physician orders. Review revealed 30 documentation omissions for resident #1. Omissions for resident #1 were omitted by 2 employees. RN #1(A) is no longer employed by the facility and RN #2 (ADON) was counseled on February 18, 2017. The on call physician for Resident #1 was notified. Review also revealed 8 documentation omissions for Resident #5. Omissions for resident #5 were omitted by 3 Licensed Nurses. RN#1 (A) is no longer employed at the facility. LVN #1 and LVN #2 were counseled regarding the omissions. The on call physician for Resident #5 was notified. Systematic Changes: All in services below were initiated on 2 17 2017 and will be completed on 2 18 2017. No nursing employee will be allowed to work their scheduled shift until they have received in servicing on the topics identified below. All In services will be completed by the Director of Nursing or Designee. An In service with Licensed Nurses, entitled, Missed Dose Protocol for Nurses, was initiated on February 17, 2017. The in service stated that, anytime a medication is not given the doctor must be notified and the NP can only be notified if they are the NP for that physician. An In service was initiated with the Medication Aides on February 17, 2017, entitled, Missed Dose Protocol for CMA's. The in service stated that anytime there is a medication issue or a medication not given, the nurse must be notified. An In service was initiated with the Licensed Nurses, entitled, Ensuring Proper Drug Regimens for [MEDICAL TREATMENT] Residents. The in service informed staff that if [MEDICAL TREATMENT] times conflicts with scheduled medication administration times, then the physician needs to be contacted to make appropriate administration time adjustments. On February 17, 2017, the facility's Medical Director provided education to nurse practitioner regarding [MEDICATION NAME] withholding for [MEDICAL TREATMENT] residents. A disciplinary action was completed with the ADON for failure to notify MD and the DON of [MEDICAL TREATMENT] time conflicting with scheduled time of [MEDICATION NAME] administration. Expectations for ADON outlined in disciplinary action. DON or designee will review MAR's daily to ensure proper administration procedures are followed and no omissions are present. If any missed doses are identified they will follow up to ensure that the MD has been notified. Monitoring and Quality Assurance: Nursing administration will review MAR'S daily to validate medication administration as per order. And if any missed doses are identified they will follow up to ensure MD has been notified. Nursing Administration will review labs for residents on anti coagulants to ensure labs are completed. Nursing Administration followed up with physician to ensure PT/INR ordered monthly at a minimum for residents on [MEDICATION NAME] Therapy. Nursing Administration will audit medication administration records for resident's receiving [MEDICAL TREATMENT] twice a week to ensure they are receiving medications as ordered. The results of audits, observations, and reviews will be reviewed by the Regional Clinical Specialist and or designee and shared with the QA team monthly to ensure continued compliance. Any issues identified will be addressed as the QA team deems necessary. IJ Removal Completion Date: February 18, 2017 The Surveyor monitored the current plan of removal from 02/17/17 to 02/18/17 as follows: Review of the records of five (5) other residents (Residents #4, #5, #6, #7, and #8 on anticoagulants and findings were listed above for Resident #5. No other concerns found for the other listed residents. Observation on 02/18/2017 at 10:49 AM, revealed the DON provided an in service for the nursing staff on Medication Administration, Omissions, and Notification to the Physician. The DON provided the in service and sign in sheets. Interviews on 02/18/2017 at 12:42 PM through 1:16 PM with RN B, LVN D, and MA H; they stated understanding of the in service provided. Review of the In Services entitled Ensure Proper Drug Regime for the [MEDICAL TREATMENT] Residents, Missed Dose Protocol for Nurses, Missed Medications/Dose Protocol for CMAs dated 02/17/2017 reflected the staff were trained on these topics/policies and over 70 percent of the nurses and medication aides were trained. The Administrator was notified on 02/18/2017 at 1:56 PM, that the IJ was removed, however, the facility remained out of compliance at a Severity level of Harm at a Scope of Pattern that is not IJ due to the facility required time to train all staff and monitor their Plan of Removal. The facility provided a list of ten (10) residents in the facility that were prescribed anticoagulants.

Based on observation, interview, and record review the facility failed to immediately inform the resident; and consult with the resident's physician; when there was a significant change in the resident's physical, mental, or psychosocial status for two (2) of six (6) residents (Resident #1 and Resident #5) reviewed for notification of change of condition when: The facility failed to administer physician ordered [MEDICATION NAME] to Resident #1. Resident #1 was not administered the [MEDICATION NAME] on Mondays, Wednesdays, or Fridays by RN A (the times Resident #1 went to [MEDICAL TREATMENT]). RN A did not notify the physician about not administering the [MEDICATION NAME]. ADON did not notify the physician when she was aware of the omissions on 12/20/2016. The Administrator and DON were also not notified. Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. The facility failed to administer physician ordered [MEDICATION NAME] to Resident #5. Resident #5 was not administered the [MEDICATION NAME] for six (6) days in December 2016. The physician, Administrator, and DON were not notified of the omissions. This resulted in an Immediate Jeopardy (IJ) on 02/17/2017. While the IJ was removed on 02/18/2017, the facility remained out of compliance at a severity level of actual harm with a scope of pattern that is not IJ. This deficient practice affected Resident #1 and Resident #5 and placed 10 residents prescribed anticoagulant therapy at risk for [MEDICAL CONDITION] Embolisms, blood clots, and possible death. Findings include: Review of the Face Sheet for Resident #1 dated 11/22/2016 reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Care Plan for Resident #1 dated 12/20/2016 reflected he was prescribed an Anticoagulant and staff were to administer the medication as ordered, perform lab work as ordered to monitor therapeutic levels, and notify the physician of any abnormal results. He also needed [MEDICAL TREATMENT] treatments and staff were to communicate with the [MEDICAL TREATMENT] center and monitor lab values as ordered. Review of the 60-day MDS Assessment for Resident #1 dated 02/06/2017, reflected a BIMS score of 14 indicated cognitively intact. He had an Active [DIAGNOSES REDACTED]. He also received an Anticoagulant for four (4) of seven (7) days. He was also received [MEDICAL TREATMENT] while he was a resident. Review of the Physician order [REDACTED]. Review of Resident #1's admission orders [REDACTED]. Review of the Treatment Administration Record (TAR) for Resident #1 dated February 2017, reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM, with an order date and start date of 12/12/2016. The TAR reflected the circled initials of RN A on 02/01/2017, 02/03/2017, 02/06/2017, and 02/08/2017. There were no explanations of the circled initials for the [MEDICATION NAME]; but RN A gave the reason for not administering a [MEDICATION NAME] on 02/01/2017 at 3:00 PM, as Resident #1 was at [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. There were no initials for 02/09/2017 and 02/10/2017 on the [MEDICATION NAME] order-indicated the medication was not given. Review of the TAR for Resident #1 dated January 2017, reflected [MEDICATION NAME] 3 mg tablet one per mouth every day at 5:00 PM with an order and start date of 12/12/2016, had circled initials of RN A on 01/02/2017, 01/04/2017, 01/06/2017, 01/11/2017, 01/13/2017, 01/16/2017, 01/18/2017, 01/20/2017, 01/23/2017, 01/25/2017, 01/27/2017, and 01/30/2017. The TAR reflected the explanation of the circled initials on 01/02/2017 only was out to [MEDICAL TREATMENT] on M, W, F (Monday, Wednesday, Friday). Review of the TAR for Resident #1 dated December 2016, reflected [MEDICATION NAME] 3 mg one per mouth at 5:00 PM (hand written). The order had circled initials of RN A on 12/14/2016, 12/16/2016, 12/19/2016, 12/21/2016, 12/23/2016, 12/26/2016, and 12/28/2016. There was an explanation for the circled initials of Res (Resident) has [MEDICAL TREATMENT] on M, W, F and leaves at 2:15p and doesn't return til 8p. The TAR had no initials for 12/24/2016, 12/25/2016, 12/29/2016, 12/30/2016, or 12/31/2016. Review of the History and Physical Report from the hospital for Resident #1 dated 02/12/2017, reflected he was short of breath. The medications listed for him included [MEDICATION NAME] ([MEDICATION NAME]) 5 mg a day. The Report reflected he had swollen legs. The lab findings reflected his [MEDICATION NAME] level was below therapeutic levels. The [DIAGNOSES REDACTED]. Review of the Progress Note from the hospital for Resident #1 dated 02/16/2017, reflected .Patient was diagnosed with [REDACTED]. In an interview on 02/17/2017 at 11:35 AM, Resident #1's spouse (also a Resident at the facility) stated Resident #1 was not getting his evening time medications from RN A on Mondays, Wednesdays, or Fridays because he was at [MEDICAL TREATMENT]. She stated she talked to ADON, who told her (Resident #1's spouse) that she (ADON) would find out what should be done. Resident #1's spouse stated the ADON said it was okay for Resident #1 to miss the [MEDICATION NAME] medication on his [MEDICAL TREATMENT] days. Resident #1's spouse stated she questioned the response from ADON, but she continued to assure Resident #1's spouse it would be okay. Resident #1's spouse stated Resident #1 went to the hospital on Sunday (02/12/2017) for shortness of breath around 12:30 PM. She stated Resident #1 had blood clots in both of his legs and his lung. In an interview on 02/17/2017 at 5:04 PM, RN A stated she was not giving Resident #1 his [MEDICATION NAME] on his [MEDICAL TREATMENT] days because he was gone at 5:00 PM. She stated Resident #1 left on Monday, Wednesday, and Friday around 2:00 PM and returned around 8:30 PM. She stated she worked at the facility from 2:00 PM to 10:00 PM every Monday through Friday. She stated she did not notify the physician or the DON about the doses of [MEDICATION NAME] she was not giving on Monday, Wednesday, or Friday. She stated she should have called to inform the physician of the missed doses, but she was not sure if the [MEDICATION NAME] could be given at a different time. In an interview on 02/17/2017 at 5:21 PM, the on-call physician stated he did not know Resident #1 and he could not give any information, because the hospital did not allow the physicians to follow their residents at the hospital; they (the hospital) had their own doctors. He stated the physicians were alerted when their residents were in the hospital and when they return. He stated they sometimes received notes from the hospital to review. He also stated the physician for Resident #1 was not available at this time. In an interview on 02/17/2017 at 5:52 PM, Resident #1's spouse called the hospital while this surveyor was in the room. The nurse from the hospital confirmed the [DIAGNOSES REDACTED]. Resident #1 was also on the phone and stated he had not been receiving the [MEDICATION NAME] when he went to [MEDICAL TREATMENT]. Resident #1's spouse stated he also was not getting the levels checked by lab work. Review of medical records for Resident #1, reflected no orders or results for labs since 12/12/17 through the investigation date of 02/17/17. In an interview on 02/17/2017 at 6:10 PM, DON stated she received the paperwork from the hospital (Progress Note dated 02/16/2017) and she confirmed Resident #1 had a [MEDICAL CONDITION] Embolism. DON stated she was not aware Resident #1 was not receiving the ordered [MEDICATION NAME] on his [MEDICAL TREATMENT] days. DON stated the facility standard was for residents on [MEDICATION NAME] to have monthly lab draws for PT/INR, unless the physician ordered something weekly. In an interview on 02/17/2017 at 6:15 PM Administrator stated she was not made aware Resident #1 was not receiving his ordered [MEDICATION NAME]. Administrator stated RN A was suspended on 02/11/2017, and had not returned. In an interview on 02/17/2017 at 7:00 PM, the ADON stated at first she was not aware of Resident #1 not getting his [MEDICATION NAME]. Then ADON stated she had discussed the medication [MEDICATION NAME] with Resident #1 and his wife Resident #8. The ADON stated she was aware he was not getting the [MEDICATION NAME] on [MEDICAL TREATMENT] days. She stated she was taking with a NP at the facility about [MEDICATION NAME] and the NP mentioned it was okay to not get the [MEDICATION NAME] on days a resident goes to [MEDICAL TREATMENT] because the medications are washed out. The ADON stated she did not call Resident #1's physician to notify him of the situation. She stated after looking at the MARs and TARs, she was aware of the situation since 12/20/2016. She stated she also did not alert DON. Review of the Face Sheet of Resident #5 dated 02/18/2017, reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS Assessment for Resident #5 dated 01/23/2017, reflected a BIMS score of 10 indicated moderate cognitive impairment. She had active [DIAGNOSES REDACTED]. She also received anticoagulant therapy medications for all 7 days of the assessment period. Review of the Care Plan for Resident #5 dated 09/28/2016, reflected she was on anticoagulant therapy and staff would encourage safety awareness to prevent injury, monitor for bleeding, perform labs as indicated, and notify Physician of any abnormal findings. Review of the Physician order [REDACTED]. Review of the TAR for Resident #5 dated December 2016, reflected a hand written order for [MEDICATION NAME] 2 mg one tablet every day. The order started on 12/21/2016, but was not given on 12/21/2016, 12/22/2016, 12/23/2016, 12/26/2016, 12/27/2016, or 12/29/2016. In an interview on 02/17/2017 at 7:42 PM, the Administrator and DON stated they were not aware of the omissions of [MEDICATION NAME] for Resident #5. Review of the facility's policy entitled Medication Administration General Guidelines dated 2007 and revised 09/2010, reflected Medications are administered in accordance with written orders of the prescriber .If necessary, the nurse contacts the prescriber for clarification. The Policy also reflected Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR indicated [REDACTED].,tags, colored plastic strips, or paper clips). After completing the medication pass, the nurse returns to the missed resident to administer the medication. The policy reflected under Documentation: .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time .), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. The facility Administrator, DON, and Corporate Clinical Specialist (on phone) were advised on 02/17/2017 at 7:42 PM that an IJ had been identified due to failures listed in the above evidence. On 02/18/2017 at 9:19 AM the Administrator provided surveyor with a written Plan of Removal that was accepted on 02/18/2017 at 12:47 PM and reflected: Concern: On February 17, 2017, facility administration was made aware of an immediate jeopardy concerning resident #1 not receiving [MEDICATION NAME] on his [MEDICAL TREATMENT] days and the presence of omissions on the Medication Administration Record [REDACTED] Resident Specific Actions: Resident #1 is presently in the hospital. The facility was unable to contact the residents attending physician regarding the missed doses of [MEDICATION NAME] for resident #1 and the documentation omissions for resident #5, therefore the on call physician who is also the Medical Director was contacted, February 17, 2017, and informed of the missed doses and the concerns voiced by agency. Actions Taken to Identify Other Residents with the potential to be effected by this practice: Medication Administration Records for the last 3 months reviewed for all residents receiving anti-coagulant therapy to ensure all doses have been given per physician orders. Review revealed 30 documentation omissions for resident #1. Omissions for resident #1 were omitted by 2 employees. RN #1(A) is no longer employed by the facility and RN #2 (ADON) was counseled on February 18, 2017. The on call physician for Resident #1 was notified. Review also revealed 8 documentation omissions for Resident #5. Omissions for resident #5 were omitted by 3 Licensed Nurses. RN#1 (A) is no longer employed at the facility. LVN #1 and LVN #2 were counseled regarding the omissions. The on call physician for Resident #5 was notified. Systematic Changes: All in-services below were initiated on 2-17-2017 and will be completed on 2-18-2017. No nursing employee will be allowed to work their scheduled shift until they have received in-servicing on the topics identified below. All In-services will be completed by the Director of Nursing or Designee. An In-service with Licensed Nurses, entitled, Missed Dose Protocol for Nurses, was initiated on February 17, 2017. The in-service stated that, anytime a medication is not given the doctor must be notified and the NP can only be notified if they are the NP for that physician. An In-service was initiated with the Medication Aides on February 17, 2017, entitled, Missed Dose Protocol for CMA's. The in-service stated that anytime there is a medication issue or a medication not given, the nurse must be notified. An In-service was initiated with the Licensed Nurses, entitled, Ensuring Proper Drug Regimens for [MEDICAL TREATMENT] Residents. The in-service informed staff that if [MEDICAL TREATMENT] times conflicts with scheduled medication administration times, then the physician needs to be contacted to make appropriate administration time adjustments. On February 17, 2017, the facility's Medical Director provided education to nurse practitioner regarding [MEDICATION NAME] withholding for [MEDICAL TREATMENT] residents. A disciplinary action was completed with the ADON for failure to notify MD and the DON of [MEDICAL TREATMENT] time conflicting with scheduled time of [MEDICATION NAME] administration. Expectations for ADON outlined in disciplinary action. DON or designee will review MAR's daily to ensure proper administration procedures are followed and no omissions are present. If any missed doses are identified they will follow up to ensure that the MD has been notified. Monitoring and Quality Assurance: Nursing administration will review MAR'S daily to validate medication administration as per order. And if any missed doses are identified they will follow up to ensure MD has been notified. Nursing Administration will review labs for residents on anti-coagulants to ensure labs are completed. Nursing Administration followed up with physician to ensure PT/INR ordered monthly at a minimum for residents on [MEDICATION NAME] Therapy. Nursing Administration will audit medication administration records for resident's receiving [MEDICAL TREATMENT] twice a week to ensure they are receiving medications as ordered. The results of audits, observations, and reviews will be reviewed by the Regional Clinical Specialist and or designee and shared with the QA team monthly to ensure continued compliance. Any issues identified will be addressed as the QA team deems necessary. IJ Removal Completion Date: February 18, 2017 The Surveyor monitored the current plan of removal from 02/17/17 - 02/18/17 as follows: Review of the records of five (5) other residents (Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) on anticoagulants and findings were listed above for Resident #5. No other concerns found for the other listed residents. Observation on 02/18/2017 at 10:49 AM. revealed the DON provided an in-service for the nursing staff on Medication Administration, Omissions, and Notification to the Physician. The DON provided the in-service and sign-in sheets. Interviews on 02/18/2017 at 12:42 PM through 1:16 PM, with RN B, LVN D, and MA H; they stated understanding of the in-service provided. Review of the In-Services entitled Ensure Proper Drug Regime for the [MEDICAL TREATMENT] Residents, Missed Dose Protocol for Nurses, Missed Medications/Dose Protocol for CMAs dated 02/17/2017, reflected the staff were trained on these topics/policies and over 70 percent of the nurses and medication aides were trained. The Administrator was notified on 02/18/2017 at 1:56 PM that the IJ was removed; however, the facility remained out of compliance at a Severity level of Harm at a Scope of Pattern that is not IJ due to the facility required time to train all staff and monitor their Plan of Removal. The facility provided a list of ten (10) residents in the facility that were prescribed anticoagulants.

Based on observation, interview and record review the facility failed to provide pharmaceuticals to meet the needs of each resident for two (2) of eight (8) residents reviewed for medication omissions and errors (Residents #3 and #6). A. Resident #3 received Lyrica 100 mg. twice daily instead of once daily. from 01/21/15-01/28/15 which led to her requiring IV fluids for hypotension, unnecessary lab studies, an altered mental status, poor fluid and food intake due to the altered mental status, incontinence, and dependence on staff for activities of daily living. B. Resident #6 was admitted to the facility on [DATE] and did not receive any physician ordered medications until 01/28/2014 at 5:00 pm, when they were available on the morning of 01/28/2015. These deficient practices could place a facility census of 85 residents at risk for ineffective physician interventions and treatments, worsening of medical conditions, unnecessary lab studies and medical interventions, and decline in activities of daily living. The Findings Include: A. Resident # 3 was [AGE] years old and had an original admission date of [DATE] and a readmission date of [DATE] with diagnoses which included, Parkinson's, Urine Retention, Paralysis Antigens, Abnormality of gait, Schizophrenia unspecific and Bipolar Disorder. Review of a MDS for Resident #3 dated 11/19/14 reflected the following: assistance of one for stability with toileting, always continent of bowel and occasional incontinence of urine, assistance of one to two persons with dressing and hygiene and cueing needed for encouragement to eat. Review of a physician's progress note for Resident #3 dated 01/25/15 reflected the following: Vital signs-pulse 59 regular, blood pressure 89/41 (normal blood pressure is 110/70). This is a patient of another provider, but is also known to me. I have known this patient and this certainly is not her baseline. Patient currently being treated for [REDACTED]. hour. Staff tried five attempts to start her IV but were unsuccessful. I started IV on first attempt. Lab studies ordered for 01/26/15 (CBC, CPM, and Lithium level) During an interview on 01/29/15 at 8:30 am, on initial tour, LVN Z stated Resident #3 had recently had a decline and change in condition after returning from a hospital stay for a urinary tract infection. LVN Z stated when Resident #3 returned to the facility on [DATE] she was alert and happy to see the staff and went to the dining room for a meal. Since then she had become increasingly unresponsive, incontinent of bowel and bladder and was receiving IV fluids for dehydration and low blood pressure. Resident #3 was observed in bed and unresponsive while two CNAs were providing incontinent care. Review of physician orders [REDACTED]. one capsule daily. Lyrica is a medication which can be used to treat seizures and agitation. Some of the sides effects are confusion, hypotension, somnolence (a very sleepy state) and dizziness. Further review of the physician orders [REDACTED]. one table twice daily for convulsions,Sinemet 25-100 one tablet twice daily for secondary Parkinsonism, Propranolol 10 mg. one tablet three times a day, Baclofen 10 mg. three times a day for muscle spasms, and Propranolol 10 mg. one tablet for tremors. Review of an electronic MAR for Resident #3 dated 01/21/15 reflected Lyrica 100 mg. twice daily (9:00 am and 5:00 pm). Further review of the MAR indicated [REDACTED]. twice daily from 01/21/15 through 01/28/15. In an interview on 01/29/15 at 11:30 am LVN Z stated she had transcribed Resident #3's physician orders [REDACTED]. one capsule twice daily rather than one capsule daily. In an interview on 01/29/15 at 11:40 a.m. the NP for the facility reviewed the electronic MAR for Resident #3 and confirmed she was receiving Lyrica 100 mg. twice daily rather than once daily as ordered. The NP stated this was more than likely the reason for her increased unresponsiveness, hypotension and loss of bowel and bladder continence. The NP stated she and the physician were confused by her rapid change in condition despite the fact her lab studies were within normal limits. In an interview at 11:47 am on 01/30/15 the NP stated Resident #3's vital signs had stabilized and she was more alert. The NP added she was glad the medication error had been identified because she and the physician were thinking about a referral for hospice services due to her decline. In an interview and observation on 01/30/15 at 12:00 noon CNA A was assisting Resident #3 to the wheelchair from her bed. Resident #3 was not able to assist in the transfer but she did engage in conversation with CNA A and requested a hug from her and was smiling. CNA A stated she had taken care of Resident #3 for the past 3 years and was on duty when she returned from the hospital the morning of 01/21/15. CNA A went on to say Resident #3 saw her when she first returned to the facility and she was alert and happy to be back. CNA A stated over the course of the next few days after her return she became very weak and would only respond to her name. She stated Resident #3 had to be transferred by two staff and she was incontinent of bowel and bladder as well. B . Review of a face sheet for Resident # 6 reflected she was [AGE] years old and was admitted to the facility on [DATE] at 4:05 PM with no diagnosis listed. Review of the January 2015 admission orders [REDACTED]. Review of the Admission physician orders [REDACTED].#2 reflected the following: - Lorazepam 1 mg tablet by mouth every 8 hours for anxiety - Tiagabine 4 mg tablet by mouth twice a day for seizures Review of a telephone order dated 01/27/2015 at 2:20 pm reflected the following: Wellbutrin 75 mg tablet by mouth at bedtime for depression The review of the January 2015 admission orders [REDACTED]. The review of Medication Cart on 01/29/2015 at 1:30 pm revealed all of the ordered medications were available to be administered. The observation of the card of Wellbutrin 75 mg revealed none of the 30 tablets ordered on [DATE] had been administered. In an interview on 01/29/2015 at 4:15 pm LVN Y stated he had ordered Resident # 6's medication's on 01/27/2015 and that they were delivered to the facility on [DATE] at 3:00 am. LVN Y stated he had administered the initial dose of Lorazepam 1 mg on 01/28/2015 at 5:00 pm and the initial dose of Tiagabine 4 mg on 01/28/2015 at 9:00 pm. LVN Y also stated after reviewing Resident # 6's admission orders [REDACTED]. In an interview on 01/29/15 at 11:50 am the DON stated she had been the DON for 3 months. The DON stated at this point in time there was no system in place to prevent or identify medication errors other than when physician orders [REDACTED]. In an interview on 01/30/15 at 4:00 pm the Administrator stated even though the facility recently changed to a new pharmacy service staff were inserviced on the process and there was no reason new admissions should miss medications and medications should be ordered in a timely manner to ensure availability. The Administrator also provided a corporate tool that the DON should be utilizing in the daily morning interdisciplinary meetings to review physician orders [REDACTED]. In an interview on 01/30/15 at 3:00 pm the Medical Director was informed of Substandard Quality of Care for significant medication errors and he was in agreement and expressed his concern. Errors and omissions were reviewed with him and he confirmed the errors and omissions were significant and he would address the matter with the administrator and DON immediately. Review of a facility form Daily Nursing Management Tool reflected the following: - Review 24 hour report to identify any at risk residents -Review telephone orders -New admissions: Validate all documentation is completed Review of a facility policy and procedure for Administering Medications dated 04/2007 reflected the following: -The Director of Nursing will supervise and direct all nursing staff personnel who administer medications and/or have related functions. -Medications must be administered in accordance with the orders, including any required time frame. The DON provided that 85 residents received medications at the facility.

Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors for one (1) of eight (8) residents reviewed for significant medication errors (Resident #3). Resident #3 received double the amount of [MEDICATION NAME] prescribed for 8 days (1/21/15-1/28/15) ([MEDICATION NAME] is a medication for nerve pain which can be used to treat [MEDICAL CONDITION] and agitation) which led to her requiring IV fluids for [MEDICAL CONDITION], unnecessary lab studies, an altered mental status, poor fluid and food intake due to the altered mental status, incontinence, and dependence on staff for activities of daily living. These deficient practices could place a facility census of 85 residents at risk for ineffective physician interventions and treatments, worsening of medical conditions, unnecessary lab studies and medical interventions, and decline in activities of daily living. The Findings Include: Resident # 3 was [AGE] years old and had an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #3 dated 11/19/14 reflected the following: assistance of one for stability with toileting, always continent of bowel and occasional incontinence of urine, assistance of one to two persons with dressing and hygiene and cueing needed for encouragement to eat. Review of a care plan for Resident #3 dated 11/15/14 reflected the following: Assist with transfers as needed, keep calllight within reach, continent of bladders with occasional incontinence, continent of bowel, takes 9 or more medications- Observe resident for any complications of taking multiple medications. Review of a physician's progress note for Resident #3 dated 01/25/15 reflected the following: Vital signs-pulse 59 regular, blood pressure 89/41 (normal blood pressure is 110/70). This is a patient of another provider, but is also known to me. I have known this patient and this certainly is not her baseline. Patient currently being treated for [REDACTED]. hour. Staff tried five attempts to start her IV, but were unsuccessful. I started IV on first attempt. Lab studies ordered for 01/26/15 (CBC, CPM, and [MEDICATION NAME] level). During an interview on 01/29/15 at 8:30 am, LVN Z stated Resident #3 had recently had a decline and change in condition after returning from a hospital stay for a urinary tract infection. LVN Z stated when Resident #3 returned to the facility on [DATE] she was alert and happy to see the staff and went to the dining room for a meal. Since then she had become increasingly unresponsive, incontinent of bowel and bladder and was receiving IV fluids for dehydration and low blood pressure. Resident #3 was observed in bed and minimally responsive to her name while two CNAs were providing incontinent care. Review of physician orders [REDACTED]. one capsule daily. Some of the sides effects of [MEDICATION NAME] are confusion, [MEDICAL CONDITION], somnolence (a very sleepy state) and dizziness. The phycian orders also included [MEDICATION NAME] 100 mg. one table twice daily for convulsions,[MEDICATION NAME] 25-100 one tablet twice daily for secondary Parkinsonism, [MEDICATION NAME] 10 mg. one tablet three times a day, [MEDICATION NAME] 10 mg.three times a day for muscle spasms, and [MEDICATION NAME] 10 mg. one tablet for tremors. Review of an electronic MAR for Resident #3 dated 01/21/15 reflected [MEDICATION NAME] 100 mg. twice daily (9:00 am and 5:00 pm). Further review of the MAR indicated [REDACTED]. twice daily from 01/21/15 through 01/28/15. In an interview on 01/29/15 at 11:30 am LVN Z stated she had transcribed Resident #3's physician orders [REDACTED]. one capsule twice daily rather than one capsule daily. In an interview on 01/29/15 at 11:40 a.m. the NP for the facility reviewed the electronic MAR for Resident #3 and confirmed she was receiving [MEDICATION NAME] 100 mg. twice daily rather than once daily as ordered (error identified by the Investigator). The NP stated this was more than likely the reason for her increased unresponsiveness, [MEDICAL CONDITION] and loss of bowel and bladder continence, but they would have to monitor her after discontinuing the second dose. The NP stated she and the physician were confused by her rapid change in condition despite the fact her lab studies were within normal limits. In an interview on 01/30/15 at 11:47 am the NP stated Resident #3's vital signs had stabilized and she was more alert. The NP added she was glad the medication error had been identified because she and the physician were thinking about a referral for hospice services due to her decline. Review of a facility nursing 24 hour report dated 01/26/15 read : Continues to be unresponsive and an overall decline. Hospice Service Referral? In an interview and observation on 01/30/15 at 12:00 noon CNA A was assisting Resident #3 to the wheelchair from her bed. Resident #3 was not able to assist in the transfer, but she did engage in conversation with CNA A and requested a hug from her and was smiling. CNA A stated she had taken care of Resident #3 for the past 3 years and was on duty when she returned from the hospital the morning of 01/21/15. CNA A went on to say Resident #3 saw her when she first returned to the facility and she was alert and happy to be back. CNA A stated over the course of the next few days after her return she became very weak and would only respond to her name. She stated Resident #3 had to be transferred by two staff and she was incontinent of bowel and bladder as well. In an interview on 01/29/15 at 11:50 am the DON stated she had been the DON for 3 months. The DON stated at this point in time there was no system in place to prevent or identify medication errors other than when physician orders [REDACTED]. In an interview on 01/30/15 at 4:00 pm the Administrator stated even though the facility recently changed to a new pharmacy service staff were inserviced on the process and there was no reason new admissions should miss medications. The Administrator also provided a corporate tool that the DON should be utilizing in the daily morning interdisciplinary meetings to review physician orders [REDACTED]. In an interview on 01/30/15 at 3:00 pm the Medical Director was informed of Substandard Quality of Care for significant medication errors and he was in agreement and expressed his concern. Errors and omissions were reviewed with him and he confirmed the errors and omissions were significant and he would address the matter with the administrator and DON immediately. Review of a facility form Daily Nursing Management Tool reflected the following: - Review 24 hour report to identify any at risk residents -Review telephone orders -New admissions: Validate all documentation is completed Review of a facilty policy and procedure for Administering Medications dated 04/2007 reflected the following: -The Director of Nursing will supervise and direct all nursing staff personnel who administer medications and/or have related functions. -Medications must be administered in accordance with the orders, including any required time frame. Resources: [MEDICATION NAME].com- prescribers information The DON provided that 85 residents received medications at the facility.