Every finding on record at Lake Village Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS. The facility failed to submit staffing data to CMS for FY Quarter 1 2026 (October 1 - December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included:Review of the CMS PBJ report for CMS for FY Quarter 1 2026 (October 1 - December 31) indicated the facility had failed to submit data for the quarter triggered. During an interview on 05/05/26 at 11:25 AM, HR stated been HR at this facility for 3.5 years. HR stated the workflow process was to create a contingent worker profile, followed by keying in the work hours. HR stated the SC is our Home Office. Upon our submission of the time record(s); the SC then obtains the hours from the documents submitted to them. They in turn submit them to CMS for PBJ requirements. During an interview on 05/05/26 at 11:38 AM, the DON stated part of her duties would be to review the staff hours, and make sure the times accurate before submitting them to HR. HR, would then submit them to the SC. The SC submits them to CMS. This instance it was submitted on 2/13/26. It was not until the following date we found out there was a software glitch. The DON stated it was added to our QAPI meeting to be reviewed quarterly, to ensure it is accurate to provide the SC the correct information in a timely manner.During an interview on 05/05/26 at 1:15 PM, ADMIN stated he has been ADMIN here for 5 years. He stated staff goes by the guidelines that CMS provides regarding PBJ submission. ADMIN stated the facility compiles the information and data, and submit to the SC, and they in turn submit it to CMS. The ADMIN stated that it would affect the facility's star rating and cause the facility to default to a 1 star for 4 quarters. ADMIN said it would affect the facility's quality measures by causing the facility to lose stars. When asked how late or omitted PBJ submissions could affect the facility residents, the Administrator said that it created the potential for the facility to be inadequately or inappropriately staffed, but should not if monitoring staffing appropriately, and it can affect the residents negatively. The ADMIN stated, since that time, no staffing issues were reported. He stated the information is compiled and data submitted to the SC and they in turn submit it to CMS.Record review of the Facility's Q4 PBJ submission internal investigation revealed. The PBJ data submitted to CMS 2/13/26 at approximately 4:30 PST by facility payroll Vendor.- At 12:26 am 2/14/26 CMS loaded the [NAME] report showed failed submission (Top right of [NAME] report)- Submitted PBJ data for 256 employees. 1 of those employees didn't match due to new software that went live 1/1/26. This caused submission failure. (see page 2 of the [NAME] report 4016/Fatal)- On 2/16/26 realized the report didn't submit and initiated internal root cause analysis while also enlisting Simple LTC to aid in research. - Root Cause Analysis PBJ submission in the correct format occurred prior to the deadline but was rejected due to a coding error attached to employee positions contained within the file. Facility payroll vendor system was upgraded in January and February of 2026, resulting in an unanticipated increased length of time for the Facility to review and validate data to be submitted and facility was not notified of this increased time requirement. The coding issue was not identified or recognized prior to the contracted service submission of the PBJ file. The contracted service did not discover the issue until the submission error occurred and extensive investigation identified the coding error several days past the submission deadline, preventing resubmission. Upgrades to payroll vendors and contracted service providers occurred too close and overlapping with data validation process of the PBJ reporting submission date preventing opportunity for the Facility to complete thorough review and validate submission.- After finding the root cause to be software change issues, on 2/23/26 an appeal was filed with CMS to try and resubmit data. Software issues are one of the few reasons they list for possible appeal.- 2/23/26 AHCA also contacted CMS on 's behalf.- 2/24/26 CMS denied the Appeal- Plan of Correction was created by the Facility leaders in conjunction with. (please see doc Process Improvement Plan: F851 - Payroll-Based Journal (PBJ) Staffing Data Submission)- Plan of Corrections run through QAPI in anticipation of May 15, Q1, deadline. Record review of the facility's Email correspondence with CMS dated 02/24/26 revealed. CMS Nursing Home Staffing RE: Appeal for late PBJ Submissions. Stated the following: Unfortunately, it is not possible to submit or correct PBJ data once a submission deadline has passed. There are no exceptions. To post staffing measures and ratings for all facilities on a set schedule, it is critical that the submission deadline is met. We calculate the measures for all ~15,600 facilities at once {not individual facility's measures one-by-one). We hope you can understand that to maintain a complex system that collects and processes millions of pieces of data effectively, we cannot easily deviate from set processes. Also, in order to maintain fairness and objectivity for all facilities, we need to hold all facilities accountable to the same standards {which have been public for quite some time). All providers should be running the staffing reports that are available in CASPER to check the accuracy and completeness of their final submissions before the submission deadline has passed. Providers are given 45 days from the end of the quarter, and we have cautioned providers that they should not be waiting until the last few days before the deadline to be making their final submissions as they must allow time to deal with any issues that may occur. Providers using a third-party vendor are still ultimately responsible for their PBJ submissions. This Appeal and Request for Reconsideration is being filed on behalf of 45 individual facilities, by their contracted service provider and authorized agent, [NAME] Services, Inc. (ESI). ESI performs certain administrative services for and on behalf of approximately 357 skilled nursing facilities, including but not limited to the processing and submission of PBJ data.This Request seeks approval for the 45 affected facilities to resubmit their PBJ data for the quarter ending December 31, 2025. It is based on the PBJ Technical Manual and related authority which expressly grants CMS the discretion to rescind, modify or otherwise respond to a submission failure resulting from unexpected circumstances. Each of the 45 facilities that experienced a fatal error relative to their PBJ submission were impacted by the same technical data migration issue which prevented the submission from being successful. We have attached the following documentation in support of this request:1. Separate appeal documents for each of the facilities with appropriate identifying information (e.g., name, CCN, etc.) as well as a detailed description of the issue and the basis for the appeal. (PBJ Appeal detaLl.s_.zip)2. CMS confirmation report letters for each of the affected facilities. (PBJ Confirmation Reports.zip). Record request from the ADMIN on 05/05/26 at 12:26 PM, for their PBJ policy, the ADMIN stated, We don't have a policy other than following CMS guidelines for PBJ reporting. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.7, June 2025, section 1.2 Submission Timeliness and Accuracy, reflected Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 1 date range as October 1-December 31. Policy manual reflected, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Based on observation, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date and were properly sealed. These failures could place residents at risk for food contamination and food-borne illness. Finding included: An observation on 05/03/26 between 9:10 AM and 9:45 AM in the facility's kitchen revealed:One gallon bag containing yellow cake mix dated 04/23/26 with no visible expiration date.One gallon bag containing corn flakes dated 02/04/26 with no visible expiration date. One 5 lb. bag of muffin mix dated 05/29/26 with no visible expiration date, not properly sealed and exposed to air contaminants.One gallon bag containing corn flakes date 01/22/26 with no visible expiration date. One gallon bag containing Lime gelatin mix dated 03/04/26 with no expiration date. One gallon bag containing Lime gelatin mix dated 02/01/26 with no expiration date.One 10 lb. bag of spaghetti pasta noodles dated 04/30/26 with no expiration date. One gallon bag containing powdered sugar dated 12/26 with no visible expiration date. One gallon bag containing mashed potatoes with no visible dates. One gallon bag containing pinto beans with no visible use by date or expiration date. One gallon bag of chicken gravy dated 04/27/26 with no visible expiration date. One 32-quart bin containing creamer mix not properly sealed and exposed to air contaminants. One gallon bag of chocolate syrup dated 04/28/26 with no visible expiration date was observed. One gallon bag of vegetable mix dated 04/29/26, with no visible expiration date was observed.One bag of pork chops with freezer burn that had visible freezer burn. One gallon bag containing hot dogs was undated and revealed no expiration date. One gallon bag containing chicken nuggets dated 04/27/26 with no visible expiration date. One gallon bag containing battered corn nuggets dated 02/09/26 with no visible expiration date was observed.During an interview on 05/05/26 at 10:14 AM, the DM stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. DM confirmed the surveyor observations and stated the listed items would be corrected. DM stated once items were opened, they should be properly sealed and dated. DM stated he was responsible for ensuring policy was followed. DM stated he and the kitchen aides were responsible for labeling and making sure that the items were labeled properly. The DM stated the risk to residents if policy was not followed was a health risk to the residents. DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DM stated if food items were not dated when opened, then they would not know how long the item would last. DM stated a full in-service completed in reference to food rotation and storage pertaining to what the proper procedures were dealing with food rotation and storage. The DM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated, could cause food borne illness. During an interview on 05/05/2026 at 10:45 AM, the ADMIN stated he oversaw all departments, and ensured residents were taken care of. ADMIN stated the DM made him aware of the concerns observed in the kitchen, and he had spoken with the DM. He stated the issues could cause food contamination, and that matter would be resolved. He stated if items were expired, they should not serve them to residents. The ADMIN stated the risk of all those concerns observed in the kitchen could result in residents getting sick. The ADMIN said the policy or procedure for storing food was, everything needed to be dated, and if opened, it needed to have an open date and an expiration date. He said the risk to residents if policy was not followed, was they could get sick from food borne illnesses. The ADMIN stated he would expect the DM to ensure that the kitchen followed all guidelines, including ensuring the food items were labeled properly in the kitchen. The ADMIN stated he expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. Record review of the facility's Food and Nutrition Services Policy, dated January 2022, indicated 3. All foods shall be labeled and dated prior to being stored. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to provide an effective pest control program treat the kitchen for cockroaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Observation tour of the kitchen on 05/03/26 at 9:10 AM, revealed a dead roach in the kitchen area. During an interview on 05/05/26 at 11:58 AM, MS stated has been in Maintenance at this facility for approximately 24 years. MS stated an ac unit was installed in the window and had to cover the space around the window. It has been scheduled two times a month to correspond with laundry department to clean the area, which included the exhaust vent, ac window area, and to add a disinfectant when needed. The kitchen staff check these areas bout two times a week. The MS stated recently there have not been any issues with roaches and gnats. MS if there was an issue it would be coordinated the pest control company. When the Pest Control services would come out set up bait and traps. MS stated when they receive reports, pest control is contacted. This is followed up with a deep clean at the floor level. During an interview on 05/05/26 at 12:05 PM, the DON stated food service areas create serious risks including contamination with bacteria (Salmonella, E. coli, Staphylococcus), spread of disease to immunocompromised residents, and allergen exposure.During an interview on 05/05/26 at 12:15 PM, DM confirmed state surveyor observations over the issue of pests in the kitchen. DM stated a while back went through the kitchen with the MS, during the tour of the kitchen area observed an area around the AC window unit where they observed water. The condensation looked like it was coming down into the kitchen area. MS sealed the area up, and since then we have had no more issues, other than when it rains, we have had a few every now and then.During an interview on 05/05/26 at 12:30 PM, ADMIN stated the pest control agency did the treatment twice a month and it was up to date. The ADM said the pest control treatment might not be fully effective since there were insect activities at the facility. The ADMIN stated he was committed to have a pest-free facility as they were harmful to residents in many ways like causing insect bites or spreading various diseases. He stated, however, no one has reported to him about any insect activities at the facility. Record review of pest control records revealed the pest control agency visited the facility and did the treatment on 02/06/2026. It was also revealed they visited the facility every 15 days for treatment. Record review of the facility provided Pest Control Statements revealed the facility received pest control service on the following dates:02/06/202602/12/202603/13/2026 03/30/2026 04/07/202604/28/2026 Record review of the contracts provided by the facility revealed the facility had a contract with a pest control company and the facility was serviced for roaches and pests twice per month. The most recent visit was 6 days prior to the sighting of the rodent, on 05/03/2026. The contractor serviced every area of the facility, including exterior areas and the kitchen.Record review of Pest Control Scope of Services and Compensation dated 04/20/2023 revealed: Service: will perform regular service Monthly/Weekly/Bi-Weekly for the control of: Roaches, Rats, Mice, Ants Treatment: Treat the exterior, Bait the exterior, Inspect/Treat entry points, Inspect/Treat Common Areas, Inspect Exterior StationsProposal Specifications: will implement a twice a month service for these location covering general pests, and rodents.Record review of the facility-provided policy titled Safe/Comfortable/Homelike Environment dated February 2026 reflected, Policy Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Procedure1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. Cleanliness and order;

Based on observation, interview, 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 one of ten residents (Resident #91) reviewed for respiratory care.The facility failed to ensure Resident #91's nasal cannula was stored properly when not in use on 05/03/2026.This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #91's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and pulmonary edema (accumulation of fluid in the lungs).Record review of Resident #91's Comprehensive MDS Assessment, dated 05/01/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #91's Comprehensive Care Plan, dated 04/29/2026, reflected that the resident had oxygen therapy and one of the interventions was to provide oxygen therapy as ordered. Record review of Resident #91's Physician's Order, dated 04/29/2025, reflected O2 at 2 L/MIN via NASAL CANNULA (flexible tube used to deliver oxygen to the nose through two prongs) as needed for SOB, RESPIRATORY DISTRESS (person struggles to get enough air), CYANOSIS (low levels of oxygen in the blood), LABORED BREATHING, related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) WITH (ACUTE) EXACERBATION; ACUTE PULMONARY EDEMA.During an observation and interview on 05/03/2026 at 9:14 a.m. revealed that Resident #91 was in his bed, awake. It was observed that a nasal canula, connected to an oxygen concentrator, was on top of the resident's side table. The nasal cannula was not bagged. The resident said he did not use the oxygen always and the last time he had the oxygen was the day before. He said the nurse put it on, but he was not sure who took it off. He said he was not the one who took it off, and there would be no way that he could reach his side table. During an observation on 05/03/2026 at 9:20 a.m. revealed CNA E and LVN B changed Resident #91's linen. After they were done with the linen changed, both staff left the room. Neither staff addressed the unbagged nasal cannula. During an interview on 05/03/2026 at 12:20 p.m., LVN B said he saw the unbagged nasal cannula, and it did not occur to him to change it, bag it, or even notify his nurse about it. He said the nasal cannula should be bagged to prevent cross contamination and any kind of respiratory infection because the table might adhere to the nasal cannula and could eventually go inside the lungs.During an interview on 05/03/2026 at 12:50 p.m., LVN C said she saw the nasal cannula on top of the Resident #91's side table when she hung the resident's antibiotics. She said she had already changed it and put it in a plastic bag. She said she did not notice it being unbagged when she did her morning round, nor did she know who took it off. She said the nasal canula should be bagged to prevent cross contamination and respiratory infection.During an interview on 05/05/2026 at 6:30 a.m., ADON A said the nasal canula should be bagged when not in use to prevent any respiratory infection. She said the staff were responsible for bagging the nasal cannula. She said if they saw the nasal cannula was not bagged, then they should throw it and change them. She said there should always be a plastic bag for the nasal cannula. She said the expectation was that the nasal cannula would be bagged after it was taken off. She said they already started an in-service about bagging the nasal cannula.During an interview on 05/05/2026 at 7:09 a.m., the DON said the staff were responsible in making sure the nasal cannula was bagged when not in use to keep it clean and prevent respiratory infection. She said the expectation was for the staff not to forget to bag the nasal cannula when not in use. She said she already started an in-service about bagging the nasal cannula when not in use as soon as she heard about the issue.During an interview on 05/05/2026 at 7:47 a.m., the Administrator said the expectation was for the staff to bag the nasal cannula when not in use to prevent respiratory issues. He said the DON had already started an in-service about bagging the nasal cannula, and they would continue to re-educate them. He said they would also monitor closely if the staff understood what the in-service was all about. He said they would also do random checking if the staff were bagging the nasal cannulas of the residents.Record review of the facility's policy Respiratory Policy & Procedures revised April 2026 reflected PURPOSE: To provide guidelines for exceptional infection control within all respiratory related practices and care of equipment . PROCEDURE . 4. When not in use, all tubing should be stored in plastic bags or other approved storage bag method.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of twenty residents (Residents #8 and Resident #34) reviewed for medication storage. 1. The facility failed to ensure that Resident #8 did not have a pain reliever gel inside her room on 05/03/2026. 2. The facility failed to ensure that Resident #34 did not have a tube of hydrocortisone cream (used to treat inflammation and itching) inside her room on 05/03/2026.These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1. Record review of Resident #8's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia and aphasia (an impairment that affects an individual's comprehension or formulation of language). Record review of Resident #8's Comprehensive MDS Assessment, dated 04/08/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident had dementia aphasia. Record review of Resident #8's Comprehensive Care Plan, dated 04/20/2026, reflected that the resident was at risk for impaired cognitive function related to dementia and aphasia one of the interventions was to provide consistent care to decrease confusion.Record review on 05/03/2026 of Resident #8's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage her own medications.During an observation and interview on 05/03/2026 at 11:24 a.m. revealed Resident #8 was sitting at the side of her bed. It was observed that a tube of pain reliever gel, which was almost empty, was on top of the resident's side table and was in plain view. The resident pointed to her hip and then did a rubbing motion when asked what the gel was for. 2. Record review of Resident #34's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia. Record review of Resident #34's Comprehensive MDS Assessment, dated 04/06/2026, reflected that the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had dementia. Record review of Resident #34's Comprehensive Care Plan, dated 04/03/2026, reflected that the resident had an impairment to the skin integrity and one of the interventions was to administer treatments as ordered.Record review on 05/04/2026 of Resident #34's Physician Order reflected that the resident did not have an order for hydrocortisone cream.Record review on 05/04/2026 of Resident #34's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage her own medications. During an observation and interview on 05/03/2026 at 9:18 a.m. revealed that Resident #34 was in her bed, awake. It was observed that a tube of hydrocortisone was on top of the resident's side table and was on plain view. The resident said it was for bottom that was usually itchy. She said the cream had always been on her side table, and she was not sure if the staff saw them or not.During an observation and interview on 05/03/2026 at 6:09 a.m., LVN C said she did not notice that Resident #34 had a tube of hydrocortisone inside her room. She said she would talk to the resident and explain to her that she should not have any medications inside her room. She went inside Resident #34's room, talked to the resident, and took the medication with her when she left the room. She said she knew Resident #34 did not have an assessment that she could administer her own medication. She said Resident #34 also did not have an order for hydrocortisone. She said she would request an order, but the staff would be the one administering it when the resident needed it. She then went to Resident #8's room and did the same. She said the residents could not have medications inside the room because the staff would not know how often and how much the residents were applying the topical medications. She said too many topical medications could cause skin irritation. She said some confused residents might go inside Resident #8 and Resident #34's rooms, take the medications, and consume them causing adverse effects. She said she would also call the family members to remind them that they need to inform the staff if they were bringing any medications. She said medications should be inside the carts.During an interview on 05/05/2026 at 6:30 a.m., ADON A said medications should not be inside the rooms of the residents because some residents were confused and might ingest them or might thought that the topical medications were just ordinary lotions and apply them all over their body. She said the expectation was for the staff to be vigilant in scanning the rooms of the residents if they have any medications. She said the staff could not open the drawers of the residents but if the medications were in plain view, then the staff should talk to the residents about the medications. She said they had already started an in-service about medication at bedside. She said they would also remind the family members about letting the staff know that they were supposed to give the staff any medications that they would be bringing.During an interview on 05/05/2026 at 7:09 a.m., the DON said medications, in whatever form, should not be inside the residents' rooms because the residents might use them inappropriately that could result in adverse reactions, such as overdosing, irritations, and upset stomach. She said confused residents might get hold of the topical medications and consume them. She said the expectation was for the staff to be observant if there were medications inside the room of the residents. She said she had already started an in-service about medication at bedside, and the in-service was for all the staff going inside the residents' rooms.During an interview on 05/05/2026 at 7:47 a.m., the Administrator said that there should be no medications inside the rooms of the residents to make sure that they were not taking any medications that were not prescribed. He said confused residents could grab them and consume them. He said they already started an in-service, and they would go around to check if there were medications inside the rooms of the residents.Record review of the facility's policy Safety, Resident Policy/Procedure revised April 2026 reflected POLICY: It is the policy of this facility to create a safe environment for the resident . PROCEDURES . 5. Ensure all medications . are kept locked/ secured . 7. Conduct room checks routinely by staff members . to ensure safety of residents residing in the facility. Room checks include but not limited to resident observation (wearing appropriate clothing, oral hygiene, assistive devices, etc.) and bedside observation (call lights within reach, no unauthorized medications, ointments, lotions at bedside, infection control, etc.).

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twenty residents (Resident #43 and Resident #91) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene during Resident #43's incontinent care on 05/04/2026. 2. The facility failed to ensure CNA E did not put Resident #91's catheter bag on top of the resident's bed on 05/03/2026. 3. The facility failed to ensure LVN B and CNA E wore gowns when they changed Resident #91's linen, who had a catheter on 05/03/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #43's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting and atrophy.Record review of Resident #43's Comprehensive MDS Assessment, dated 03/23/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated that the resident was incontinent for bladder and bowel. Record review of Resident #43's Comprehensive Care Plan, dated 04/07/2026, reflected that the resident had bowel and bladder incontinence and one of the interventions was to check as required for incontinence.An observation on 05/04/2026 at 6:51 a.m. revealed CNA F was about to do Resident #43's incontinent care. She washed her hands, put on a pair of gloves, and proceeded with incontinent care. She took a brief from the resident's overbed table, opened it, and placed it at the side of the resident's head. She took off her gloves and put on a new pair of gloves. She did not sanitize her hands before putting on a pair of gloves. She unfastened the brief and tucked it between the residents' legs. She took off her gloves and put on a new pair. She did not sanitize her hands before putting on the new pair of gloves. She then cleaned the resident's perineal area. She took off her gloves and put on a new pair. She did not sanitize her hands before putting on the new pair of gloves. She rolled the resident and cleaned the resident's bottom. It was observed that the resident had a bowel movement. After cleaning the resident's bottom, she took off her gloves and put on a new pair. She did not sanitize her hands before putting on the new pair of gloves. She took the brief from the resident's side, placed it under the resident, and fixed it.During an interview on 05/04/2026 at 7:17 a.m., CNA F said she knew she messed up because she did not sanitize her hands when she changed her gloves. She said she had a bottle of sanitizer in her pocket, but forgot to use it. She said hands should be sanitized before putting on a new pair of gloves to prevent cross contamination and infection. She said she did have an in-service about hand hygiene.2. Record review of Resident #91's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive reflux uropathy and urinary tract infection.Record review of Resident #91's Comprehensive MDS Assessment, dated 05/01/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter.Record review of Resident #91's Comprehensive Care Plan, dated 04/29/2026, reflected that the resident had an indwelling Foley catheter r/t obstructive and reflux uropathy, and one of the interventions was to provide catheter care.Record review of Resident #91's Physician Order, dated 04/28/2026, CATHETER CARE EVERY SHIFT. MONITOR URETHRAL SITE FOR S/S OF SKIN BREAKDOWN, PAIN/DISCOMFORTS, UNUSUAL ODOR, URINE CHARACTERESTIC OR SECRETIONS, CATHETER PULLING CAUSING TENSION every shift.An observation and interview on 05/03/2026 at 9:14 a.m. revealed Resident #91 was in his bed, awake. The resident had a catheter with the bag hanging at the side of the bed. The resident said he had the catheter for months, but he did not know what the exact date was.An observation on 05/03/2026 at 9:16 a.m. revealed CNA E was about to change Resident #91's bed linens. She went inside the resident's room, bringing with her a fitted sheet, a blanket, and some pillowcases. She went out of the room to ask somebody to assist her in turning the resident. Before she went out of the room, she placed the resident's catheter bag on top of the resident's bed. 3. Record review of Resident #91's Comprehensive Care Plan, dated 04/29/2026, reflected that the resident had an indwelling Foley catheter r/t obstructive and reflux uropathy and was on antibiotic therapy r/t UTI present on admission. Intervention for both was to use enhanced barrier precautions.Record review of Resident #91's Physician Order, dated 04/29/2026, Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication:Indwelling Catheter & IV access every shift.Record review of Resident #91's Physician Order, dated 04/28/2026, reflected PICC LINE (long, flexible tube inserted into the vein used for administering intravenous medications) FLUSHING: FLUSH WITH 10 CC 0.9 % NS IV SOLUTION Q SHIFT every shift.An observation and interview on 05/03/2026 at 9:14 a.m. revealed Resident #91 was in his bed, awake. It was observed that the resident had a catheter and had a PICC line. The resident said he was receiving antibiotics because he had a UTI. It was also observed that there was a sign on the resident's door that the resident was on EBP. The sign indicated that staff needed to wear gloves and gowns when changing linens.An observation on 05/03/2026 at 9:22 a.m. revealed CNA E returned to Resident #91's room with LVN B. Both staff started to change the resident's linen. They rolled the resident towards LVN B while CNA E was making half of the bed. It was observed that LVN B was in contact with the resident's torso while he was assisting the resident not to roll back. Both LVN B and CNA E were not wearing a gown. An interview on 05/03/2026 at 12:20 p.m., LVN B said it did not occur to him that the catheter bag should not be on top of the bed, because it was dirty. He said since Resident #91 had a catheter and a PICC line, they should have worn gowns in addition to the gloves because the resident was on EBP. He said he did not know why he forgot to wear a gown when CNA E called him to assist her in changing the resident's linens. He said he saw that CNA E did not have a gown and did not occur to him as well to tell her to wear a gown because the resident was on EBP. He said, even though they changed the linens, the catheter had contact with the foot board, and could indirectly cause infection. He said gowns were required to make sure the staff would not transfer any microorganisms to residents with indwelling medical devices.Aan interview on 05/03/2026 at 12:28 p.m., CNA E said she knew the catheter bag was dirty and putting it on top of the bed made the bed dirty also. She said she did not notice that there was a sign outside Resident #91's door that indicated that the resident was on EBP. She said they had an in-service before that would say PPE was needed for residents with catheter and with IV. She said putting something dirty on the bed and not wearing a gown when needed could cause infection.An interview on 05/05/2026 at 6:30 a.m., ADON A said they were in-servicing the staff about infection control almost on a weekly basis to remind them to sanitize their hands before putting on a new pair of gloves and to wear PPE when required. She said they needed to re-educate the staff about the importance of hand hygiene and wearing a gown during provision of care. She said putting the catheter bag on top of the bed was also an infection control issue because something dirty had contact with the bed and foot board. She said the expectation was that the staff would understand the in-service about infection control and put them in practice. She said they already started an in-service about hand hygiene, EBP, and infection control.An interview on 05/05/2026 at 7:09 a.m., the DON said if a resident was on EBP, then the staff doing care should wear a gown every time they had contact with the resident to prevent cross contamination and spread of infection. She said for a resident with a catheter and a PICC line, a gown was needed to change the resident's linens. She said residents who were on EBP and required PPE to prevent the spread of infection from one resident to another. She said hands should be sanitized first before putting on a new pair of gloves. She said the catheter bag should not have been placed on top of the bed because it was dirty. She said the concerns discussed were all infection control issues. She said the expectation was for the staff to not introduce any cause of infection that could affect the health of the residents. She said she already started an in-service about hand hygiene, EBP, and infection control. She said they would keep on re-educating the staff about infection control.An interview on 05/05/2026 at 7:47 a.m., the Administrator said the expectation was for the staff to wear gowns in addition to the gloves if the residents were on EBP, sanitize between changing of gloves, not to put something dirty on the bed. He said the DON already started an in-service, but they would monitor the staff if they understood the in-service and if they were compliant to the policy. He said they would also do some spot checks and check offs. He said there was no specific policy about not putting the catheter bag on top of the bed, but it was given that the protocol was from clean to dirty and not dirty to clean.Record review of the facility's policy, IPCP Standard and Transmission-Based Precautions Infection Control revised April 2026 reflected Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . 3. Enhanced Barrier Protection (EBP}: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident . c. Examples of high-contact resident care activities requiring gown and glove . v. Changing linens . vii. Device care or use: central vascular line (flexible tube inserted into a large vein in the neck, chest, or arm) . urinary catheter.Record review of the facility's policy Hand Hygiene Infection Control revised April 2026 reflected Policy: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards . Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection . 2. Use an alcohol-based hand rub . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids . m. After removing gloves.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for two of four residents (Resident #43 and Resident #91) reviewed for incontinent care. 1. The facility failed to ensure that CNA F did not use the wipes that she used to clean Resident #43's inguinal area (lower portion of the abdomen) to clean the perineal area (area between the legs) on 05/04/2026.2. The facility failed to ensure that CNA E did not place Resident #91's catheter bag on top of the resident's bed rendering the catheter to be not below the bladder while the resident's linen was being changed on 05/03/2026. These failures could place the residents at risk for urinary tract infection.Findings included: 1. Record review of Resident #43's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of a body part).Record review of Resident #43's Comprehensive MDS Assessment, dated 03/23/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated that the resident was incontinent (uncontrolled) for bladder and bowel. Record review of Resident #43's Comprehensive Care Plan, dated 04/07/2026, reflected that the resident had bowel and bladder incontinence and one of the interventions was to check as required for incontinence.During an observation on 05/04/2026 at 6:51 a.m. revealed CNA F was about to do Resident #43's incontinent care. She washed her hands, put on a pair of gloves, and proceeded with incontinent care. She pulled some wipes and cleaned the sides of the perineal area (area between the legs); after cleaning the sides, she cleaned the vulva (external female genitals) of the resident using the wipes she used to clean the sides.During an interview on 05/04/2026 at 7:17 a.m., CNA F said she should have pulled some new wipes to clean the middle portion of Resident #43's perineal area because the wipes she used to clean the sides were already soiled. She said her actions could cause UTI.2. Record review of Resident #91's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive reflux uropathy (a blockage in the urinary tract).Record review of Resident #91's Comprehensive MDS Assessment, dated 05/01/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #91's Comprehensive Care Plan, dated 04/29/2026, reflected that the resident had an indwelling Foley catheter (device used to help drain urine from bladder) r/t obstructive and reflux uropathy and one of the interventions was to secure the catheter to facilitate flow of urine.Record review of Resident #91's Physician Order, dated 04/28/2026, CATHETER CARE EVERY SHIFT. MONITOR URETHRAL SITE (a tube where urine exits the body) FOR S/S OF SKIN BREAKDOWN, PAIN/DISCOMFORTS, UNUSUAL ODOR, URINE CHARACTERESTIC OR SECRETIONS, CATHETER PULLING CAUSING TENSION every shift.During an observation and interview on 05/03/2026 at 9:14 a.m. revealed Resident #91 was in his bed, awake. It was observed that the resident had a catheter with its bag hanging at the side of the bed. The resident said he had the catheter for months, but he did not know what the exact date was.During an observation on 05/03/2026 at 9:16 a.m. revealed CNA E was about to change Resident #91's bed linens. She went inside the resident's room carrying with her a fitted sheet and a blanket. She went out of the room to ask somebody to assist her in turning the resident. Before she went out of the room, she placed the resident's catheter bag on top of his bed. It was observed that there were urine and streaks of blood in the catheter tubing.During an observation on 05/03/2026 at 9:21 a.m. revealed CNA E returned to Resident #91's room with LVN B. LVN B noticed that there was blood in the catheter tubing but did ask CNA E why the catheter bag was on top of the bed nor hang it on the bed's railing.During an interview on 05/03/2026 at 12:20 p.m., LVN B said it did not occur to him that the catheter bag should not be on top of the bed and should always be below the bladder to prevent urine from flowing back to the bladder that could result to infection. He said for Resident #91, it was not only urine that could go back to the bladder but also some blood that was in the tubing.During an interview on 05/03/2026 at 12:28 p.m., CNA E said she knew the catheter bag should always be below the bladder so that urine will not go back to the inside the Resident #91's body. She said she was not sure if the urine from the catheter bag went back inside the body. She said she put it on the bed because it might be pulled when the resident was turned. She said the catheter bag could be hung to the other side once the resident was turned instead of putting it on top of the bed.During an interview on 05/05/2026 at 6:30 a.m., ADON A said the catheter bag should always be below the bladder to prevent urine from going back to the bladder that could eventually cause urinary tract infection. She said the staff could hang the catheter bag on the other side if they needed to turn the resident. She said the staff should have changed her wipes after she cleaned the sides of the perineal area because they were already dirty. She said the right procedure was to discard the wipes with every stroke. She said the expectation was that catheter bags would always be below the bladder and that the staff would perform the right procedure in doing incontinent care. She said the DON had already started an in-service about placement of the catheter bag and perineal care.During an interview on 05/05/2026 at 7:09 a.m., the DON said the catheter bag should always be below the bladder to prevent backflow of urine from the catheter bag to the bladder. She said if there was a backflow, it could result to urinary tract infection. She said the staff could always hang the catheter bag to the other side of the bed if they needed to turn the resident. She said the right procedure in cleaning a female resident was to clean the sides first and then the middle portion, but the staff could not use the same wipes because it could cause urinary tract infection. She said the expectation was for the staff to keep the catheter bag below the bladder and to do the right procedure in performing incontinent care. She said she already started an in-service about catheter care and incontinent care.During an interview on 05/05/2026 at 7:47 a.m., the Administrator said the expectation was that the catheter bag should be below the bladder at all times to prevent the urine from returning into the bladder. He said soiled wipes could not be used to clean the middle part of the female's perineal area. He said both issues could result to urinary tract infection. He said the expectation was for the catheter bags to be below the bladder and that the right procedures for incontinent care were followed. He said the DON already started an in-service about the issue, and they would continually re-educate the staff about the issues. He said they would closely monitor that the staff understood what the in-service was all about. He said they would also do random checking and check off for incontinent care.Record review of the facility's policy Indwelling Urinary Catheter Care Policy & Procedure revised April 2026 reflected Policy: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection . Procedure . 13. Maintain the drainage tubing below the level of the bladder.Record review of the facility's Perineal Care Checklist, undated, reflected Perineal Care Procedure . I. Female Procedure . Cleaning downward from front to back using a clean part of cloth/wipe with each stroke.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for one of eighteen residents (Resident #55) reviewed for accident hazard.The facility failed to ensure there were no unattended container of germicidal wipes (substance that destroys germs and microorganism) on a table at the lobby, where Resident #55 was on 05/03/2026.This failure could place residents at risk of having an environment that was not free from exposure toxic chemicals.Findings included:Record review of Resident #55's Face Sheet, dated 05/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and depression (persistent feeling of sadness or loss of interest). Record review of Resident #55's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 04/17/2026, reflected that the resident had severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident had dementia and depression. Record review of Resident #55's Comprehensive Care Plan, dated 02/24/2026, reflected that the resident was at risk for impaired cognitive function and had depression. The interventions were to engage in simple and structured activities and to observe confusion.During an observation on 05/03/2026 at 9:07 a.m. revealed that an unattended container of germicidal was on top of a table at the reception area. It was observed that Resident #55 was near the table with an unattended container of germicidal wipes.During an interview on 05/03/2026 at 9:56 a.m. revealed Resident #55 still sitting in the lobby. She did not reply when asked about the container of germicidal wipes on top of the table.During an observation and interview on 05/03/2026 at 11:50 a.m. revealed the Activity Director was sitting at the table in the reception area. She said she did not see the container of germicidal wipes when she stepped inside the facility. She said somebody might be cleaning the table and forgot to store the container of germicidal wipes properly. She said germicidal wipes could be harmful to the residents when ingested. She said if the container had Keep out of reach of children should not be accessible to the residents because some of them were confused.During an interview on 05/03/2026 at 12:20 p.m., LVN B said he did not notice the container of germicidal wipes when he went to the reception area. He said he did not know who left it on top of the table. He said there could be confused residents sitting in the lobby that could get hold of the wipes and use them inappropriately, like wiping their eyes and skin with them, and could cause irritations. He said whoever used it should have stored it properly after using it.During an interview on 05/03/2026 at 12:50 p.m., LVN C said she did not notice the container of germicidal wipes in the lobby left unattended. She said a confused resident might open it and pull some wipes to use on their face and body. She said the wipes had chemicals in them that could cause irritation to the eyes and skin. She said it should be stored somewhere that the resident could not reach them.During an interview on 05/04/2026 at 9:57 a.m., HK G said she was in the facility the day before; she said she was not the one who left the container of germicidal wipes on top of the table in the reception area and did not know who did. She said the wipes had chemicals that could be harmful to the residents.During an interview on 05/05/2026 at 6:30 a.m., ADON A said they normally keep the containers of germicidal wipes in the carts or somewhere that withing reach of the residents. She said if the containers of germicidal wipes were left unattended, the resident might easily open it, pull some wipes, and use them. She said the wipes could be harmful when used to wipe the face and skin. She said the expectation was for the staff to be vigilant and leave containers of germicidal wipes accessible to the residents. She said they would re-educate the staff about germicidal wipes. She said they already started an in-service about not leaving germicidal wipes within reach of the residents. During an interview on 05/05/2026 at 7:09 a.m., the DON said the container of germicidal wipes should not be within reach of the residents because they might be able to get some wipes and use them to clean their eyes, nose, ears, and skin. She said contact with the wipes might result to irritations and chemical burns. She said the germicidal wipes should be stored inside the last drawer of the cart for safe keeping. She said anything that had Keep out of reach of children as an instruction should be considered harmful because the facility had confused residents that may not know germicidal wipes from ordinary wipes. She said the expectation was for the staff not to leave germicidal wipes or anything with chemicals unattended. She said she already started an in-service about not leaving the germicidal wipes unattended as soon as she heard about the issue.During an interview on 05/05/2026 at 7:47 a.m., the Administrator said the container of germicidal wipes should have been stored properly after using it because the facility had confused residents that could use the wipes inappropriately. He said the expectation was for the staff to store the germicidal wipes properly, not left unattended, and not within reach of the residents. He said the DON had already started an in-service about the germicidal wipes, and they would continue to re-educate them. He said they would also monitor closely that the staff understood what the in-service was all about.Record review of the facility's policy Safety, Resident Policy/Procedure revised April 2026 reflected POLICY: It is the policy of this facility to create a safe environment for the resident . PROCEDURES . 5. Ensure all medications, chemicals, cleaning supplies, and any other potential hazardous materials are kept locked/ secured when staff has completed their use.

Based on interview, and record review, the facility failed to make sure every resident had full visual privacy for 1 of 4 residents (Resident #1) reviewed for dignity. The facility failed to ensure Resident #1 had full visual privacy and dignity by leaving Resident #1 lying in bed dressed only in a shirt and brief without a bed sheet, blanket, curtains, or a closed door from 2:19 AM to 4:43 AM. This was determined to be past non-compliance from 11/04/2025 to 11/5/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of emotional or psychosocial harm by not receiving appropriate measures for privacy and dignity. Findings included: Review of the Care Plan dated 11/07/2025 for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia (Persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Malignant Neoplasm of the Pancreas (Pancreatic Cancer), Anxiety (Persistent fear or worry), Hypertension (High Blood Pressure), Hypothyroidism (Thyroid does not produce enough hormones, underactive), and Depression (Sadness and loss of enjoyment), Frequent Falls, and Pain. Review of the BIMS (Brief Interview for Mental Status) dated 9/29/2025 for Resident #1 revealed that he received a score of 3, indicating severe cognitive impairment. Review of Video dated 11/04/2025 from 2:19 AM to 4:43 AM revealed LVN I entered the open door of Resident #1's room. She provided incontinent care and removed the sheet and blanket from Resident #1's bed. She left the room with the door open. At 4:43 AM LVN I returned to check on Resident #1, his door remained open the entire time between 2:19 AM to 4:43 AM. She then left the room and had a conversation with CNA J. The audio revealed that LVN I had previously instructed CNA J to take care of Resident #1, but that CNA J had forgotten. In the audio CNA J was heard telling LVN I that it was an accident and that she had gotten busy. CNA J then entered the room and made sure Resident #1 had appropriate clothing and linens for privacy and dignity. Review of the Inservice for Dignity dated 11/05/2025, revealed staff received training on Bed Lining Changes with Incontinence Care, Communication and Customer Service. The in-service stated Care should be provided every 2 hours or per resident request. It also stated, When bed lining are soiled you must change the bed pad, and or lining if required. Review of the Grievance dated, 11/05/2025, revealed Family Member F had concerns about the incontinent episode that occurred overnight on 11/05/2025. The immediate brief change was taken care of by LVN I but there was a delay in getting the linen replaced properly. There was an in-service with staff on incontinent care. Review of the Employee Statement written by LVN I on 11/05/2025 at 7:00 AM revealed LVN I stated she had gone to pass medications and perform her rounds. She discovered Resident #1 was wet. She stated that his penis was outside of his brief above the waistband of his brief. She reportedly removed his wet linens and brief and provided peri-care. It was documented that CNA J finished the task. Later, she circled back and discovered CNA J had not yet provided clean linens, so LVN I went to get CNA J at that time to finish the task. CNA J was highly apologetic to LVN I. Review of the Employee Statement written by CNA J on 11/05/2025. Confirmed LVN I had provided peri-care and asked CNA J to assist with the linen change. CNA J stated that she was busy and didn't go immediately but did eventually assist Resident #1. During an interview on 11/07/25 at 1:30 PM, Administrator G, stated that he was aware of the incident that involved Resident #1 being left in a brief and shirt without linens. Administrator G stated that in-services were performed for incontinent care. Administrator G stated that LVN I was an agency nurse and would not be returning to the facility. During an interview on 11/10/25 at 3:15 PM, Director of Nursing B, stated that Family Member F was upset that Resident #1 was left in his bed with nothing more than a brief and a shirt. She stated that the staff had been in-serviced on 11/05/2025 to make sure that it did not happen again. She stated that LVN I had provided incontinent care to Resident #1 but left him in the room without linens because CNA J was instructed to finish the rest of the task. She stated the staff did eventually bring the linens but that it was at a later time. During an interview on 11/10/25 at 4:00 PM, CNA J, stated that she was aware of the incontinent episode that occurred on 11/05/2025. She stated that she entered the room around 4 AM and saw that Resident #1 was lying in bed with nothing but underwear, socks, and shirt. She stated that he did have a pillow on the bed, but he did not have linens covering him. She stated that his door had been open, so he was visible from the hallway to anyone passing by his room. She stated that she had to get a fitted sheet for Resident #1's bed because he did not have one on the bed when she entered the room. She stated she had to get him a blanket and top sheet also. She stated that she was told by LVN I to go to his room about 10 minutes prior to entering. She stated that it was the expectation that he was to be checked on every 2 hours. She stated that she received in-service training. During an interview on 11/17/25 at 3:49 PM, LVN A stated that on 11/04/2025 she became aware of the incident that occurred overnight from Family Member F. She stated she was told Resident #1 was left in nothing but a shirt and a brief for 2-4 hours after an incontinent change. Review of facility policy dated 7/2017 and titled Resident Rights reflected the following: As a resident of this nursing facility, you have the right to a dignified existence. Respect and Dignity: You have the right to be treated with respect and dignity. Review of facility Long Term Care Ombudsman Program document dated 1/2025 and titled Your Rights in a Nursing Facility reflected the following: Dignity and Respect Live in safe, decent, and clean conditions Be treated with dignity, courtesy, consideration and respect

Based on interview, and record review, the facility failed to administer medications according to physician's orders for 1 of 4 residents (Resident #1) reviewed for medications. The facility failed to input a physician's order on the day that the order was received to ensure Resident #1 received Hydromorphone 4mg/ml MG every 4 hours instead of every 6 hours as previously scheduled. This was determined to be past non-compliance from 11/04/2025 to 11/5/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of harm by not receiving their scheduled medication in a timely manner. Findings included: Review of the Care Plan dated 11/07/2025 for Resident #1 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia (Persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Malignant Neoplasm of the Pancreas (Pancreatic Cancer), Anxiety (Persistent fear or worry), Hypertension (High Blood Pressure), Hypothyroidism (Thyroid does not produce enough hormones, underactive), and Depression (Sadness and loss of enjoyment), Frequent Falls, and Pain. Review of the BIMS (Brief Interview for Mental Status) dated 9/29/2025 for Resident #1 revealed that he received a score of 3, indicating severe cognitive impairment. Review of physician orders for Resident #1 reflected an order was written 11/04/25 for Hydromorphone 4mg/ml. The order was changing the frequency of doses to every 4 hours from every 6 hours. A standing PRN order for Hydromorphone 4mg/ml was also issued. Review of the MAR (Medication Administration Record) dated 11/10/2025 for Resident #1 revealed that although the facility did not input the order of Hydromorphone 4mg/ml to be given every 4 hours per physician order, the facility still administered Hydromorphone 4mg/ml as needed by the previous standing Hydromorphone 4mg/ml PRN order. Resident #1 was still receiving pain medication uninterrupted from 11/04/2025 until 11/05/2025. Review of the Progress Note dated 11/04/2025 at 5:34 PM for Resident #1 revealed LVN A documented that a new order was received from Hospice Nurse D. Per orders the Hydromorphone 4mg/ml every 6 hours was discontinued and replaced by a new order of Hydromorphone 4mg/ml every 4 hours. An additional Hydromorphone 4mg/ml as PRN was included. Review of the Inservice for Physician Orders dated, 11/05/2025, revealed LVN A received training on how to input orders, communication, checking the system to make sure the orders were inputted successfully, and customer service. During an interview on 11/10/25 at 1:00 PM, Hospice Nurse D stated that she delivered a written order to LVN A and DON B to change Resident #1's Hydromorphone 4mg/ml MG to every 4 hours instead of every 6 hours. She stated that Resident #1 had been receiving the scheduled medication every 6 hours in combination with PRN. She stated that the facility was giving the PRN routinely so it was decided that Resident #1 should be on a more frequent schedule to keep him comfortable. She stated that the facility should have implemented the order on the same day so that there was not any risk to Resident #1 missing the newly scheduled regiment. During an interview on 11/10/25 at 1:30 PM, Hospice Director E stated that the facility failed to input the order for Resident #1 that was delivered to LVN A and DON B from Hospice Nurse D on 11/04/2025. She stated that since Resident #1 had a PRN order and still received pain medication as ordered then the resident would likely be at a low risk of injury. The issue would have been if the facility did not give the PRN pain medication as required for the time leading up until they discovered their mistake. She stated that had Resident #1 not have had a PRN medication to cover for their mistake then it could have been a risk to his comfort level since the pain medication is to keep him from being in pain and agitated while on hospice services for end of life care. She stated that the facility should have implemented the order on the same day so that there was not any risk to Resident #1 missing the newly scheduled regiment. During an interview on 11/10/25 at 3:15 PM, Director of Nursing B, stated that Hospice Nurse D delivered a written order to the facility on [DATE]. She stated that Hospice Nurse D arrived right before she was leaving for the day. She stated Hospice Nurse D attempted to give her the written order but that she told Hospice Nurse D to go talk to LVN A about inputting the order. She stated that Hospice Nurse D placed them in a box and told LVN A that DON B knows about the orders. She stated that she interviewed LVN A and discovered that LVN A observed DON B and Hospice Nurse D having a conversation about the orders and assumed that DON B was going to handle the order. She stated that she did not input the order. She stated that the next day the situation was resolved. She stated that LVN A received a communication in-service discussing checking orders and following up on orders so that this issue does not happen again. She stated that Resident #1 was to be changing his pain medication from every 6 hours to every 4 hours. She stated that Resident #1 had a PRN medication that was being given in the time period that covered their mistake. She stated that there was no lapse in his care or medication. During an interview on 11/14/25 at 4:20 PM, Hospice Physician F stated that it is her expectation that the facility input written orders on the same day that they are received. She stated that the risk would be if a resident failed to receive medications as ordered. She stated that Resident #1 was at a low risk of injury from missing his medications and being in pain. She stated that he was already receiving his medications every 6 hours with an additional PRN order available to him if he needed it. She stated that the reason for the change to every 4 hours was because the facility was giving Resident #1 his PRN order already and they decided to go ahead and schedule it every 4 hours because Resident #1 was more agitated or uncomfortable. She stated that if the facility continued to give the PRN medication in addition to the previous 6-hour regiment then he was at a low risk of injury. During an interview on 11/17/25 at 3:49 PM, LVN A stated that 11/04/2025 was her first day to work with Resident #1. She stated that she was not familiar with Resident #1 or his previous orders. She stated that Hospice Nurse D had called the facility to speak with her and attempted to change Resident #1's order over the telephone. She stated that she informed Hospice Nurse D that she could not take an order over the telephone and that she needed the written order. She stated Hospice Nurse D arrived at the facility for her scheduled visit and also brought the written order with her. Hospice Nurse D was instructed to go discuss the order change with Family Member F. Afterwards, Hospice Nurse D attempted to talk to LVN A but LVN A told her that she was on the phone and to go talk to DON B. Hospice Nurse D approached DON B with the order and was told to deliver the orders to LVN A. She stated that she observed DON B and Hospice Nurse D talking about the orders, so she assumed that the orders were being handled by DON B. The next day she arrived at work and DON B approached her about the orders. It was discovered that the orders were supposed to be put in by LVN A. She stated that she received an in-service on communication and inputting orders. She stated that Hospice Nurse D should have communicated with her about DON B's expectations. She stated that although she failed to input the order, she did have knowledge of the order because Hospice Nurse D had already expressed what the order was about prior. She stated that she inputted a progress note and initiated a 24-hour report so that the staff knew when to administer the medications for the new order change. The only issue was the order itself was not input and had the problem not been fixed within the 24-hour period it may have gone unnoticed, and Resident #1 would have gone back to receiving medication every 6 hours. She stated that it did not happen that way and that there were no gaps in his medication administration. She stated that anytime an order is given the facility should input it and she can verify that it was not done on 11/04/2025 because on 11/05/2025 she doublechecked and it was not there. She stated that if she had not documented the medication change in the 24-hour report and/or progress note then harm could have been done to Resident #1. She stated that he would have been in pain without his medication as ordered. However, that was not the case. Resident #1 still received the new changes and doses required by the order because she put it in the 24-hour report. That means for the next 24 hours it would show the nursing staff the scheduled doses. However, after 24 hours if the order was not placed it would disappear as if there were no order changes for Resident #1. The residents could have been at harm after the 24-hour period of missing their medications. Review of facility policy dated 1/2025 and titled Physician Orders reflected the following: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments 4. Verbal orders must be recorded immediately in the residents' chart by the person receiving the order and must include the date and time of the order. 6. Orders for medications must include:A. Name and strength of the drug;B. Quantity or specific duration of therapy;C. Dosage and frequency of administration;D. Route of administration if other than oral; andE. Reason or problem for which given.

Based on interview and record review the facility failed to incorporate the recommendations from the PASARR evaluation report into the resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 3 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for nursing facility specialized services in the long-term care online portal within 20 business days after the annual interdisciplinary team meeting on 03/04/2025. Resident #1 did not receive a repositioning wedge as recommended on the PASRR Comprehensive Service Plan. This failure could place residents at risk of not receiving individualized care and specialized services to meet their needs. The findings include: Record review of Resident #1's Face Sheet, dated 09/16/2025, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included frontal lobe executive function deficit (impacts the ability to manage thoughts, emotions, and behavior effectively) following cerebral infarction (blood vessel to the brain is blocked), bipolar disorder (extreme mood swings, including emotional highs and lows), schizophrenia (severe mental disorder marked by impairments in how reality is perceived, leading to symptoms such as hallucinations, delusions, and disorganized thinking), and other voices and resonance disorders (affects the way a person speaks or produces sounds). Record review of Resident #1's PCSP (form used to streamline the process of documenting and managing specialize services for individuals with disabilities), dated 03/04/2025, reflected an annual meeting was conducted with Resident #1. The PCSP indicated Resident #1 was PASRR (screening tool used to ensure residents are not inappropriately placed in nursing facilities for long term care) positive for intellectual and developmental disabilities only. The PCSP indicated a repositioning wedge was recommended for Resident #1. Record review of Resident #1's Quarterly MDS (tool used to assess health status) Assessment, dated 08/22/2025, reflected intact cognition with a BIMS (screening tool to assess cognitive status) score of 15. Section I (Active Diagnoses) reflected Resident #1 was diagnosed with functional quadriplegia, morbid (severe) obesity, and limitation of activities due to disability. Section O (Special Treatments, Procedures, and Programs) indicated Resident #1 received physical therapy, occupational therapy, and speech therapy services. Record review of Resident #1's Comprehensive Care Plan, dated 08/20/2025, reflected the resident was PASRR positive for developmental disability. Interventions included therapy services as ordered, notifying the local authority of any significant changes, completing IDT (a group of professionals from various disciplines who work together to support the health and well-being of individuals) meeting as required, and providing specialized services as determined by the interdisciplinary team meeting. Resident #1's Comprehensive Care Plan did not reflect the use of a repositioning wedge. Record review of Resident's #1's Order Summary report, dated 09/16/2025, reflected the resident did not reflect an order for a repositioning wedge. During an interview on 09/16/2025 at 2:02 PM, the MDS Coordinator stated the facility completed PASRR assessments on admission and annually and the local authority completed quarterly assessment. The MDS Coordinator stated she was not working at the facility when the care plan meeting was held on 03/04/2025 and the previous MDS Coordinator was no longer employed at the facility. She stated she was not aware of the request for a positioning wedge. She stated if a request for services required follow up, the MDS Coordinator was responsible for that. During an interview on 09/16/2025 at 3:45 PM, the DON stated each morning staff met and discussed care plans and interventions to put in place. She stated resident #1 had been at the facility for a long time and received ongoing PASRR services. She stated she was unaware a positioning wedge was recommended for Resident #1 on 03/04/2025. She printed Resident #1's PCSP which reflected the recommendation for a repositioning wedge. She stated page 7 of the PCSP did not reflect any changes to his care plan. She stated if new needs were identified, they would be documented there. She stated Resident #1 had his last PCSP meeting on 08/25/2025 and it reflected a repositioning wedge was not needed. During an interview on 09/16/2025 at 3:55 PM, the Administrator stated after an IDT meeting, staff members discussed any items that needed follow up and he followed up with the MDS Coordinator to ensure the PCSP was complete. The Administrator stated he was not told Resident #1 needed a positioning wedge or the facility would have already purchased one. He stated it was important for the facility to provide recommended services to ensure the resident's needs were met.During a telephone interview on 09/19/2025 at 4:30 PM, the Habilitation Coordinator stated the repositioning wedge was recommended during the 03/04/2025 interdisciplinary team meeting, because Resident #1 leaned to one side, and she had approved it. She stated the nursing facility emailed her about the visit from a state surveyor requesting information about Resident #1. She stated the facility requested an interdisciplinary team meeting and she scheduled a meeting on October 1st to evaluate Resident #1's needs. Record review of the facility's policy Resident Assessment: PASRR, reviewed 05/2021, reflected It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the state. (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such a level of services, whether the individual requires specialized services for the intellectual disability.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents observed for infection control. The facility failed to ensure that LVN B washed her hands or used hand sanitizer while administering medication to Resident #2 on 09/16/2025. This failure could place the residents at risk of cross-contamination and the development of infections.Findings include:Review of Resident #2's Face Sheet, dated 09/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included hypertension (elevated blood pressure) and cellulitis (skin infection) of the right lower limb. Review of Resident #2's Quarterly MDS Assessment, dated 08/30/2025, reflected moderately impaired cognition with a BIMS score of 08. Section I (Active Diagnoses) reflected Resident #2 was treated for cellulitis and Section N (Medications) indicated the resident was administered antibiotics. Review of Resident #2's Comprehensive Care Plan, dated 08/28/2025, reflected Resident #2 had cellulitis of the lower right leg related to trauma. Interventions included Give antibiotics for infection and mild analgesics to relieve discomfort as prescribed by Physician. During an observation and interview on 09/16/2025 at 9:22 AM, LVN B was observed administering medication to Resident #2. The medication cart was parked outside Resident #2's door. LVN B opened the laptop on the medication cart to view the resident's orders and removed the medications to administer. The pills were placed in a medicine cup on top of the medication cart. LVN B put on clean gloves to open a capsule and poured the contents into a medicine cup. She crushed the other pills as ordered and removed her gloves. LVN B was not observed performing hand hygiene before putting on gloves or after removing the gloves. LVN B opened the pudding container on top of the cart and used a clean plastic spoon to remove the pudding and mixed it with the crushed medication. LVN B took the cup of medication to the resident's room and placed it on the bedside table. She used the bed controller to raise the head of the resident's bed and administered the medication. Resident #2 requested medication for pain. LVN B returned to the medication cart and viewed the resident's orders. LVN B was not observed to have performed hand hygiene upon exiting the resident's room. She removed pain medication from the locked box in the medication cart and documented it in the narcotic log. LVN B opened the top of the pudding container and used a clean plastic spoon to add pudding to the medicine cup. LVN B administered pain medication to Resident #2. LVN B washed her hands in the resident's restroom before leaving the room. LVN B stated she should have used hand sanitizer or washed her hands each time she entered and exited the resident's room. She stated she should have used hand sanitizer between the glove change. LVN B stated it was important to prevent cross contamination when caring for the residents. During an interview on 09/16/2025 at 4:50 PM, the DON stated the expectation was for staff to wash their hands or use hand sanitizer when removing gloves or in between touching surfaces that could be dirty. She stated it was important for staff to sanitize when going in and out of a resident's room. She stated it was important to prevent the spread of germs, and the facility had begun in-service training for staff. During an interview on 09/16/2025 at 4:55 PM, the Administrator stated it was important for staff to wash or sanitize their hands before going in or leaving a resident's room. He stated that anytime a staff member removed their gloves, it was important to sanitize. He stated it was important to prevent the spread of infection. Review of the facility's policy Hand Hygiene: Infection Control, revised 10/2022, reflected Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associate infection. Use and alcohol based hand rub or alternatively soap and water for the following situations . Before and after direct contact with residents; Before preparing or handling medications. After contact with objects in the immediate vicinity of the resident; After removing gloves.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Residents #35, #36, #49, #168, #169, and #171) of twenty residents reviewed for Infection Control. 1. The facility failed to ensure CNA D and CNA E changed their gloves and performed hand hygiene while providing incontinent care to Resident #35 on 03/04/2025. 2. The facility failed to ensure LVN J sanitized the blood pressure cuff and the pulse oximeter while administering medications and checking the vital signs of Residents #36, #49, #168, #169, and #171 on 03/05/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #35's Face Sheet, dated 03/04/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #35's Comprehensive MDS Assessment, dated 12/12/2024, reflected the resident had a score of 99 on her BIMS summary implying that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident was always incontinent for both bowel and bladder. Record review of Resident #35's Comprehensive Care Plan, dated 02/03/2025, reflected the resident had bowel/bladder incontinence and one of the interventions was to check as required for incontinence. Observation on 03/04/2025 at 11:20 AM revealed CNA D and CNA E were about to do incontinent care for Resident #35. Both CNAs washed their hands before putting on the gloves. CNA D positioned herself on the right side of the resident and CNA E went to the left side of the resident. CNA E unfastened the resident's brief, pushed it at the middle of the legs, and cleaned the lower abdomen of the resident. CNA E then cleaned the resident's perineal area (area between the legs) using the front to back technique. After cleaning the perineal area, CNA E assisted the resident to turn to her right side. CNA D assisted in turning the resident. It was observed that the resident was heavily soiled. CNA E cleaned the resident's bottom. After cleaning the resident's bottom, CNA E pulled the soiled brief, threw it inn the trash can, and rolled the soiled padding towards the middle of the bed. CNA E removed her gloves and put on a new pair of gloves. She did not sanitize her hands before putting on a new pair of gloves. CNA D then put a new padding beneath the resident and placed the new brief on top of the new padding. CNA D and CNA E then assisted the resident to turn to her other side. This time, CNA D cleaned the other side of the resident's bottom and placed the soiled wipes on the soiled padding. After cleaning the resident's bottom, CNA D pulled the soiled padding and handed it over to CNA E. CNA E placed the soiled padding on top of the trash can. CNA D pulled the other half of the padding and the brief and fixed them. CNA D did not change her gloves after cleaning the resident's bottom. CNA E fastened the brief on both sides. CNA E did not change her gloves after touching the soiled padding and before fixing the new brief. Both CNAs washed their hands after incontinent care. In an interview on 03/04/2025 at 11:35 AM, CNA E stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she did wash her hands before doing Resident #35's incontinent care. She said during the process, she changed her gloves but did not sanitize her hands before putting on a new pair of gloves. She said after putting the soiled padding on top of the trash can, she should have changed her gloves. She said she would be mindful the next time she does incontinent care to do hand hygiene and change her gloves after touching something soiled during incontinent care. In an interview on 03/04/2025 at 11:40 AM, CNA D stated she assisted CNA E during Resident #35 incontinent care. She said she did clean the other half of the resident's bottom. She said after cleaning the resident's bottom, she pulled the soiled padding and handed it over to CNA E. She said after handing the soiled padding to CNA E, she assisted in fixing the new brief. She said she should have changed her gloves. She said the gloves should be changed after she cleaned the resident's bottom and before touching the new brief because the gloves that she used to clean the resident's bottom were already soiled. She said she would be mindful the next time she does incontinent care to change her gloves after touching something soiled during incontinent care. She said she had trainings for pericare but did not know why she forgot to wash her hands and change her gloves. 2. Record review of Resident #168's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with atherosclerotic (the buildup of fats, cholesterol, and other substances in and on the artery walls) heart disease. Record review of Resident #168's Physician Order, dated 02/22/2025, Vitals q shift for skilled charting. Record review of Resident #169's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #169's Physician Order, dated 03/04/2025, reflected Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN hold for SBP less than 110 or HR less than 60 (Do not crush). Record review of Resident #36's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with congestive heart disease (condition in which the heart cannot pump blood well enough to meet the body's needs). Record review of Resident #36's Physician Order, dated 01/27/2025, reflected Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure hold medication if Apical Pulse is less than 60. Record review of Resident #171's Face Sheet, dated 03/05/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #171's Physician Order, dated 01/27/2025, Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for High blood pressure HOLD SBP LESS THAN 110 HOLD DBP LESS THAN 60 HOLD HR LESS THAN 60. Record review of Resident #49's Face Sheet, dated 03/05/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with cardiac murmur. Record review of Resident #49's Physician Order, dated 01/31/2025, reflected Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for hypertension related to CARDIAC MURMUR, UNSPECIFIED HOLD IF SBP IS LESS THAN 110 OR DBP IS LESS THAN 60 OR HR IS LESS THAN 60. Observation on 03/05/2025 from 6:46 AM to 7:58 AM revealed LVN J was passing medication. She went inside Resident #168's room and checked the resident's blood pressure using a mobile floor stand for the blood pressure cuff. She also checked Resident #168 oxygen saturation. The mobile floor stand had a small basket where the blood pressure cuff and the pulse oximeter where placed. There were no sanitizing wipes in the mobile floor stand basket. After taking the blood pressure and the oxygen saturation, she administered Resident #168's medication and put back the blood pressure cuff and the oximeter on the basket. She did not sanitize the blood pressure cuff and the pulse oximeter. After administering Resident #168's medication, LVN J went to Resident #169's room, took the resident's blood pressure and the O2 saturation, and then prepared the resident's medication. She went back inside the resident's room to administer the medications. She did not sanitize the blood pressure cuff and the pulse oximeter after use. After administering Resident #169's medication, she went to Resident #36's room, took the resident's blood pressure and the O2 saturation, and then prepared the resident's medication. She went back inside the resident's room to administer the medications. She did not sanitize the blood pressure cuff and the pulse oximeter after use. After administering Resident #36's medication, she went to Resident #171 's room, took the resident's blood pressure and the O2 saturation, and then prepared the resident's medication. She went back inside the resident's room to administer the medications. She did not sanitize the blood pressure cuff and the pulse oximeter after use. After administering Resident #171's medication, she went to Resident #49's room, took the resident's blood pressure and the O2 saturation, and then prepared the resident's medication. She went back inside the resident's room to administer the medications. She did not sanitize the blood pressure cuff and the pulse oximeter after use. In an interview on 03/05/2025 at 7:58 AM, LVN J stated she obtained the blood pressures of the residents before giving the medication for hypertension to know if the medication needed to be held or not. She said she would also obtain the heart rate if the resident was on digoxin. She also said, for some residents, she would just get the vital signs for documentation. She said she did sanitize her hands before preparing residents' medication but was not able to sanitize the blood pressure cuff and the pulse oximeter after using them in between residents. She said not sanitizing the blood pressure cuff and the pulse oximeter in between residents could cause infection to transfer from one resident to another. LVN J opened the last drawer of the cart of her nurse's cart, pulled some wipes, and sanitized the blood pressure cuff and the pulse oximeter. In an interview on 03/05/2025 at 4:48 PM, ADON B stated hand hygiene was the most effective way to prevent cross contamination and infection. She said gloves should be changed after cleaning the resident's bottom and after touching the soiled padding. She said hands should also be sanitized before putting on a new pair of gloves. She added the blood pressure cuff should be sanitized before using or after every use. She said the above issues could cause cross contamination and infections. She said the expectations were for the staff to be mindful with how they take care of the residents. She said she would collaborate with the DON to do in-service regarding infection control and hand hygiene. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated not changing the gloves when going from soiled to clean, not sanitizing the hands before putting on a new pair of gloves, and not sanitizing the blood pressure cuff and the pulse oximeter could contribute to cross contamination and infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said the DON already started an in-service for the staff about hand hygiene and infection control. In an interview on 03/06/2025 at 7:17 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after cleaning the resident's bottom and after throwing the soiled padding because the gloves were already deemed dirty. She said the expectation was for the staff to wash their hands before and after any care, change their gloves when going from dirty to clean, sanitize their hands before putting on a new pair of gloves, and sanitize the blood pressure cuff after use. She said she already started an in-service about infection control and hand hygiene. She said she would personally monitor the staff's adherence to the policy and procedure of infection control. Record review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves. Record review of facility policy, Perineal Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly. Record review of facility policy, Infection Control Plan: Overview Infection Control Policy & Procedure updated 3/2023 revealed Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection . Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination . Fundamentals of Infection Control Precautions . Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection . Before and after assisting a resident with personal care . After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves . Resident care equipment . Non-invasive resident care equipment is cleaned daily or as needed between use.

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one cart (nurse's cart) of seven carts observed. The facility failed to ensure that LVN G locked her nurse's cart while passing medication at hall 300 on 03/04/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications. Findings included: Observation on 03/04/2025 at 9:32 AM revealed a nurse's cart was in the middle of hall 300 hallway. The nurse's cart was left unlocked. The drawers of the cart contained various blister packs of medication, eyedrops, insulin, and insulin paraphernalia. Several staff passed by the nurse's cart and did not notice the cart was unlocked. Observation and interview with ADON A on 03/04/2025 at 9:38 AM revealed ADON A saw the nurse's cart was not locked. She pushed the cart's lock and said the cart should not be left unlocked. She said the staff should lock the cart to prevent untoward incidents. She said residents might be able to open it and ingest something that they were allergic to. She said, if it was a medication cart that was left unlocked, any resident, staff, or visitor could open it and get some medications. She said the expectation was for the staff to lock the carts before leaving them. She also said the carts should not be left in the middle of the hall where they could be easily accessed by others. She said she would collaborate with the DON about the issue on locking the cart. In an interview on 03/04/2025 at 10:26 AM, LVN G stated she was not aware that she left her cart unlocked. She said the cart should be locked every time a staff left it because anybody could open it and could get anything from the cart. She said residents could open it and accidentally ingest a medication the resident was allergic to or choke on some medication. She said she would be mindful next time to always lock the cart every time she left it unattended. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated the carts should always be locked so residents, other staff, and visitors could not open them and have access to the medications. He said it could result in accidental ingestion and overdose, especially if nobody was monitoring the cart. He said the residents could also choke and nobody would know. He said the expectation was for the staff to make sure the carts were locked every time they leave them. She said she would collaborate with the DON to do an in-service about locking the cart. In an interview on 03/06/2025 at 7:17 AM, the DON stated any cart should always be locked when left unattended to prevent any residents from opening it and taking something from it. She said residents could accidentally drink or ingest something from the cart that could result in allergic reactions and choking. She said the expectation was the cart would be always locked and secured. The DON stated she would start an in-service about the importance of locking the cart. Record review of the facility's policy, Medications - Storage and Reconciliation Pharmacy Services revised 01.2022 revealed Policy: It is the policy of this facility to safeguard access and storage of . drugs . Procedure . 2. Medications stored . in locked cabinet . medications in the medication cart . locked drawer on the cart.

Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #62) of twelve residents reviewed for Respiratory Care. The facility failed to ensure Resident #62 had an order for her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 03/04/2025. This failure could place residents at risk for not having their respiratory needs met. Findings included: Record review of Resident #62's Face Sheet, dated 03/04/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #62's Quarterly MDS Assessment, dated 02/27/2025, reflected the resident was unable to complete an interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident was on non-invasive mechanical ventilator (respiratory support such as CPAP) while a resident of the facility. Record review of Resident #62's Comprehensive Care Plan, dated 02/23/2025, reflected no care plan for CPAP usage. Record review of Resident #62's Physician Order on 03/04/2025 reflected no physician order for the CPAP. Observation and interview on 03/04/2025 at 9:28 AM revealed Resident #62 was in her room sitting in a wheelchair. The resident stated she was using her CPAP every night and every time she took a nap. She said she had been using the CPAP for months. Observation and interview on 03/05/2025 at 11:22 AM, LVN H stated Resident #62 had a diagnosis of sleep apnea that was why she used a CPAP at night. She said the resident was capable of putting the CPAP on at night and taking it off in the morning. LVN H said she would check if the resident had an order for the CPAP. LVN H opened her computer and opened the resident's physician orders. LVN H checked the list of the resident's physician orders twice and said the resident did not have an order for the CPAP. She said there should be a physician order. In an interview on 03/05/2025 at 5:06 PM, ADON A stated there should be a physician order for the CPAP because it was a treatment, and the staff must make sure it was tailored to the needs of the resident like the correct setting and if the resident knew proper placement. She said even though the resident was the one putting it on and taking it off, there should be an order for the CPAP. She said without the order, the staff might not know she was on a CPAP and would not be able to assess the CPAP's effectiveness. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated there should be a Physician Order for the resident's CPAP. He said there should be an order for everything that was done for the resident. There should be physician orders for medications, treatment, diet, and therapies. He said a CPAP is a medical device and there should be medical supervision to ensure a safe and effective treatment. He said without a physician order, the staff would not be aware that the resident was using a CPAP. He said he would coordinate with the DON and would find out the reason why the resident did not have a physician order for the CPAP and would do an in-service about it. In an interview on 03/06/2025 at 7:17 AM, the DON stated there should be an order for Resident #62's CPAP. She said the staff knew she was using a CPAP but was not able to check if she had an order. She said it was also her responsibility to check the orders of the residents. She said the physician orders were fundamental and served as instructions on how to ensure the residents were receiving proper care. She said she would do an in-service about making sure there was a physician order on everything done for the residents. Record review of undated facility policy, Oxygen delivery & Maintenance revealed Procedure: The administration of oxygen will follow professional guidelines for safe administration . against provider orders . 10. Monitor . respiratory status per physician orders. Record review of facility policy, Physician Orders Pharmacy Services revised 10/2022 revealed POLICY: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments . 6. Orders for medications must include . A. Name and strength of the drug; B. Quantity or specific duration of therapy; C. Dosage and frequency of administration; D. Route of administration if other than oral; and E. Reason or problem for which given.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #45) of twenty residents reviewed for Dignity. The facility failed to ensure CNA F did not stand behind Resident #45 while assisting the resident to eat during lunchtime on 03/04/2025. This failure placed residents at risk of not having their right to a dignified existence maintained. Findings included: Review of Resident #45's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with lack of coordination and muscle weakness. Review of Resident #45's Quarterly MDS Assessment, dated 02/27/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required moderate assistance (refers to providing assistance that is approximately 50% of the task) in eating. Review of Resident #45's Comprehensive Care Plan, dated 01/26/2025, reflected the resident was dependent on staff for activities and one of the interventions was to provide assistance with activities of daily living. Observation on 03/04/2025 at 12:12 PM revealed CNA F was assisting Resident #45 during lunch. It was observed that CNA F was standing behind the resident and would give the food to the resident while standing behind the resident. She stood behind the resident until the resident was done with lunch. CNA F was not interacting with the resident and the only thing she asked the resident was if she was done eating. After the resident was done eating, CNA F ushered the resident to her room. In an interview on 03/04/2025 at 12:29 PM, CNA F stated she assisted Resident #45 during lunchtime. She said when assisting a resident in the dining room, the staff should sit beside the resident and not stand up beside or at the back of the resident. She said they needed to sit down beside the resident to see if the resident was swallowing the food, there was a problem in swallowing, or if the resident was pocketing the food. She said there was no room for another chair in the table, but she should have transferred the resident to another table that could accommodate both of them. She said it was a dignity issue because it was as if she was in a hurry to finish feeding the resident. Observation and interview on 03/04/2025 at 1:09 PM revealed Resident #45 sitting on her wheelchair inside her room. When asked how was lunch, The resident did not reply. When asked if it was okay for any staff to stand when assisting her for lunch, the resident did not reply. In an interview on 03/05/2025 at 4:48 PM, ADON B stated the staff assisting a resident during mealtime should be sitting alongside the resident to provide dignity. She said sitting beside the resident would allow better observation of the resident's needs during mealtime. She said sitting beside the resident encouraged interaction and promoted safety when eating. When a staff was behind the resident, the staff would not know, at once, if the resident was in distress, or she was too fast in assisting the resident to eat and may cause the resident to be frustrated. She said the expectation was for the staff to provide dignity, not only during mealtime but every time the staff provide care to the residents. She said they would do an in-service about dignity. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated staff should not stand behind or beside the residents when feeding the residents. He said the staff should sit beside the resident to convey respect and to show the residents that the staff were there to support them. He said if a staff stood behind a resident seems disrespectful and a dignity issue. He said he would collaborate with the DON and the ADONs to re-educate the staff about dignity of the residents. In an interview on 03/06/2025 at 7:17 AM, the DON stated staff should sit down next to the resident when assisting or feeding the resident. She said sitting beside the resident promoted dignity and respect, allowed close observation of the resident's eating habits, and ensured the resident was not in any distress. She said standing up behind the resident gave the impression that the staff was in a hurry. She said she would do an in-service regarding dignity specifically about sitting down when providing assistance during mealtime. Record review of facility's policy, Dignity and Respect Policy/Procedure - Nursing Administration revised 07/2024 revealed POLICY: It is the policy of this facility that all residents be treated with kindness, dignity, and respect . PROCEDURES . 1. The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on observation, interview, and record review, the facility failed to secure confidential and personal medical records for one (Residents #8) of twenty residents reviewed for Privacy and Confidentiality. The facility failed to ensure LVN G closed, locked, or minimized her laptop's monitor while administering medication to Resident #8 on 03/04/2025. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals. Findings included: Review of Resident #8's Face Sheet, dated 03/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder (intense or excessive fear or worry). Review of Resident #8's Quarterly MDS Assessment, dated 12/23/2024, revealed the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had anxiety disorder. Review of Resident #8's Comprehensive Care Plan, dated 01/08/2025, reflected the resident was on anti-anxiety medication and one of the interventions was to monitor side effects and effectiveness. Review of Resident #8's Physician Order, dated 12/12/2024, reflected Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth three times a day for anxiety. Review of Resident #8's Physician Order, dated 09/26/2024, reflected (AA)- MONITOR FOR SIDE EFFECTS OF ANTI-ANXIETY/ANXIOLYTICS (medications to prevent anxiety): COMMON S/E: SEDATION (making a person calm), DROWSINESS (a feeling of being sleepy), ATAXIA (poor muscle control), DIZZINESS, NAUSEA, CONFUSION, NASAL CONGESTION. LESS COMMON S/E: VOMITTING, SKIN RASH, FALLS, AGITATION. RARE S/E: HYPOTENSION, BLURRED VISION, ATAXIA, MOOD SWINGS. NOTIFY PROVIDER IF PRESENT every shift. Observation on 03/04/2025 at 9:32 AM revealed a nurse's cart was in the middle of hall 300 hallway. There was a laptop on top of the cart. The laptop was open and displayed Resident #8's name, status, location, gender, date of birth, age, name of physician, latest vital signs, allergies, code status, emergency instructions, and physician orders. The screen of the computer was facing the hallway. Observation and interview with ADON A on 03/04/2025 at 9:38 AM revealed ADON A saw the computer was open and Resident #8's information was visible to everybody that would pass by. ADON A closed the computer. She stated the staff should close the computer or minimize the monitor before leaving the cart unattended. She said the resident's information was confidential and should not be seen by unauthorized individuals. She said some residents might be embarrassed that others would know they had such sickness or was taking a certain type of medication. She said she would collaborate with the DON about the issue on privacy and confidentiality. In an interview on 03/04/2025 at 10:26 AM, LVN G stated the monitor of her computer should be locked, minimized, or closed every time she left the cart. She said the purpose was to protect the health or personal information of the residents. She said ADON A told her that she left the monitor open when she was in hall 300 and Resident #8's information was displayed. She said the resident's information was confidential. She said she should be mindful to close her computer every time she left it. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated the staff must make sure the residents' information was not exposed and protected because it was a violation of the resident's privacy and confidentiality of the care they were receiving. He said the expectation was for all the staff to make sure the resident's information and treatment were not visible to unauthorized individuals. He said she would collaborate with the DON to do an in-service about privacy and confidentiality. In an interview on 03/06/2025 at 7:17 AM, the DON stated personal and medical information about a resident should not be exposed for everybody to see. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all employees were expected to provide full privacy and confidentiality of information for all residents. The DON stated the failure to not protect the resident information could cause poor self-esteem and embarrassment for the resident. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. Record review of facility's policy, Confidentiality of Resident Information Policy/Procedure revised 7/2024 revealed POLICY . The types and amount of information gathered from the resident shall be limited to that information necessary to carry out the function of the person or service requesting the information . PROCEDURES: 1. All individuals engaged in collection, handling, or dissemination of resident-related information shall be specifically informed of their responsibility to protect the confidentiality of the information.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #62) of eight residents reviewed for Care Plans. The facility failed to ensure Resident #62's care plan, dated 02/23/2025, included her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) usage. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #62's Face Sheet, dated 03/04/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #62's Quarterly MDS Assessment, dated 02/27/2025, reflected the resident was unable to complete an interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident was on non-invasive mechanical ventilator while a resident of the facility. Record review of Resident #62's Comprehensive Care Plan, dated 02/23/2025, reflected no care plan for CPAP usage. Record review of Resident #62's Physician Order on 03/04/2025 reflected no physician order for the CPAP. Observation and interview on 03/04/2025 at 9:28 AM revealed Resident #62 was in her wheelchair inside her room. The resident stated she was using her CPAP every night and every time she took a nap. She said she had been using the CPAP for months. Observation and interview on 03/05/2025 at 11:22 AM, LVN H stated Resident #62 had a diagnosis of sleep apnea and that was why she used a CPAP at night. She said the resident was capable of putting the CPAP on at night and taking it off in the morning. LVN H said she would check if the resident had a care plan for the CPAP. LVN H opened her computer and opened the resident's care plan. LVN H checked the list of the resident's physician orders and said the resident did not have a care plan for the CPAP. She said there should be a care plan so the staff would know the goal and intervention with regards to the resident's CPAP. In an interview on 03/05/2025 at 2:22 PM, The MDS Nurse stated she was the one responsible in doing the care plans of the residents. She said the care plan was the facility's contract with the resident of what care and services would be provided for the resident. She said the care plan should be in place so the staff know the interventions and goal for the resident and would be in sync in terms of the care to be provided. The MDS Nurse said she would check if Resident #62 had a care plan for the CPAP. She logged on to her computer and checked if the resident had a care plan for the CPAP. She said she did not see any care plan for the CPAP. She said she also did not see any order for the CPAP and that was why she was not able to do a care plan for the CPAP. She then checked if there was any documentation about the resident's CPAP and said there was documentation about the resident's CPAP. She said the documentation should have prompted her to ask or personally assess the resident if the resident was using a CPAP. She then checked the resident's MDS and saw the resident was coded for non-invasive mechanical ventilator and said she coded it but was not able to do the care plan. She said if the residents do not have a care plan, there would be a possibility of confusion about the care to be provided or the care would be not provided at all. She said would do an audit of the care plans of the residents. In an interview on 03/05/2025 at 5:06 PM, ADON A stated if a resident was using a CPAP, there should be a care plan for the CPAP or sleep apnea. She said the care plan is important so the staff are in sync with the care of the residents. She said without the care plan, appropriate intervention might not be provided. She said the expectation was all the issues of the residents were care planned. She said she would coordinate with the DON and the MDS Nurse on how to make sure the residents were care planned accordingly. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. He said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned appropriately. He said he would coordinate with the DON to make sure all the residents were care planned. In an interview on 03/06/2025 at 7:17 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's problem lists, goals, and interventions. She said the care plan should be resident-centered and should show what specific care the resident needed. She said the expectation was for all residents to have a complete and detailed care plan. She said she would coordinate with the MDS Nurse to audit the care plans of the residents. Record review of the facility's policy, Comprehensive Person-Centered Care Planning Policy and Procedure revised 1.2022 revealed Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . Procedure . 4. The facility IDT will develop and implement a comprehensive person-centered care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment.

Based observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #36) of five residents reviewed for Pharmaceutical Services. The facility failed to ensure LVN J disposed of Resident #36's Tramadol properly on 03/05/2025. This failure could place residents at risk of not receiving medications as ordered by the physician. Findings included: Record review of Resident #36's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with polyneuropathy (a condition that damages many nerves in the body) and osteoarthritis (inflammation of one or more joints). Record review of Resident #36's Quarterly MDS Assessment, dated 02/04/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had polyneuropathy and osteoarthritis. Record review of Resident #36's Quarterly Care Plan, dated 02/03/2025, reflected the resident was on pain medication and one of the interventions was administer medication as ordered. Record review of Resident #36's Physician Order, dated 03/07/2025, reflected Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth three times a day for pain. Observation and interview on 03/05/2025 at 7:19 AM revealed LVN J was preparing Resident #36's pain medication. When she pushed the medication out of the blister card, the medication fell on top of the nurse's cart. She said she would waste the medication because it was already dirty. She placed the tramadol tablet inside a pill crusher pouch and crushed it. She then said she would look for another nurse to co-sign the wasted tramadol. After signing the wasted tramadol, she placed drops of water to the pouch and then threw it in the trash can at the side of the nurse's cart. It was observed that the pouch thrown in the trash can still had residuals and uncrushed particles of the tramadol. She said she threw it in the trash can because she did not have the solution used for wasted narcotics. She said the medication aide's cart had one on the cart. She said she would ask MA I where she could get the solution. In an interview on 03/05/2025 at 8:08 AM, MA I stated there was a solution inside the medication room for wasting narcotics. She said she had not wasted a narcotic, but she knew in case she needed to it, it must be placed in the solution. She said she told LVN J where she could get the solution used for wasting a narcotic. In an interview on 03/05/2025 at 8:18 AM, the DON stated narcotics were not disposed of in the trash can. She said there was solution where the staff could use to dispose the narcotics. She said the narcotics were placed in a locked box inside the carts so nobody unauthorized could access them. She said the same principle applied in disposing of the narcotics. She said the residual or particles of the tramadol should not be accessible to the residents, staff, and visitors. She said she was already doing an in-service about proper disposal of narcotics. In an interview on 03/05/2025 at 5:06 PM, ADON A stated narcotics were not disposed of in the trash can. She said the facility had solutions for the wasted narcotics. She said if tramadol was disposed of in a trash can, confused residents might access it and could lead to adverse reactions. She said the expectation was not to throw any narcotics in the trash can. She said she would coordinate with the DON to do an in-service regarding proper disposal of narcotics. In an interview on 03/06/2025 at 6:30 AM, the Administrator stated narcotics should be disposed of properly to prevent untoward incidents. He said a confused resident that was allergic to tramadol might pick it up and consume it. He said discontinued narcotics were given to the DON and were locked inside her office. The DON would dispose of them along with the pharmacist that would come once a month. He said if a staff needed to waste a narcotic, the facility had a solution where the wasted narcotics could be placed. He said the expectation was for staff to dispose of the narcotics properly. He said another expectation was if the staff did not know where to get the solution or how to properly dispose of narcotics, the staff should ask somebody how to dispose of the narcotics. He said he would collaborate with the DON to do an in-service about how to dispose of narcotics. Record review of the facility's policy, Controlled medications - Storage and Reconciliation Pharmacy Services revised 01.2022 revealed Policy: It is the policy of this facility to safeguard access and storage of controlled drugs . this facility will maintain a process for monitoring, administration, documentation, reconciliation and destruction of controlled substances.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 (Rooms 303b, 307 b) of 6 resident rooms and all hallway handrails in the facility reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms # 303b, and 307 b were thoroughly cleaned and sanitized. The facility failed to ensure that the facility hallway handrails were cleaned. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 12/04/24 at 10:40 AM of all the facility hallway handrails revealed dark and light dirt along the brown wooden rails. An observation on 12/04/24 at 12:00 PM of room [ROOM NUMBER] b reflected the top of the 5-drawer chest had a large circular white patch of powdery substance. Interview on 12/04/24 at 12:06 PM, the resident in room [ROOM NUMBER]b (BIMS 12) stated that the facility only cleaned her room once a week. She stated housekeeping was supposed to clean her room on 12/03/24 but they had not cleaned her room. She stated they never cleaned the floors, and they did not empty her trash can. An observation on 12/04/24 at 12:07 PM of room [ROOM NUMBER] b reflected the floor around the toilet, had a white substance circling it. No interview was able to be conducted with the resident in room [ROOM NUMBER]b due to decreased cognitive status., no BIMS was able to be assessed for this resident. In an interview on 12/04/24 at 2:16 PM, the Housekeeping Supervisor stated she had been at the facility for [AGE] years. She stated they were to clean everything, especially the resident rooms daily. She stated they wiped the handrails down daily. She was shown pictures of the concerns observed in Rooms #303b , and 307b , as well as the hallway rails. She stated the risk the resident was that they were not in a safe clean, and homelike environment. She stated they cleaned all the areas mentioned but had not gotten to those areas yet because they had one housekeeping cleaning two halls. She was advised that there was a complaint made regarding the cleanliness of the facility and there was also an interview from a current resident that stated her room was not cleaned daily. She stated she would address the concerns observed. In an interview on 12/04/24 at 2:31 PM, the Administrator was shown pictures of the concerns observed in Rooms # 303b, and 307 b , and the hallway rails. He stated he would meet with the housekeeping supervisor to address the concerns observed. He stated the risk of the residents' rooms not being thoroughly cleaned was a dignity and infection control concern. Review of the facility's policy on Safe/Comfortable/Homelike Environment (01/2022) reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control. The facility DON (Infection Preventionist) failed to ensure: Residents who had the flu had appropriate signage on their door and PPE for use outside their door. Facility staff were utilizing appropriate PPE when caring for residents in isolation rooms. Facility staff notified the families of flu negative roommates that they were at risk of being infected with the flu. Flu negative residents were cohorted in the same room as flu positive residents. Flu negative roommates were offered the prophylactic treatment for the flu. An IJ was identified on 01/24/24. The IJ template was provided to the facility on [DATE] at 4:45PM. While the IJ was removed on 01/26/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because all staff had not been trained on the POR. These failures could place residents at risk for the spread of infection through cross-contamination of pathogens and illness which could result in a decline in health and well-being or even death. Findings included: Record review of Flu Positive Residents, dated 01/24/24, and received from the DON, revealed 10 residents had the flu: o Resident #1 (Roommate - Resident #25 was flu negative) o Resident #41 (Roommate - Resident #31 was flu negative) o Resident #2 (No roommate) o Resident #55 (Roommate - Resident #42 was flu negative) o Resident #64 (Roommate - Resident #39 was flu negative) o Resident #12 (Roommate - Resident #49 was flu negative) o Resident #3 (No roommate) o Resident #46 (Roommate - Resident #4 was flu negative) o Resident #24 (No roommate) o Resident #70 (Roommate - Resident #57 was flu negative) 1. Review of Resident #1's MDS admission assessment, dated 01/08/24, reflected she was an [AGE] year-old female admitted on [DATE]. Her cognitive status was severely impaired. Her diagnoses included non-Alzheimer's disease. 2. Review of Resident #41's MDS quarterly assessment, dated 01/08/23, reflected she was a [AGE] year-old female admitted on [DATE]. Her cognitive status was intact. Her diagnoses included non-Alzheimer's disease. 3. Review of Resident #2's MDS quarterly assessment, dated 10/25/23, reflected she was an [AGE] year-old female admitted on [DATE]. The resident was rarely understood. Her diagnoses included non-Alzheimer's disease. 4. Review of Resident 55's MDS quarterly assessment, dated 12/14/23, reflected he was a [AGE] year-old male admitted on [DATE]. His cognitive status was intact. His diagnoses included post-traumatic stress disorder. 5. Review of Resident 64's MDS quarterly assessment, dated 01/04/24, reflected she was an [AGE] year-old female admitted on [DATE]. Her cognitive status was severely impaired. Her diagnoses included Alzheimer's disease. 6. Review of Resident #12's MDS quarterly assessment, dated 10/15/23, reflected she was an [AGE] year-old female admitted on [DATE]. The resident was rarely understood. Her diagnoses included non-Alzheimer's disease. 7. Review of Resident #3's MDS admission assessment, dated 01/18/24, reflected she was an [AGE] year-old female admitted on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included non-Alzheimer's disease. 8. Review of Resident #46's MDS quarterly assessment, dated 12/27/23, reflected he was a [AGE] year-old male admitted on [DATE]. His cognitive status was not assessed. His diagnoses included heart failure. 9. Review of Resident #24's MDS quarterly assessment, dated 01/04/24, reflected she was a [AGE] year-old female admitted on [DATE]. Her cognitive status was not assessed. Her diagnoses included stroke. 10. Review of Resident #70's MDS quarterly assessment, dated 12/15/23, reflected he was a [AGE] year-old male admitted on [DATE]. His cognitive status was severely impaired. His diagnoses included non-Alzheimer's disease. An observation on 01/24/24 at 10:47 AM of Resident #49's room revealed the resident was lying in B bed. The door was open, a sign to see the nurse was posted, and a bin with PPE was outside the door. Resident #49 requested water and CNA A entered the resident's room wearing a mask only. CNA A picked up the water bottle and gave the resident a drink. CNA A left the room. CNA A said the resident was in isolation and she got busy and forgot to wear all of her PPE into the room. She said it was important to wear PPE so that the infection did not spread. Neither resident had the curtain drawn in the room to separate them. Resident #49's flu positive roommate was not wearing a mask. An interview on 01/24/24 at 3:00 PM with the family of Resident #49 revealed they were never notified that the resident was in an isolation room with a resident that had the flu. The family member said they would not want Resident #49 to remain in the room. The family member said the facility did not contact them about administering medication prophylactically to treat for possible flu. An observation on 01/24/24 at 10:40 AM with Resident #46 revealed there was no signage on his door and there was no PPE outside of his room. The resident was interviewed by the Surveyor and said he felt ill. He was sitting up in bed with a congested cough. Resident #46 had a roommate (flu negative) who was lying in his bed. Resident #46 was not wearing a mask. An observation and interviews on 01/24/24 between 12:36 PM - 12:40 PM revealed staff shut Resident #46's door. Staff placed signage on the door and a PPE bin outside of the door. LVN C was standing next to her med cart outside of Resident #46's door. LVN C said Resident #46 was supposed to be in isolation because he had the flu. LVN C said she did not know why the resident did not already have signage on the door and PPE outside of the door prior to 12:36 PM. The DON walked to Resident #46's door. The DON said the resident was supposed to be in isolation because he had the flu. The DON said Resident #46's roommate did not have the flu, but there were no rooms to move him to and his family did not want him to move. An observation on 01/24/24 at 1:16 PM revealed Resident #3 had his door open. He was in his room seated in his wheelchair. There was a sign outside the room which reflected, All proper PPE must be worn upon entering. There was no PPE cart outside the room. It was not clear if the resident was in isolation or not. An interview on 01/24/24 at 1:29 PM with LVN D revealed she did not know for sure if Resident #3 had the flu . LVN D said the resident was being treated with Tamiflu (flu medication). LVN D said if the resident had the flu then there needed to be PPE outside their door because the resident would be contagious. An observation and interview with the DON on 01/24/24 at 1:47 PM revealed Resident #3 was supposed to be in isolation. The resident's door was still open. The DON said that staff must have taken the PPE cart instead of refilling it . An interview on 01/25/24 at 02:38 PM with the ADON revealed 10 residents had the flu according to the 24-hour report. She said an additional resident had been sent to the hospital for low oxygen saturation. The ADON said she would identify which residents were in isolation because they would have PPE outside of their door. The ADON said facility staff needed to wear a gown, gloves, face shield, and N95 mask to provide care to a resident with the flu. Interviews on 01/24/24 at 2:29 PM and on 01/25/24 at 3:03 PM with the DON revealed the flu outbreak started on 01/17/24 when some of the residents first showed signs and symptoms of the flu. She said flu tests were sent to the lab, but results were not received until 01/21/24. The DON said some residents started Tamiflu and some did not. She said staff were educated to wear PPE. The DON said residents and staff were not tested unless they were symptomatic. She said the facility was following the CDC guidelines for managing the flu infection and the health department had been contacted. The DON said she did not know why families of roommates of flu positive residents were not contacted by the charge nurse and she started contacting families on 01/24/24 . The DON said she did not know why staff were not changing their masks when exiting an isolation room. She said staff were supposed to wear PPE in isolations rooms which included an N95 mask, goggles/face shield, gown, and gloves . She said she saw staff were not wearing PPE appropriately and she was in-servicing them. She said 10 residents and 2 staff had the flu. She said it important to wear PPE and keep flu positive residents cohorted to prevent cross contamination. The DON said the infection spread partially because Resident #70 was ill but would walk through the halls of the facilit y. The DON said facility staff would encourage the resident to stay in her room. The DON said she did not know how many of the flu positive residents received the flu vaccine or which of their roommates received the vaccine. She said staff knew which residents had the flu because of shift-to-shift report and the signs on the door and PPE bins outside of the door. Review of the website: https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm on 01/24/24 reflected: Preventing transmission of influenza viruses and other infectious agents within healthcare settings, including in long-term care facilities, requires a multi-faceted approach that includes the following: Influenza Vaccination Influenza Testing Infection Prevention and Control Measures Antiviral Treatment Antiviral Chemoprophylaxis . Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Examples of Droplet Precautions include: Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another. Wear a facemask (e.g., surgical or procedure mask) upon entering the resident's room. Remove the facemask when leaving the resident's room and dispose of the facemask in a waste container. Communicate information about patients with suspected, probable, or confirmed influenza to appropriate healthcare personnel . exposed residents on units or wards with influenza cases in the long-term care facility (currently impacted wards) should receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined . When at least 2 patients are ill within 72 hours of each other and at least one resident has laboratory-confirmed influenza, the facility should promptly initiate antiviral chemoprophylaxis with oral oseltamivir to all non-ill residents living on the same unit as the resident with laboratory-confirmed influenza (outbreak affected units), regardless of whether they received influenza vaccination during the current season. Antiviral chemoprophylaxis is meant for residents who are not exhibiting influenza-like illness but who may be exposed or who may have been exposed to an ill person with influenza, to prevent transmission . Review of the facility policy and procedure, IPCP Standard and Transmission-Based Precautions, dated October 2022, reflected: .4. Droplet Precautions (TBP) are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (e.g. influenza). See CDC Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions for other conditions and infections in which droplet precautions are indicated. a. Implement source control by placing a mask on the patient. b. Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. c. Use personal protective equipment (PPE) appropriately. Don mask (and eye protection if indicated) upon entry into the patient room or patient space. d. Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside of the room is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette . 6. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. b. Make PPE, including gowns and gloves, available immediately outside of the resident room . e. Provide education to residents and visitors as needed. The facility Administrator was notified an Immediate Jeopardy (IJ) had been identified on 01/24/24 at 4:45 PM and was provided with the IJ template at that time. A Plan of Removal was requested. The Plan of Removal (POR) was accepted on 01/25/24 at 4:45 PM and reflected: Immediate Action: 1. The Medical Director was notified of the IJ on 01/24/2024 at 5:00 pm. 2. PPE was placed at the entrance of each isolation room and signs were posted on 1/24/24. 3. The families of the roommates were notified 1/24/24. 4. Residents will be actively monitored for signs/symptoms of influenza via physician orders that were placed 1/24/24. This process was initiated 1/24/24 and will continue for 1 week after last laboratory confirmed case of influenza is identified. Upon identification of signs and symptoms of respiratory illness; the resident will be assessed for change in condition and placed on droplet precautions, staff caring for the resident will be notified of the need for precautions, physician and family notified, tested for influenza. If positive, resident will remain in droplet precautions, physician notified, new orders for treatment/ medications will be obtained, family notified, staff caring for resident will be updated on positive flu and precautions will continue. This was included in the training with staff, initiated 1/24/24 and completed 1/25/24. 5. Staff are screened for signs and symptoms of respiratory illness using Simpliscreen prior to the start of their shift. Visitors also screen in with each visit. Signs are posted at the entrance to stop and screen, also QR code is available to both staff and visitors to screen in. 6. Following CDC guidance on discontinuation of transmission precautions: Resident's positive for influenza will be monitored for the 7-day isolation period and precautions will be discontinued only after the resident is assessed as having resolving symptoms and having no fever for more than 24 hours. The Infection Preventionist will communicate this to the Attending Physician to obtain the orders to discontinue precautions. The family will also be notified that precautions are being discontinued. This process was initiated 1/24/24 and will be documented on as their precautions are discontinued. This process was included in staff training under outbreak procedures and droplet precautions/discontinuation of precautions. 7. The Attending Physicians were notified of outbreak and CDC recommendations on administering prophylactic antivirals. All recommended antiviral use and gave orders. Families/residents were notified of recommendations and either consented or declined the orders. Documentation was completed with either the consent or declination, orders placed and awaiting delivery of medication for administration. This process was initiated 1/24/24 and completed 1/25/24. 8. Cough etiquette signs were posted on entrance doors and hallways on 1/24/24. 9. Train the trainer in-servicing was given to the DON/Infection Preventionist, ADON, Rehab Director and RN Cluster Partners by the Clinical Resource. The training includes masking, donning/doffing PPE, droplet precautions and discontinuation of precautions, procedures for outbreak including identifying respiratory illness, disinfection and handwashing all based on CDC guidance for influenza. This was completed 1/24/24 prior to start of training for all other staff. 10. Training and competency on donning and doffing PPE, handwashing, droplet precautions and discontinuation of precautions, and outbreak procedures including identifying respiratory illness and disinfecting practices will be completed with all staff by 1/25/24. This training was initiated on 01/24/24 will be completed on 1/25/24 with all staff prior to the start of their next shift. The training includes masking, donning/doffing PPE, droplet precautions and discontinuation of precautions, procedures for outbreak/disinfection and handwashing all based on CDC guidance and will be provided by the DON, ADON, Clinical Resource, Cluster Partners, Rehab Director, and Executive Director and completed by 1/25/24. Train the trainer in-service was given by the Clinical Resource RN and was completed with DON, ADON, Cluster Partners, Rehab Director, and Executive Director on 1/24/24. 11. This training will be completed in-person by 1/25/24 with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency. 12. An ad hoc meeting regarding items in the IJ template will be completed on 01/24/2024. Attendees will include the DON/Infection Preventionist, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 13. The DON, ADON, or Clinical Resource RN will verify staff competency with 10 staff weekly using the PPE and handwashing competency checklists. This will be completed weekly after the initial training and competency began on 01/24/2024. 14. Influenza positive residents will be reviewed during weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and influenza positive residents are reviewed. This meeting will begin on 01/24/2024. 15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x4 weeks beginning 1/25/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal reflected: Observations on 01/26/24 between 9:00 AM - 4:00 PM revealed residents with the flu were in isolation and there was appropriate signage and PPE available outside of their doors. Resident #24 was observed leaving her room (isolation room) and entered the hall without wearing a mask. The ADON intervened and escorted the flu positive resident back to her room and shut her door. Staff donned and doffed PPE appropriately when entering and exiting isolation rooms. Interviews on 01/26/24 between 9:51 AM - 4:00 PM with 13 staff from all shifts, (CNA E, LVN F, LVN G, CNA H, CNA I, CNA J, ADON, CNA K, CNA L, MA M, CNA N, CNA O, and LVN P) revealed the staff were in-serviced on hand hygiene, donning and doffing PPE appropriately, identifying residents with flu symptoms and what to do with those residents. Facility staff were checked off on hand hygiene and donning and doffing PPE. Staff were able to correctly identify which residents had the flu and were in isolation. Staff said everyone was responsible for ensuring isolation rooms were correctly identified. Staff nurses said they were responsible for notifying the physician, family, facility staff, and administrative staff regarding residents with flu symptoms. Facility staff said if the flu positive resident had a roommate they would notify the family and physician to determine if they were to be treated prophylactically and if they were to remain in the room with the flu positive resident. Facility nurses said the physician had to be notified before a resident could be removed from isolation and the residents were supposed to be in isolation for 7 days. An interview with the DON on 01/26/24 at 03:34 PM revealed she had received a Train the Trainer in-service. She said she identified errors during the flu outbreak that included a delay in receiving lab results which led to a delay with when residents were placed in isolation. She said there was a rapid spread of the flu virus and that staff thought isolation ended after 5 days and were removing PPE bins before they were supposed to. The DON said that her role in the POR was to educate staff, monitor PPE use, monitor handwashing, and ensure that families were contacted. An interview with the Medical Director on 01/26/24 at 2:47 PM revealed he was contacted by facility staff regarding the Immediate Jeopardy. He said his role in the POR would be to ensure tracking was completed and that residents were prophylactically treated. He said he felt at that time the flu outbreak was under control. An interview with the Administrator on 01/26/24 at 3:48 PM revealed the issues he identified with the outbreak were that the facility did not respond correctly to ensure staff followed infection control protocols. He said his role in the POR was to educate staff and monitor to ensure the education was completed and followed through on. He said going forward a response plan would be implemented with each positive case and the issues would be discussed in QAPI meetings. He said he would ensure contact tracing and tracking of the anti-viral medication administration would be completed. The Administrator was informed the IJ was removed on 01/26/24 at 5:15 PM. While the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of no actual harm due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for one (Resident #2) of nine residents reviewed for neglect. The facility failed to ensure Resident #2 was monitored to prevent elopement from the facility. An Immediate Jeopardy was identified on 10/31/16. While the Immediate Jeopardy was removed on 11/02/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the five residents with a history of elopement by placing them at risk for injury and/or death. Findings included: An observation on 10/31/16 at 2:20 p.m. revealed Resident #2 exited the facility as a visitor held the door open for him. The visitor asked the surveyor if it was okay for the resident to be outside, and the surveyor responded she did not know. The surveyor instructed the visitor to alert the facility staff, and the visitor walked back into the facility to alert the facility staff. Resident #2 then walked quickly with his walker across the parking lot. The surveyor started walking towards the resident as he neared the street and two facility staff members caught up with the resident and escorted him back into the facility. The facility staff members reported the resident did not have a Wanderguard device. An interview with LVN D on 11/01/16 at 10:25 a.m. revealed all staff was notified to keep an eye on Resident #2. An interview on 11/01/16 at 10:45 a.m. with RN C revealed Resident #2 had eloped from the facility many times. Facility staffs were instructed to keep a close eye on the resident and the code on the exit door had been changed. She reported one night, date unknown, he was found by the gas station at about 8 p.m. The gas station was about 0.25 miles away from the facility. RN C reported on a different day, she found Resident #2 at a private home on the other side of the duplex apartments across the parking lot from the facility. An interview with RN N on 11/01/16 at 10:48 a.m. revealed the nurses were instructed to distract Resident #2 to keep him from exiting the facility. RN N reported one day, date unknown, the resident exited the facility and was close to the street. She had to help bring him back into the facility. An interview with CNA Z on 11/01/16 at 10:51 a.m. revealed all staff was supposed to keep an eye on Resident #2 to keep him from exiting the building. An interview with CNA AA on 11/01/16 at 11:00 a.m. revealed staff was supposed to watch Resident #2 to keep him from going outside. CNA AA reported Resident #2 would exit the facility, go to the parking lot, and she would have to bring him back into the facility and take him to the nurse. Resident #2's MDS assessment, dated 10/10/16, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severely impaired cognitive skills with wandering behaviors that occurred daily. Resident #2's comprehensive care plan, dated 07/22/16, reflected the resident was at risk for elopement related to impaired safety awareness and aimless wandering. Facility interventions included distract resident from wandering and document wandering behavior. Resident #2's incident reports reflected: 08/01/16 11:52 a.m. - A family member of another resident noticed Resident #2 walking down the street. The family member called the facility and notified staff. The resident was redirected and brought back to the facility. 08/24/16 1:21 a.m. - Resident #2 was found outside and brought back in to the facility. The resident was constantly monitored until he went to bed. The doctor and family were notified. 08/31/16 1:19 p.m. - Resident #2 followed a visitor outside and proceeded to walk down the parking lot with his walker. The resident was redirected and brought back to the facility. 09/02/16 9:44 a.m. - Resident #2 was found walking across the parking lot to the apartments next to the facility. The resident was redirected and brought back to the facility. 09/02/16 8:30 p.m. - The nurse went to check Resident #2's blood sugar and could not locate the resident. The resident was found at the shopping complex next to the railroad tracks. (The commuter train railroad tracks were approximately 0.25 miles away from the facility.) The resident was brought back to the facility, a head to toe assessment was done, the DON was notified, a monitoring log was started until morning, resident's family was notified, and the NP was notified. The NP suggested the facility place a Wanderguard monitoring system on the resident. 10/22/16 3:32 p.m. - Resident #2 exited the facility after visitors opened the door. The resident was found at the building next door. The resident was brought back to the facility. The family and NP were notified. Resident #2's progress notes reflected: 09/10/16 5:28 p.m. - Resident #2 was found outside on the side walk nearing traffic without his walker. He was redirected back to the facility and family was notified. 09/12/16 6:05 p.m. - Resident #2 slipped out the front door after a visitor. Resident redirected back to facility. 09/19/16 2:39 p.m. - Resident #2 followed a visitor out the door. Physician and family notified. An interview with the DON and the ADON on 10/31/16 at 3:00 p.m. revealed Resident #2 was the only resident in the facility who eloped and the facility was trying to place him in a secured facility. An interview with the Social Worker on 10/31/16 at 3:25 p.m. revealed the facility was trying to find a secured facility for Resident #2 to transfer to, but no openings were available. She stated the facility did not have a Wanderguard system, but the facility did move the resident to a room closer to the front to keep a better eye him. She also stated the facility encouraged the family to visit the resident more often. The Social Worker revealed the 300 Hall door was the only door in the facility that did not have an alarm or security code, and the resident had tried to exit through the 300 Hall door prior to the facility changing his room. The Social Worker reported the only monitoring in place for the resident was frequent visual checks. A subsequent interview with LVN D on 11/01/16 at 12:25 p.m. revealed the Hall 300 door did not have an alarm. The facility's current Elopement Policy and Procedure, dated October 2007, reflected the following: Policy: It is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility. Procedures: 1. Residents who are at risk for elopement will have an appropriate plan of care developed to address the risk. 2. All available staff shall begin a search of the facility grounds (inside and outside) to locate the resident. This search shall include all resident rooms in the facility or any other place an adult could hide (including behind locked doors). 3. In the event that the resident cannot be located within the confines of the facility grounds, the licensed nurse shall initiate the following procedure: A. The DNS and/or Administrator shall be promptly notified. B. Notify the police and request the presence of an officer at the facility to take a missing person report. The police will need a photograph of the resident if available from the chart and a physical description. Be sure to include what the resident was wearing, the resident's current cognitive status and when any staff member last saw the resident. C. Notify the attending physician. D. Notify the responsible party. E. Staff member shall begin a perimeter search within at least a one-mile radius of the facility either by foot or by car. Staff shall go in pairs in case the resident has any physical/mental crisis to address. 4. The licensed nurse shall document all appropriate information in the clinical record before he or she ends his or her shift. All charting and reports must be complete before leaving. This shall include but not be limited to: A. When the resident was last see and by whom. B. What the resident's mental/cognitive status was prior to elopement? C. State the names of all persons called and the time. Include the badge number of the police officer and the time he arrived to take the report and the time the facility notified the police and who was spoken to. D. Complete all appropriate reports per facility policy for unusual occurrences. E. Update the plan of care if warranted. 5. When the resident is located and/or returned to the facility, the individuals notified of the resident's absence shall be notified when whereabouts is known. The facility's current, undated Facility Policy and Procedure for Abuse Prevention reflected: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An Immediate Jeopardy was identified on 10/31/16. The Administrator, the DON, and the ADON were notified of the Immediate Jeopardy at 5:00 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal was accepted on 11/01/16 at 9:00 a.m. and reflected the following: Resident #2 was discharged to another skilled nursing facility with a locked unit at approximately 6 00 p.m. on 10/31/16. Resident #2 had 13 elopement incidents since January 2016. Those dates were: 01/11/16, 01/23/16, 06/11/16, 08/01/16, 08/24/16, 08/31/16, 09/02/16 (1), 09/02/16 (2), 09/10/16, 09/19/16 (1), 09/19/16 (2), 10/22/16, and 10/31/16. As a result of those elopement incidents, the facility performed the following: - Moved the resident to a different room on a different hall. This change resulted in no new elopement episodes for one month (9/19/16 to 10/22/16) - Changed the entry code on the front door. - Instructed staff to be more vigilant about Resident #2's location. - Attempted to place the resident at sister facilities in Carrollton, TX. The facilities were unable to admit him. - The facility's Social Services Director placed Resident #2 on the waiting list, 09/22/16, for a SNF with a locked unit. They had no openings at the time. Immediate Action Taken: - At approximately 3:00 p.m. on 10/31/16, LVN D, assessed Resident #2 and found no injuries. - At approximately 3:00 p.m. on 10/31/16, LVN D notified both the physician and the responsible party, of the resident, regarding the elopement. - Starting at 3: 00 p.m. on 10/31/16, the resident was placed on Q15 (every 15) minute watch. No further elopement incidents occurred. - At 4: 00 p.m. on 10/31/16, The Facility Administrator in Training, placed a sign on the front lobby door (inside and out) that reflected, Attention visitors, please do not allow unaccompanied residents to follow you upon your exit. - At approximately 5:00 p.m. on 10/31/16, the Director of Social Services, notified the responsible party, that Resident #2 was in need of an emergency transfer to another facility with a locked unit due to his elopement risk. - At approximately 6:00 p.m. on 10/31/16, LVN D informed the family member and the resident's physician that a facility was found with a locked unit that was willing to accept Resident #2. Both the family member and the physician approved the discharge. - At 6:00 p.m. on 10/31/16, the resident was discharged to another skilled nursing facility with a locked unit. - At 7:13 p.m. on 10/31/16, the facility Administrator notified the facility's Medical Director of the Immediate Jeopardy. - On 10/31/16, the facility Administrator and Maintenance Director inspected all doors with alarms and key pads. All were found to be working properly. - On 10/31/16 The DON, the ADON, and nurses completed an elopement/wandering evaluation on all residents. Four residents scored high on the elopement assessment; however, the facility believed they were at low risk based their elopement criteria, which was: Discharge to a facility with a locked unit will be initiated for any resident who had two (2) elopement incidents in a 30 day period. Elopement incident is defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave. Starting on 10/31/16, the following in-service would be completed: Trainer: DON Audience: All nurses Initiated: 10/31/2016 Completed: 11/1/2016 Topics: - Create incident reports for all elopement attempts - Follow up all elopement attempts with a User Defined Assessment (UDA) - Update Care plans with elopement attempts. - Resident assessment after elopement attempt - Notification of doctor and family - Perform admission and quarterly elopement assessments Starting on 10/31/16, the following in-service would be completed: Trainer: Nurse Resource, DON and/or ADON Audience: All clinical staff (CNA, RNA, MA and Nurses) Initiated: 10/31/2016 Completed 11/1/2016 Topics: - Elopement drill - How to search facility grounds (inside and out) - How to search resident rooms - How to search hiding places - How to search behind locked doors - What to do when a resident cannot be located Systemic Change to Prevent Recurrence: Charge nurses would continue to assess all residents upon admission, quarterly, and with significant changes of condition, for elopement risk. Discharge to a facility with a locked unit would be initiated for any resident who had two (2) elopement incidents in a 30 day period. Elopement incident is defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave. Any resident with one elopement attempt, as defined above, would be placed on a 30 minute watch for 72 hours. Charge nurse would document 30 minute watch results on the 30 Minute Elopement Watch sheet. Since the facility had been classifying everything as an elopement, even when it was just a door being opened to look outside, the following in-service would be conducted to improve the accurate capture of what fully constituted an elopement: Trainer: DON Audience: All clinical staff (CNA, RNA, MA and Nurses) Initiated: 10/31/2016 Completed 11/1/2016 Topics: - Definition of an elopement - Opening the door just to look outside does not constitute an elopement. - When a resident is found outside the facility attempting to walk away with the intent to leave, constitutes an elopement For any perceived elopement event where the elopement definition is unclear, the charge nurse will call the DON or the ADON for clarification. Monitoring to Ensure Ongoing Compliance: On a daily basis, excluding weekends where Sat and Sun would be reviewed on Monday, Nurse Management (DON and/or ADON) would review the incident reports from the previous day to identify any resident who met the elopement definition (defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave) to ensure compliance as described above. Any elopement attempts would be reviewed, discussed, and documented during the weekly Standards of Care meeting to ensure care plans and appropriate interventions had been addressed. Elopement findings would be discussed during the daily stand-up meeting and captured on the daily stand-up meeting template to ensure 30 minute watch is initiated, when necessary. A summary of elopement results would be shared during the quarterly QA & A committee for review and follow-up (as necessary). An interview with the Administrator, DON, and the ADON on 11/01/16 at 3:15 p.m. revealed the facility was going to install a lock on the Hall 300 door to prevent further resident elopements. An interview with the Administrator on 11/01/16 at 8:16 p.m. revealed a company was coming to the facility on [DATE] to install a key pad on the Hall 300 door and the four residents identified by the facility to be at risk for elopement were placed on every 30 minute visual checks. An interview with the Administrator on 11/02/16 at 10:15 a.m. revealed all care plans for residents at risk for elopement had been updated. An observation on 11/02/16 at 10:37 a.m. revealed an alarm was being installed on the Hall 300 door. Interviews were conducted on 11/01/16 starting at 1:50 p.m. and continued through 11/02/16 at 10:50 a.m. Twenty-five staff members from various shifts were interviewed, they were: CNA A, CNA M, RN N, RN F, LVN O, Med Aide P, CNA Q, CNA R, CNA S, Medical Records Clerk, CNA T, CNA L, CNA G, CNA U, RN C, LVN V, LVN K, CNA W, Receptionist, PTA E, CNA X, Med Aide Y, Hospitality Aide, PT J, and the Speech Therapist. Responses revealed the staff received an in-service regarding resident elopement. The staff members were able to describe the facility definition of elopement, documentation required, areas to search for the resident, who to notify, and the radius from the facility to search for the resident. Facility in-services were reviewed and reflected: Elopement and Documentation- 100% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. Definition of Elopement- 96.77% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. What to do during an identified Elopement- 96.77% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. While the Immediate Jeopardy was removed on 11/02/16 at 11:00 a.m., the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy, and at a scope of pattern due to facility continuation of in-servicing and monitoring the plan of removal. The accepted facility's plan of removal, received from the facility Administrator, and dated 11/1/16 at 9:12 a.m., reflected four residents who resided in the facility scored high on the elopement assessment. One resident was discharged to another facility due to history of elopements from the facility.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #2) of five residents reviewed for elopement. The facility failed to ensure Resident #2 was monitored to prevent elopement from the facility. An Immediate Jeopardy was identified on 10/31/16. While the Immediate Jeopardy was removed on 11/02/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the five residents with a history of elopement by placing them at risk for injury and/or death. Findings included: An observation on 10/31/16 at 2:20 p.m. revealed Resident #2 exited the facility as a visitor held the door open for him. The visitor asked the surveyor if it was okay for the resident to be outside, and the surveyor responded she did not know. The surveyor instructed the visitor to alert the facility staff, and the visitor walked back into the facility to alert the facility staff. Resident #2 then walked quickly with his walker across the parking lot. The surveyor started walking towards the resident as he neared the street and two facility staff members caught up with the resident and escorted him back into the facility. The facility staff members reported the resident did not have a Wanderguard device. An interview with LVN D on 11/01/16 at 10:25 a.m. revealed all staff was notified to keep an eye on Resident #2. An interview on 11/01/16 at 10:45 a.m. with RN C revealed Resident #2 had eloped from the facility many times. Facility staffs were instructed to keep a close eye on the resident and the code on the exit door had been changed. She reported one night, date unknown, he was found by the gas station at about 8 p.m. The gas station was about 0.25 miles away from the facility. RN C reported on a different day, she found Resident #2 at a private home on the other side of the duplex apartments across the parking lot from the facility. An interview with RN N on 11/01/16 at 10:48 a.m. revealed the nurses were instructed to distract Resident #2 to keep him from exiting the facility. RN N reported one day, date unknown, the resident exited the facility and was close to the street. She had to help bring him back into the facility. An interview with CNA Z on 11/01/16 at 10:51 a.m. revealed all staff was supposed to keep an eye on Resident #2 to keep him from exiting the building. An interview with CNA AA on 11/01/16 at 11:00 a.m. revealed staff was supposed to watch Resident #2 to keep him from going outside. CNA AA reported Resident #2 would exit the facility, go to the parking lot, and she would have to bring him back into the facility and take him to the nurse. Resident #2's MDS assessment, dated 10/10/16, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severely impaired cognitive skills with wandering behaviors that occurred daily. Resident #2's comprehensive care plan, dated 07/22/16, reflected the resident was at risk for elopement related to impaired safety awareness and aimless wandering. Facility interventions included distract resident from wandering and document wandering behavior. Resident #2's incident reports reflected: 08/01/16 11:52 a.m. - A family member of another resident noticed Resident #2 walking down the street. The family member called the facility and notified staff. The resident was redirected and brought back to the facility. 08/24/16 1:21 a.m. - Resident #2 was found outside and brought back in to the facility. The resident was constantly monitored until he went to bed. The doctor and family were notified. 08/31/16 1:19 p.m. - Resident #2 followed a visitor outside and proceeded to walk down the parking lot with his walker. The resident was redirected and brought back to the facility. 09/02/16 9:44 a.m. - Resident #2 was found walking across the parking lot to the apartments next to the facility. The resident was redirected and brought back to the facility. 09/02/16 8:30 p.m. - The nurse went to check Resident #2's blood sugar and could not locate the resident. The resident was found at the shopping complex next to the railroad tracks. (The commuter train railroad tracks were approximately 0.25 miles away from the facility.) The resident was brought back to the facility, a head to toe assessment was done, the DON was notified, a monitoring log was started until morning, resident's family was notified, and the NP was notified. The NP suggested the facility place a Wanderguard monitoring system on the resident. 10/22/16 3:32 p.m. - Resident #2 exited the facility after visitors opened the door. The resident was found at the building next door. The resident was brought back to the facility. The family and NP were notified. Resident #2's progress notes reflected: 09/10/16 5:28 p.m. - Resident #2 was found outside on the side walk nearing traffic without his walker. He was redirected back to the facility and family was notified. 09/12/16 6:05 p.m. - Resident #2 slipped out the front door after a visitor. Resident redirected back to facility. 09/19/16 2:39 p.m. - Resident #2 followed a visitor out the door. Physician and family notified. An interview with the DON and the ADON on 10/31/16 at 3:00 p.m. revealed Resident #2 was the only resident in the facility who eloped and the facility was trying to place him in a secured facility. An interview with the Social Worker on 10/31/16 at 3:25 p.m. revealed the facility was trying to find a secured facility for Resident #2 to transfer to, but no openings were available. She stated the facility did not have a Wanderguard system, but the facility did move the resident to a room closer to the front to keep a better eye him. She also stated the facility encouraged the family to visit the resident more often. The Social Worker revealed the 300 Hall door was the only door in the facility that did not have an alarm or security code, and the resident had tried to exit through the 300 Hall door prior to the facility changing his room. The Social Worker reported the only monitoring in place for the resident was frequent visual checks. A subsequent interview with LVN D on 11/01/16 at 12:25 p.m. revealed the Hall 300 door did not have an alarm. The facility's current Elopement Policy and Procedure, dated October 2007, reflected the following: Policy: It is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility. Procedures: 1. Residents who are at risk for elopement will have an appropriate plan of care developed to address the risk. 2. All available staff shall begin a search of the facility grounds (inside and outside) to locate the resident. This search shall include all resident rooms in the facility or any other place an adult could hide (including behind locked doors). 3. In the event that the resident cannot be located within the confines of the facility grounds, the licensed nurse shall initiate the following procedure: A. The DNS and/or Administrator shall be promptly notified. B. Notify the police and request the presence of an officer at the facility to take a missing person report. The police will need a photograph of the resident if available from the chart and a physical description. Be sure to include what the resident was wearing, the resident's current cognitive status and when any staff member last saw the resident. C. Notify the attending physician. D. Notify the responsible party. E. Staff member shall begin a perimeter search within at least a one-mile radius of the facility either by foot or by car. Staff shall go in pairs in case the resident has any physical/mental crisis to address. 4. The licensed nurse shall document all appropriate information in the clinical record before he or she ends his or her shift. All charting and reports must be complete before leaving. This shall include but not be limited to: A. When the resident was last see and by whom. B. What the resident's mental/cognitive status was prior to elopement? C. State the names of all persons called and the time. Include the badge number of the police officer and the time he arrived to take the report and the time the facility notified the police and who was spoken to. D. Complete all appropriate reports per facility policy for unusual occurrences. E. Update the plan of care if warranted. 5. When the resident is located and/or returned to the facility, the individuals notified of the resident's absence shall be notified when whereabouts is known. An Immediate Jeopardy was identified on 10/31/16. The Administrator, the DON, and the ADON were notified of the Immediate Jeopardy at 5:00 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal was accepted on 11/01/16 at 9:00 a.m. and reflected the following: Resident #2 was discharged to another skilled nursing facility with a locked unit at approximately 6 00 p.m. on 10/31/16. Resident #2 had 13 elopement incidents since January 2016. Those dates were: 01/11/16, 01/23/16, 06/11/16, 08/01/16, 08/24/16, 08/31/16, 09/02/16 (1), 09/02/16 (2), 09/10/16, 09/19/16 (1), 09/19/16 (2), 10/22/16, and 10/31/16. As a result of those elopement incidents, the facility performed the following: - Moved the resident to a different room on a different hall. This change resulted in no new elopement episodes for one month (9/19/16 to 10/22/16) - Changed the entry code on the front door. - Instructed staff to be more vigilant about Resident #2's location. - Attempted to place the resident at sister facilities in Carrollton, TX. The facilities were unable to admit him. - The facility's Social Services Director placed Resident #2 on the waiting list, 09/22/16, for a SNF with a locked unit. They had no openings at the time. Immediate Action Taken: - At approximately 3:00 p.m. on 10/31/16, LVN D, assessed Resident #2 and found no injuries. - At approximately 3:00 p.m. on 10/31/16, LVN D notified both the physician and the responsible party, of the resident, regarding the elopement. - Starting at 3: 00 p.m. on 10/31/16, the resident was placed on Q15 (every 15) minute watch. No further elopement incidents occurred. - At 4: 00 p.m. on 10/31/16, The Facility Administrator in Training, placed a sign on the front lobby door (inside and out) that reflected, Attention visitors, please do not allow unaccompanied residents to follow you upon your exit. - At approximately 5:00 p.m. on 10/31/16, the Director of Social Services, notified the responsible party, that Resident #2 was in need of an emergency transfer to another facility with a locked unit due to his elopement risk. - At approximately 6:00 p.m. on 10/31/16, LVN D informed the family member and the resident's physician that a facility was found with a locked unit that was willing to accept Resident #2. Both the family member and the physician approved the discharge. - At 6:00 p.m. on 10/31/16, the resident was discharged to another skilled nursing facility with a locked unit. - At 7:13 p.m. on 10/31/16, the facility Administrator notified the facility's Medical Director of the Immediate Jeopardy. - On 10/31/16, the facility Administrator and Maintenance Director inspected all doors with alarms and key pads. All were found to be working properly. - On 10/31/16 The DON, the ADON, and nurses completed an elopement/wandering evaluation on all residents. Four residents scored high on the elopement assessment; however, the facility believed they were at low risk based their elopement criteria, which was: Discharge to a facility with a locked unit will be initiated for any resident who had two (2) elopement incidents in a 30 day period. Elopement incident is defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave. Starting on 10/31/16, the following in-service would be completed: Trainer: DON Audience: All nurses Initiated: 10/31/2016 Completed: 11/1/2016 Topics: - Create incident reports for all elopement attempts - Follow up all elopement attempts with a User Defined Assessment (UDA) - Update Care plans with elopement attempts. - Resident assessment after elopement attempt - Notification of doctor and family - Perform admission and quarterly elopement assessments Starting on 10/31/16, the following in-service would be completed: Trainer: Nurse Resource, DON and/or ADON Audience: All clinical staff (CNA, RNA, MA and Nurses) Initiated: 10/31/2016 Completed 11/1/2016 Topics: - Elopement drill - How to search facility grounds (inside and out) - How to search resident rooms - How to search hiding places - How to search behind locked doors - What to do when a resident cannot be located Systemic Change to Prevent Recurrence: Charge nurses would continue to assess all residents upon admission, quarterly, and with significant changes of condition, for elopement risk. Discharge to a facility with a locked unit would be initiated for any resident who had two (2) elopement incidents in a 30 day period. Elopement incident is defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave. Any resident with one elopement attempt, as defined above, would be placed on a 30 minute watch for 72 hours. Charge nurse would document 30 minute watch results on the 30 Minute Elopement Watch sheet. Since the facility had been classifying everything as an elopement, even when it was just a door being opened to look outside, the following in-service would be conducted to improve the accurate capture of what fully constituted an elopement: Trainer: DON Audience: All clinical staff (CNA, RNA, MA and Nurses) Initiated: 10/31/2016 Completed 11/1/2016 Topics: - Definition of an elopement - Opening the door just to look outside does not constitute an elopement. - When a resident is found outside the facility attempting to walk away with the intent to leave, constitutes an elopement For any perceived elopement event where the elopement definition is unclear, the charge nurse will call the DON or the ADON for clarification. Monitoring to Ensure Ongoing Compliance: On a daily basis, excluding weekends where Sat and Sun would be reviewed on Monday, Nurse Management (DON and/or ADON) would review the incident reports from the previous day to identify any resident who met the elopement definition (defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave) to ensure compliance as described above. Any elopement attempts would be reviewed, discussed, and documented during the weekly Standards of Care meeting to ensure care plans and appropriate interventions had been addressed. Elopement findings would be discussed during the daily stand-up meeting and captured on the daily stand-up meeting template to ensure 30 minute watch is initiated, when necessary. A summary of elopement results would be shared during the quarterly QA & A committee for review and follow-up (as necessary). An interview with the Administrator, DON, and the ADON on 11/01/16 at 3:15 p.m. revealed the facility was going to install a lock on the Hall 300 door to prevent further resident elopements. An interview with the Administrator on 11/01/16 at 8:16 p.m. revealed a company was coming to the facility on [DATE] to install a key pad on the Hall 300 door and the four residents identified by the facility to be at risk for elopement were placed on every 30 minute visual checks. An interview with the Administrator on 11/02/16 at 10:15 a.m. revealed all care plans for residents at risk for elopement had been updated. An observation on 11/02/16 at 10:37 a.m. revealed an alarm was being installed on the Hall 300 door. Interviews were conducted on 11/01/16 starting at 1:50 p.m. and continued through 11/02/16 at 10:50 a.m. Twenty-five staff members from various shifts were interviewed, they were: CNA A, CNA M, RN N, RN F, LVN O, Med Aide P, CNA Q, CNA R, CNA S, Medical Records Clerk, CNA T, CNA L, CNA G, CNA U, RN C, LVN V, LVN K, CNA W, Receptionist, PTA E, CNA X, Med Aide Y, Hospitality Aide, PT J, and the Speech Therapist. Responses revealed the staff received an in-service regarding resident elopement. The staff members were able to describe the facility definition of elopement, documentation required, areas to search for the resident, who to notify, and the radius from the facility to search for the resident. Facility in-services were reviewed and reflected: Elopement and Documentation- 100% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. Definition of Elopement- 96.77% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. What to do during an identified Elopement- 96.77% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. While the Immediate Jeopardy was removed on 11/02/16 at 11:00 a.m., the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy, and at a scope of pattern due to facility continuation of in-servicing and monitoring the plan of removal. The accepted facility's plan of removal, received from the facility Administrator, and dated 11/1/16 at 9:12 a.m., reflected four residents who resided in the facility scored high on the elopement assessment. One resident was discharged to another facility due to history of elopements from the facility.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #2) of nine residents reviewed for neglect. The facility failed to ensure Resident #2 was monitored to prevent elopement from the facility. An Immediate Jeopardy was identified on 10/31/16. While the Immediate Jeopardy was removed on 11/02/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the five residents with a history of elopement by placing them at risk for injury and/or death. Findings included: The facility's current, undated Facility Policy and Procedure for Abuse Prevention reflected: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility's current Elopement Policy and Procedure, dated October 2007, reflected the following: Policy: It is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility. Procedures: 1. Residents who are at risk for elopement will have an appropriate plan of care developed to address the risk. 2. All available staff shall begin a search of the facility grounds (inside and outside) to locate the resident. This search shall include all resident rooms in the facility or any other place an adult could hide (including behind locked doors). 3. In the event that the resident cannot be located within the confines of the facility grounds, the licensed nurse shall initiate the following procedure: A. The DNS and/or Administrator shall be promptly notified. B. Notify the police and request the presence of an officer at the facility to take a missing person report. The police will need a photograph of the resident if available from the chart and a physical description. Be sure to include what the resident was wearing, the resident's current cognitive status and when any staff member last saw the resident. C. Notify the attending physician. D. Notify the responsible party. E. Staff member shall begin a perimeter search within at least a one-mile radius of the facility either by foot or by car. Staff shall go in pairs in case the resident has any physical/mental crisis to address. 4. The licensed nurse shall document all appropriate information in the clinical record before he or she ends his or her shift. All charting and reports must be complete before leaving. This shall include but not be limited to: A. When the resident was last see and by whom. B. What the resident's mental/cognitive status was prior to elopement? C. State the names of all persons called and the time. Include the badge number of the police officer and the time he arrived to take the report and the time the facility notified the police and who was spoken to. D. Complete all appropriate reports per facility policy for unusual occurrences. E. Update the plan of care if warranted. 5. When the resident is located and/or returned to the facility, the individuals notified of the resident's absence shall be notified when whereabouts is known. An observation on 10/31/16 at 2:20 p.m. revealed Resident #2 exited the facility as a visitor held the door open for him. The visitor asked the surveyor if it was okay for the resident to be outside, and the surveyor responded she did not know. The surveyor instructed the visitor to alert the facility staff, and the visitor walked back into the facility to alert the facility staff. Resident #2 then walked quickly with his walker across the parking lot. The surveyor started walking towards the resident as he neared the street and two facility staff members caught up with the resident and escorted him back into the facility. The facility staff members reported the resident did not have a Wanderguard device. An interview with LVN D on 11/01/16 at 10:25 a.m. revealed all staff was notified to keep an eye on Resident #2. An interview on 11/01/16 at 10:45 a.m. with RN C revealed Resident #2 had eloped from the facility many times. Facility staffs were instructed to keep a close eye on the resident and the code on the exit door had been changed. She reported one night, date unknown, he was found by the gas station at about 8 p.m. The gas station was about 0.25 miles away from the facility. RN C reported on a different day, she found Resident #2 at a private home on the other side of the duplex apartments across the parking lot from the facility. An interview with RN N on 11/01/16 at 10:48 a.m. revealed the nurses were instructed to distract Resident #2 to keep him from exiting the facility. RN N reported one day, date unknown, the resident exited the facility and was close to the street. She had to help bring him back into the facility. An interview with CNA Z on 11/01/16 at 10:51 a.m. revealed all staff was supposed to keep an eye on Resident #2 to keep him from exiting the building. An interview with CNA AA on 11/01/16 at 11:00 a.m. revealed staff was supposed to watch Resident #2 to keep him from going outside. CNA AA reported Resident #2 would exit the facility, go to the parking lot, and she would have to bring him back into the facility and take him to the nurse. Resident #2's MDS assessment, dated 10/10/16, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severely impaired cognitive skills with wandering behaviors that occurred daily. Resident #2's comprehensive care plan, dated 07/22/16, reflected the resident was at risk for elopement related to impaired safety awareness and aimless wandering. Facility interventions included distract resident from wandering and document wandering behavior. Resident #2's incident reports reflected: 08/01/16 11:52 a.m. - A family member of another resident noticed Resident #2 walking down the street. The family member called the facility and notified staff. The resident was redirected and brought back to the facility. 08/24/16 1:21 a.m. - Resident #2 was found outside and brought back in to the facility. The resident was constantly monitored until he went to bed. The doctor and family were notified. 08/31/16 1:19 p.m. - Resident #2 followed a visitor outside and proceeded to walk down the parking lot with his walker. The resident was redirected and brought back to the facility. 09/02/16 9:44 a.m. - Resident #2 was found walking across the parking lot to the apartments next to the facility. The resident was redirected and brought back to the facility. 09/02/16 8:30 p.m. - The nurse went to check Resident #2's blood sugar and could not locate the resident. The resident was found at the shopping complex next to the railroad tracks. (The commuter train railroad tracks were approximately 0.25 miles away from the facility.) The resident was brought back to the facility, a head to toe assessment was done, the DON was notified, a monitoring log was started until morning, resident's family was notified, and the NP was notified. The NP suggested the facility place a Wanderguard monitoring system on the resident. 10/22/16 3:32 p.m. - Resident #2 exited the facility after visitors opened the door. The resident was found at the building next door. The resident was brought back to the facility. The family and NP were notified. Resident #2's progress notes reflected: 09/10/16 5:28 p.m. - Resident #2 was found outside on the side walk nearing traffic without his walker. He was redirected back to the facility and family was notified. 09/12/16 6:05 p.m. - Resident #2 slipped out the front door after a visitor. Resident redirected back to facility. 09/19/16 2:39 p.m. - Resident #2 followed a visitor out the door. Physician and family notified. An interview with the DON and the ADON on 10/31/16 at 3:00 p.m. revealed Resident #2 was the only resident in the facility who eloped and the facility was trying to place him in a secured facility. An interview with the Social Worker on 10/31/16 at 3:25 p.m. revealed the facility was trying to find a secured facility for Resident #2 to transfer to, but no openings were available. She stated the facility did not have a Wanderguard system, but the facility did move the resident to a room closer to the front to keep a better eye him. She also stated the facility encouraged the family to visit the resident more often. The Social Worker revealed the 300 Hall door was the only door in the facility that did not have an alarm or security code, and the resident had tried to exit through the 300 Hall door prior to the facility changing his room. The Social Worker reported the only monitoring in place for the resident was frequent visual checks. A subsequent interview with LVN D on 11/01/16 at 12:25 p.m. revealed the Hall 300 door did not have an alarm. An Immediate Jeopardy was identified on 10/31/16. The Administrator, the DON, and the ADON were notified of the Immediate Jeopardy at 5:00 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal was accepted on 11/01/16 at 9:00 a.m. and reflected the following: Resident #2 was discharged to another skilled nursing facility with a locked unit at approximately 6 00 p.m. on 10/31/16. Resident #2 had 13 elopement incidents since January 2016. Those dates were: 01/11/16, 01/23/16, 06/11/16, 08/01/16, 08/24/16, 08/31/16, 09/02/16 (1), 09/02/16 (2), 09/10/16, 09/19/16 (1), 09/19/16 (2), 10/22/16, and 10/31/16. As a result of those elopement incidents, the facility performed the following: - Moved the resident to a different room on a different hall. This change resulted in no new elopement episodes for one month (9/19/16 to 10/22/16) - Changed the entry code on the front door. - Instructed staff to be more vigilant about Resident #2's location. - Attempted to place the resident at sister facilities in Carrollton, TX. The facilities were unable to admit him. - The facility's Social Services Director placed Resident #2 on the waiting list, 09/22/16, for a SNF with a locked unit. They had no openings at the time. Immediate Action Taken: - At approximately 3:00 p.m. on 10/31/16, LVN D, assessed Resident #2 and found no injuries. - At approximately 3:00 p.m. on 10/31/16, LVN D notified both the physician and the responsible party, of the resident, regarding the elopement. - Starting at 3: 00 p.m. on 10/31/16, the resident was placed on Q15 (every 15) minute watch. No further elopement incidents occurred. - At 4: 00 p.m. on 10/31/16, The Facility Administrator in Training, placed a sign on the front lobby door (inside and out) that reflected, Attention visitors, please do not allow unaccompanied residents to follow you upon your exit. - At approximately 5:00 p.m. on 10/31/16, the Director of Social Services, notified the responsible party, that Resident #2 was in need of an emergency transfer to another facility with a locked unit due to his elopement risk. - At approximately 6:00 p.m. on 10/31/16, LVN D informed the family member and the resident's physician that a facility was found with a locked unit that was willing to accept Resident #2. Both the family member and the physician approved the discharge. - At 6:00 p.m. on 10/31/16, the resident was discharged to another skilled nursing facility with a locked unit. - At 7:13 p.m. on 10/31/16, the facility Administrator notified the facility's Medical Director of the Immediate Jeopardy. - On 10/31/16, the facility Administrator and Maintenance Director inspected all doors with alarms and key pads. All were found to be working properly. - On 10/31/16 The DON, the ADON, and nurses completed an elopement/wandering evaluation on all residents. Four residents scored high on the elopement assessment; however, the facility believed they were at low risk based their elopement criteria, which was: Discharge to a facility with a locked unit will be initiated for any resident who had two (2) elopement incidents in a 30 day period. Elopement incident is defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave. Starting on 10/31/16, the following in-service would be completed: Trainer: DON Audience: All nurses Initiated: 10/31/2016 Completed: 11/1/2016 Topics: - Create incident reports for all elopement attempts - Follow up all elopement attempts with a User Defined Assessment (UDA) - Update Care plans with elopement attempts. - Resident assessment after elopement attempt - Notification of doctor and family - Perform admission and quarterly elopement assessments Starting on 10/31/16, the following in-service would be completed: Trainer: Nurse Resource, DON and/or ADON Audience: All clinical staff (CNA, RNA, MA and Nurses) Initiated: 10/31/2016 Completed 11/1/2016 Topics: - Elopement drill - How to search facility grounds (inside and out) - How to search resident rooms - How to search hiding places - How to search behind locked doors - What to do when a resident cannot be located Systemic Change to Prevent Recurrence: Charge nurses would continue to assess all residents upon admission, quarterly, and with significant changes of condition, for elopement risk. Discharge to a facility with a locked unit would be initiated for any resident who had two (2) elopement incidents in a 30 day period. Elopement incident is defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave. Any resident with one elopement attempt, as defined above, would be placed on a 30 minute watch for 72 hours. Charge nurse would document 30 minute watch results on the 30 Minute Elopement Watch sheet. Since the facility had been classifying everything as an elopement, even when it was just a door being opened to look outside, the following in-service would be conducted to improve the accurate capture of what fully constituted an elopement: Trainer: DON Audience: All clinical staff (CNA, RNA, MA and Nurses) Initiated: 10/31/2016 Completed 11/1/2016 Topics: - Definition of an elopement - Opening the door just to look outside does not constitute an elopement. - When a resident is found outside the facility attempting to walk away with the intent to leave, constitutes an elopement For any perceived elopement event where the elopement definition is unclear, the charge nurse will call the DON or the ADON for clarification. Monitoring to Ensure Ongoing Compliance: On a daily basis, excluding weekends where Sat and Sun would be reviewed on Monday, Nurse Management (DON and/or ADON) would review the incident reports from the previous day to identify any resident who met the elopement definition (defined as not just opening a door to look outside, but an instance where the resident is found outside the facility attempting to walk away with the intent to leave) to ensure compliance as described above. Any elopement attempts would be reviewed, discussed, and documented during the weekly Standards of Care meeting to ensure care plans and appropriate interventions had been addressed. Elopement findings would be discussed during the daily stand-up meeting and captured on the daily stand-up meeting template to ensure 30 minute watch is initiated, when necessary. A summary of elopement results would be shared during the quarterly QA & A committee for review and follow-up (as necessary). An interview with the Administrator, DON, and the ADON on 11/01/16 at 3:15 p.m. revealed the facility was going to install a lock on the Hall 300 door to prevent further resident elopements. An interview with the Administrator on 11/01/16 at 8:16 p.m. revealed a company was coming to the facility on [DATE] to install a key pad on the Hall 300 door and the four residents identified by the facility to be at risk for elopement were placed on every 30 minute visual checks. An interview with the Administrator on 11/02/16 at 10:15 a.m. revealed all care plans for residents at risk for elopement had been updated. An observation on 11/02/16 at 10:37 a.m. revealed an alarm was being installed on the Hall 300 door. Interviews were conducted on 11/01/16 starting at 1:50 p.m. and continued through 11/02/16 at 10:50 a.m. Twenty-five staff members from various shifts were interviewed, they were: CNA A, CNA M, RN N, RN F, LVN O, Med Aide P, CNA Q, CNA R, CNA S, Medical Records Clerk, CNA T, CNA L, CNA G, CNA U, RN C, LVN V, LVN K, CNA W, Receptionist, PTA E, CNA X, Med Aide Y, Hospitality Aide, PT J, and the Speech Therapist. Responses revealed the staff received an in-service regarding resident elopement. The staff members were able to describe the facility definition of elopement, documentation required, areas to search for the resident, who to notify, and the radius from the facility to search for the resident. Facility in-services were reviewed and reflected: Elopement and Documentation- 100% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. Definition of Elopement- 96.77% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. What to do during an identified Elopement- 96.77% of staff were in-serviced by 11/02/16 at 8:55 a.m. per the facility Administrator. While the Immediate Jeopardy was removed on 11/02/16 at 11:00 a.m., the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, that is not immediate jeopardy, and at a scope of pattern due to facility continuation of in-servicing and monitoring the plan of removal. The accepted facility's plan of removal, received from the facility Administrator, and dated 11/1/16 at 9:12 a.m., reflected four residents who resided in the facility scored high on the elopement assessment. One resident was discharged to another facility due to history of elopements from the facility.

Based on observation, interview, and record review, the facility failed to conduct comprehensive and accurate assessments of each resident's functional capacity for one (Resident #1) of five residents reviewed for assessments. 1. The facility failed to assess Resident #1 accurately after Resident #1 suffered a fall on 10/06/16 which resulted in a [MEDICAL CONDITION]. 2. The facility failed to act on assessments completed for Resident #1 which indicated the resident had a change in condition. This failure caused Resident #1 to suffer pain and difficulty with transfers for nine days before receiving treatment for [REDACTED]. This failure could affect the 17 residents with a history of falls by placing them at risk for inaccurate assessments which could result in pain and a lack of treatment for [REDACTED]. Findings included: 1. Resident #1's MDS assessment, dated 10/03/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severely impaired cognitive skills. Resident #1's comprehensive care plan, dated 07/20/16, indicated the resident was at risk for falls with a facility intervention which indicated to follow the facility fall protocol. Resident #1's incident report, dated 10/21/16, reflected the resident was found to have a [MEDICAL CONDITION] femur on 10/14/16. Through facility investigation it was noted she was found on the floor on 10/06/16. Resident #1's x-ray report, dated 10/14/16, reflected the resident had a right femur fracture. Resident #1's facility investigation report, dated 10/21/16, reflected the resident was found sitting on the floor on 10/06/16 by CNA A. CNA A notified CNA B who obtained RN C to evaluate the resident. RN C instructed CNA A and CNA B to place the resident in her wheelchair. An incident report was not completed, the physician was not notified, and the family was not notified when the resident was found on the floor. On 10/07/16, LVN D was informed by CNA A that Resident #1 was complaining of hip pain during transfers. LVN D notified the NP and obtained an order for [REDACTED].#1 received physical therapy services during the week of 10/06/2016. PTA E reported the resident had a limp during standing and transfers. On the evening of 10/07/16, RN F was notified by LVN D that Resident #1 had complained of hip pain. RN F reported the resident would get up and walk, but with a slight limp. On the evening of 10/08/16, CNA G notified RN F Resident #1 was having hip pain during incontinent care. RN F offered to give Resident #1 pain medication, but the resident refused. RN C completed a skin assessment on 10/12/16 for Resident #1 and did not document any skin issues for the resident. RN C reported on 10/14/16 Resident #1 was complaining of hip pain and she notified the ADON. Orders were obtained for an X-ray of the hip and the X-ray results received on 10/15/16 confirmed the resident had a fractured right hip. The resident was sent to the hospital ER. RN C reported on 10/17/16 she was not aware Resident #1 had fallen. On 10/19/16, RN C reported she did not tell the truth on 10/17/16 and did see Resident #1 on the ground after her fall on 10/06/16. Additionally the facility investigation report revealed, There was no incident report created for the resident being found on the floor. Per inspection of several of the 24 hour reports, it did appear the nursing department was monitoring the resident for some hip pain. In addition, it was also noted some of the therapists were aware of some potential pain issues as they too were keeping nursing in the loop. The finding of the facility investigation was unconfirmed. On 10/20/16, RN C received a facility counseling/disciplinary notice from the DON for failure to assess Resident #1 after the fall on 10/06/16, failure to document, failure to notify the doctor, and failure to notify the family. In-service training was started on 10/18/16 with nurses regarding appropriate assessment when a resident was found on the floor. In-service training was started on 10/19/16 with CNAs regarding not picking up a resident off of the floor until the nurse had assessed the resident. Resident #1's facility 24 hour report for October 2016 reflected: 10/06/16: no change in resident status 10/07/16: right hip pain on the 6:00 a.m. - 6:00 p.m. shift 10/08/16: no complaints of hip pain 10/09/16: right hip pain on the 6:00 p.m. - 6:00 a.m. shift 10/10/16: right hip pain on the 6:00 p.m. - 6:00 a.m. shift 10/11/16: no change in resident status 10/12/16: no change in resident status 10/13/16: no change in resident status 10/14/16: no change in resident status 10/15/16: transferred to the hospital during the 6:00 a.m. - 6:00 p.m. shift with a right femoral fracture. 10/18/16: Resident #1 returned to the facility following right hip surgery. Resident #1's progress note, dated 10/07/16, indicated the resident was having hip pain during transfers. LVN D notified the NP and obtained an order to administer a dose of Tylenol to the resident. Resident #1's MARs, dated October 2016, reflected the resident received one dose of Tylenol 650mg orally at 10:53 AM on 10/07/2016 for pain. Resident #1's physical therapy treatment notes reflected: 10/06/06: PTA H documented Resident #1 had right hip pain with increased anxiety during resident transfer with pain limiting the resident's functional activity. The pain was treated with a moist hot pack (MHP) for 15 minutes by the PTA. Resident's pain limited ability to move and transfer. 10/07/16: PTA H documented Resident #1 verbalized pain and grimaced with movement and transfers. The pain was treated with pain medication received from nursing. Resident's pain limited her ability to perform functional activities. 10/10/16: PTA I documented Resident #1 was not able to place full weight on the right leg and noted lower extremity weakness. Resident unable to stand erect and ambulated with knees bent. 10/11/16: PTA I documented Resident #1 had pain while standing and they notified nursing staff. Resident #1 denied pain when asked by the PT, but the PT documented the resident's facial expressions and actions showed otherwise. No interventions for pain relief documented. 10/12/16: PTA E documented Resident #1 complained of right hip pain. Resident able to take a few steps with the rolling walker then refused other attempts to walk. No interventions for pain relief documented. 10/13/16: PTA E documented Resident #1 had right hip pain limiting her mobility with an antalgic gait. (Gait to avoid pain while walking) No interventions for pain relief documented. 10/14/16: PTA E documented Resident #1 had right hip pain. No interventions for pain relief documented. An interview with CNA A on 10/31/16 at 9:15 a.m. revealed on 10/06/16 during the morning shift she found Resident #1 sitting on the floor in her room. CNA A went to the door and asked CNA B to get RN C. RN C entered the room, looked at the resident, and said to put the resident in the wheelchair. CNA A reported RN C did not assess the resident. CNA A reported the resident started complaining of pain on 10/07/16. CNA A told LVN D the resident was having pain on 10/07/16. On 10/08/16 CNA A told the physical therapy department the resident could not participate in therapy because she was having pain. CNA A reported she did not tell the CNA on the next shift or LVN D about the resident's fall on 10/06/16. An interview with RN C on 10/31/16 at 10:20 a.m. revealed she was notified on 10/06/16 by CNA B Resident #1 was on the floor. RN C reported she assessed the resident after the fall, but did not document the fall or notify the physician because she got busy. RN C reported she notified LVN K that Resident #1 fell on [DATE], but she did not know if LVN K was listening to her during end of shift report. An interview with LVN K on 10/31/16 at 1:35 p.m. revealed she was the nurse assigned to Resident #1 on the night of 10/06/16 and was not notified by RN C the resident had fallen. An interview with CNA L on 10/31/16 at 11:35 a.m. revealed she provided care to Resident #1 during the night shift on 10/06/16 and reported the resident grunted during repositioning. CNA L reported she did not think much of it and did not tell the nurse about it. An interview with CNA G on 10/31/16 at 1:20 p.m. revealed she provided care to Resident #1 on 10/07/16 during the afternoon shift and notified LVN D the resident was having pain. An interview with LVN D on 10/31/16 at 9:30 a.m. revealed on 10/07/16 during the morning shift she assessed Resident #1 after being told by CNA A the resident had hip pain. LVN D reported the resident had pain when transferred to the wheelchair and had a limp while walking. LVN D reported the resident had not complained of pain or had a limp during transfers before. LVN D contacted the NP and obtained an order for [REDACTED]. An interview on 11/02/16 at 12:35 p.m. with the NP revealed she was notified on 10/07/16 Resident #1 was having pain, but was not notified the resident had fallen. An interview on 11/01/16 at 2:45 p.m. with RN F revealed she worked the night shift on 10/07/16, 10/08/16, and 10/09/16. She reported she was notified on 10/07/16 and 10/08/16 Resident #1 had hip pain. RN F thought the hip pain was due to physical therapy and arthritis. She reported she asked the resident if she needed something for pain and the resident said no. She reported she told the day nurse the resident was having pain and did not investigate further because she did not want to overstep her bounds. RN F reported staff had been working with the resident all day and assumed they would see the problem with the resident and take care of it. An interview with PTA H on 10/31/16 at 1:25 p.m. revealed he provided therapy to Resident #1 on 10/06/16 and 10/07/16. PTA H reported the resident had pain and difficulty with transfers. PTA H was told by CNA A on 10/07/16 Resident #1 fell on [DATE]. PTA H told PT J about the fall. An interview with PT J on 10/31/16 at 3:50 p.m. revealed he was notified by PTA H on 10/07/16 that Resident #1 had a fall on 10/06/16. PT J reported he looked in the computer to find nursing notes or an incident report about the fall, but did not see any documentation of the fall. PT J did not investigate further. An interview with PTA I on 10/31/16 at 2:30 p.m. revealed she provided therapy to Resident #1 on 10/11/16 and told nursing staff the resident was having pain. PTA I did not know the name of the nursing staff they spoke to. A subsequent interview with LVN D on 11/01/16 at 10:25 a.m. revealed she was not notified by therapy Resident #1 had pain on 10/11/16. An interview with PTA E on 10/31/16 at 10:00 a.m. revealed on 10/12/16 PTA E provided therapy for Resident #1 and had heard Resident #1 had fallen. PTA E reported Resident #1 had hip pain and a limp during therapy. PTA E reported she thought the nurses were aware the resident was having pain. A subsequent interview with RN C on 11/01/16 at 10:40 a.m. revealed therapy notified her on 10/14/16 Resident #1 was having pain. RN C obtained orders for the resident to have an x-ray. RN C reported she did not think the pain was due to the fall on 10/06/16, but instead was due to the resident's therapy sessions. An interview with the ADON and the DON on 10/31/16 at 1:15 p.m. revealed after a resident had a fall, the nurse was supposed to complete an assessment, document, and notify the doctor. If a resident complained of pain during transfers, the nurse was supposed to assess the resident and call the doctor. An interview on 11/01/16 at 2:20 p.m. with the Rehabilitation Director revealed it was expected when a resident had a change in condition or behavior; the therapist would notify the nurse. The Rehabilitation Director reported the physical therapy staff should have told the nurse about Resident #1's issues multiple times. The facility's current Falls Policy and Procedure, dated May 2007, reflected the following: Policy: It is the policy of this facility to evaluate the extent of injury after a fall and prevent complications. Procedure: 1. Evaluate resident's condition before moving them. .6. Notify the physician 7. Notify family or responsible party. .12. Document all appropriate information. The facility's Roster/Sample Matrix Form CMS-802, provided on 10/31/16, reflected 17 residents in the facility had a history of [REDACTED].

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care, for one (Residents #1) of five residents reviewed for pain management. The facility failed to ensure Resident #1 received pain management after Resident #1 suffered a fall on 10/06/16 which resulted in a [MEDICAL CONDITION]. This failure caused Resident #1 to suffer pain for eight days before receiving treatment for [REDACTED]. This failure could affect the 17 residents with a history of falls at risk for unrelieved pain after their fall. Findings included: 1. Resident #1's MDS assessment, dated 10/03/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severely impaired cognitive skills. Resident #1's comprehensive care plan, dated 07/20/16, indicated the resident was at risk for falls with a facility intervention which indicated to follow the facility fall protocol. Resident #1's incident report, dated 10/21/16, reflected the resident was found to have a [MEDICAL CONDITION] femur on 10/14/16. Through facility investigation it was noted she was found on the floor on 10/06/16. Resident #1's progress note, dated 10/07/16, indicated the resident was having hip pain during transfers. LVN D notified the NP and obtained an order to administer a dose of Tylenol to the resident. Resident #1's October 2016 MAR indicated [REDACTED] - Tylenol 650 mg orally every six hours as needed for pain. The resident received a dose of Tylenol 650 mg on 10/07/16 at 10:53 a.m. for a pain level of 3 on a scale of 1-10 with 1 being no pain, and 10 being severe pain. - Pain assessments every shift (6:00 a.m. - 6:00 p.m. shift and 6:00 p.m. -6:00 a.m. shift) using the pain scale of 1-10. The resident had a pain scale of 2 on the 6:00 p.m. - 6:00 a.m. shift on 10/08/16 and 10/09/16. The pain assessments documented on 10/01/16 to 10/06/16 were 0 and the pain assessments for 10/10/16 to 10/15/16 were documented as 0. Resident #1's x-ray reported dated 10/14/16 indicated the resident had a right femur fracture. Resident #1's facility investigation report, dated 10/21/16, reflected the resident was found sitting on the floor on 10/06/16 by CNA A. CNA A notified CNA B who obtained RN C to evaluate the resident. RN C instructed CNA A and CNA B to place the resident in her wheelchair. On 10/07/16, LVN D was informed by CNA A that Resident #1 was complaining of hip pain during transfers. LVN D notified the NP and obtained an order for [REDACTED].#1 was having hip pain during incontinent care. RN F offered to give Resident #1 pain medication, but the resident refused. RN C reported on 10/14/16 Resident #1 was complaining of hip pain and she notified the ADON. Orders were obtained for an X-ray of the hip and the X-ray results received on 10/15/16 confirmed the resident had a fractured right hip. The resident was sent to the hospital ER. Additionally the facility investigation report revealed, Per inspection of several of the 24 hour reports, it did appear the nursing department was monitoring the resident for some hip pain. In addition, it was also noted some of the therapists were aware of some potential pain issues as they too were keeping nursing in the loop. Facility inservices were started on 10/18/16 with the nurses on appropriate assessments when a resident is found on the floor. Inservices were started on 10/19/16 with CNAs regarding not to pick up a resident who id on the floor until they have been assessed by the nurse. Resident #1's facility 24 hour report for October 2016 reflected: 10/07/16: right hip pain on the 6 a.m. - 6 p.m. shift 10/08/16: no complaints of hip pain -0/09/16: right hip pain on the 6 p.m. - 6 a.m. shift 10/10/16: right hip pain on the 6 p.m. - 6 a.m. shift Resident #1's physical therapy treatment notes reflected: 10/06/06: PTA H documented Resident #1 had right hip pain with increased anxiety during resident transfer with pain limiting the resident's functional activity. The pain was treated with a moist hot pack (MHP) for 15 minutes by the PTA. Resident's pain limited ability to move and transfer. 10/07/16: PTA H documented Resident #1 verbalized pain and grimaced with movement and transfers. The pain was treated with pain medication received from nursing. Resident's pain limited her ability to perform functional activities. 10/10/16: PTA I documented Resident #1 was not able to place full weight on the right leg and noted lower extremity weakness. Resident unable to stand erect and ambulated with knees bent. 10/11/16: PTA I documented Resident #1 had pain while standing and they notified nursing staff. Resident #1 denied pain when asked by the PT, but the PT documented the resident's facial expressions and actions showed otherwise. No interventions for pain relief documented. 10/12/16: PTA E documented Resident #1 complained of right hip pain. Resident able to take a few steps with the rolling walker then refused other attempts to walk. No interventions for pain relief documented. 10/13/16: PTA E documented Resident #1 had right hip pain limiting her mobility with an antalgic gait. (Gait to avoid pain while walking) No interventions for pain relief documented. 10/14/16: PTA E documented Resident #1 had right hip pain. No interventions for pain relief documented. An interview with CNA A on 10/31/16 at 9:15 a.m. revealed on 10/06/16 during the morning shift she found Resident #1 sitting on the floor in her room. CNA A went to the door and asked CNA B to get RN C. RN C entered the room, looked at the resident, and said to put the resident in the wheelchair. CNA A reported RN C did not assess the resident. CNA A reported the resident started complaining of pain on 10/07/16. CNA A told LVN D the resident was having pain on 10/07/16. On 10/08/16 CNA A told the physical therapy department the resident could not participate in therapy because she was having pain. An interview with RN C on 10/31/16 at 10:20 a.m. revealed she was notified on 10/06/16 by CNA B Resident #1 was on the floor. RN C reported she assessed the resident after the fall, but did not document the fall or notify the physician because she got busy. RN C reported she notified LVN K that Resident #1 fell on [DATE], but she did not know if LVN K was listening to her during end of shift report. An interview with CNA L on 10/31/16 at 11:35 a.m. revealed she provided care to Resident #1 during the night shift on 10/06/16 and reported the resident grunted during repositioning. CNA L reported she did not think much of it and did not tell the nurse about it. An interview with CNA G on 10/31/16 at 1:20 p.m. revealed she provided care to Resident #1 on 10/07/16 during the afternoon shift and notified LVN D the resident was having pain. An interview with LVN D on 10/31/16 at 9:30 a.m. revealed on 10/07/16 during the morning shift she assessed Resident #1 after being told by CNA A the resident had hip pain. LVN D reported the resident had pain when transferred to the wheelchair and had a limp while walking. LVN D reported the resident had not complained of pain or had a limp during transfers before. LVN D contacted the NP and obtained an order for [REDACTED]. An interview on 11/02/16 at 12:35 p.m. with the NP revealed she was notified on 10/07/16 Resident #1 was having pain, but was not notified the resident had fallen. An interview on 11/01/16 at 2:45 p.m. with RN F revealed she worked the night shift on 10/07/16, 10/08/16, and 10/09/16. She reported she was notified on 10/07/16 and 10/08/16 Resident #1 had hip pain. RN F thought the hip pain was due to physical therapy and arthritis. She reported she asked the resident if she needed something for pain and the resident said no. She reported she told the day nurse the resident was having pain and did not investigate further because she did not want to overstep her bounds. RN F reported people had been working with the resident all day and assumed they would see the problem with the resident and take care of it. An interview with PTA H on 10/31/16 at 1:25 p.m. revealed he provided therapy to Resident #1 on 10/06/16 and 10/07/16. PTA H reported the resident had pain and difficulty with transfers. PTA H was told by CNA A on 10/07/16 Resident #1 fell on [DATE]. PTA H told PT J about the fall. An interview with PT J on 10/31/16 at 3:50 p.m. revealed he was notified by PTA H on 10/07/16 that Resident #1 had a fall on 10/06/16. PT J reported he looked in the computer to find nursing notes or an incident report about the fall, but did not see any documentation of the fall. PT J did not investigate further. An interview with PTA I on 10/31/16 at 2:30 p.m. revealed she provided therapy to Resident #1 on 10/11/16 and told nursing staff the resident was having pain. PTA I did not know the name of the nursing staff they spoke to. A subsequent interview with LVN D on 11/01/16 at 10:25 a.m. revealed she was not notified by therapy Resident #1 had pain on 10/11/16. An interview with PTA E on 10/31/16 at 10:00 a.m. revealed on 10/12/16 PTA E provided therapy for Resident #1 and had heard Resident #1 had fallen. PTA E reported Resident #1 had hip pain and a limp during therapy. PTA E reported they thought the nurses were aware the resident was having pain. A subsequent interview with RN C on 11/01/16 at 10:40 a.m. revealed therapy notified her on 10/14/16 Resident #1 was having pain. RN C obtained orders for the resident to have an x-ray. RN C reported she did not think the pain was due to the fall on 10/06/16, but instead was due to the resident's therapy sessions. An interview with the ADON and DON on 10/31/16 at 1:15 p.m. revealed if a resident complained of pain during transfers, the nurse was supposed to assess the resident and call the doctor. An interview on 11/01/16 at 2:20 p.m. with the Rehabilitation Director revealed it was expected when a resident had a change in condition or behavior; the therapist would notify the nurse. The facility's current Falls Policy and Procedure, dated May 2007, reflected the following: Policy: It is the policy of this facility to evaluate the extent of injury after a fall and prevent complications. Procedure: 1. Evaluate resident's condition before moving them 6. Notify the physician 7. Notify family or responsible party. 12. Document all appropriate information. The Roster Sample Matrix Form CMS-802, provided on 10/31/16, reflected 17 residents in the facility had a history of [REDACTED].

Based on 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 five (Residents #1, #2, #7, #12, and #20) of 16 residents reviewed for pharmacy services. 1. The facility failed to ensure loperamide A-D was administered to Resident #2 for the treatment of [REDACTED]. 2. RN D and LVN B failed to consult with the Physician or Nurse Practitioner when Resident #7's blood sugars were 301 or greater nine times between 10/06/16 and 10/12/16 as per physician orders. 3. MA O failed to administer Mirapex, Senokot S, and Artificial Tears eye drops to Resident #1 according to physician orders [REDACTED]. 4. RN D failed to administer sliding scale insulin at the proper time as ordered by the physician to Residents #7 and #20. 5. The facility failed to ensure clarification was obtained for an order to taper Resident #12's prednisone starting on 08/31/16, which resulted in the resident continuing to receive the medication at full dose from 08/31/16 through 10/14/16. These failures placed the facility's 73 residents at risk of adverse drug reactions, decreased therapeutic benefit, and complications and/or exaceration of clinical conditions. Findings included: 1. Resident #2's MDS assessment, dated 10/04/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on 09/27/16. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was always incontinent of bladder and bowel. Resident #2's care plan, initiated on 09/14/16, reflected the resident had an alteration in gastrointestinal status due to chronic diarrhea related to disease process. One of the care planned interventions was to give the resident medications as ordered and to monitor/document side effects and effectiveness. physician progress notes [REDACTED]. Resident #2's physician orders, dated 09/27/16, reflected the following: Loperamide A-D (Imodium A-D (antidiarrheal medication) tablet 2 mg by mouth every six hours as needed for diarrhea. Resident #2's BM (Bowel Movement) Report for 10/01/16 through 10/11/16 reflected the resident's bowel movement consistency was recorded as loose/diarrhea on the following dates and times: 10/01/16 - 4:41 a.m. 10/01/16 - 9:33 a.m. 10/01/16 - 8:00 p.m. 10/02/16 - 9:17 a.m. 10/02/16 - 7:55 p.m. 10/03/16 - 2:17 a.m. 10/04/16 - 12:10 p.m. 10/04/16 - 12:53 p.m. 10/05/16 - 9:44 a.m. 10/05/16 - 1:37 p.m. 10/05/16 - 3:37 p.m. 10/06/16 - 10:22 a.m. 10/06/16 - 1:44 p.m. 10/07/16 - 9:35 a.m. 10/07/16 - 7:47 p.m. 10/08/16 - 11:37 a.m. 10/08/16 - 8:45 p.m. 10/09/16 - 9:33 a.m. 10/09/16 - 6:42 p.m. 10/10/16 - 9:13 a.m. 10/10/16 - 10:19 a.m. 10/10/16 - 1:30 p.m. 10/11/16 - 10:07 a.m. 10/11/16 - 1:44 p.m. 10/11/16 - 1:50 p.m. Resident #2's October 2016 MAR reflected loperamide A-D tablet 2 mg give two tablets by mouth every six hours as need for diarrhea, order date 09/27/16. The MAR reflected Resident #2 received loperamide A-D for diarrhea on the following dates and times: 10/02/16 - 8:07 p.m. 10/09/16 - 1:08 a.m. There was no other documentation on Resident #2's MAR reflecting she was administered loperamide A-D when she had loose stools on 10/01/16, 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/07/16, 10/08/16, 10/09/16, and 10/10/16. Resident #2's physician progress notes [REDACTED]. An observation of Resident #2 on 10/11/16 at 11:25 a.m. revealed the resident was in bed and incontinent of a watery, loose, yellow stool. The resident's perineal area and buttocks were red and moist with a large rash. An interview with Resident #2 on 10/11/16 at 12:30 p.m. revealed she had chronic diarrhea, and the loperamide A-D worked for her to stop the diarrhea. An interview with CNA H on 10/11/2016 at 1:45 p.m. revealed she worked the 6:00 a.m. to 2:00 p.m. and Resident #2 had three bowel movement on her shift on this date and all three were bowel movement were loose. An interview with CNA H on 10/14/16 at 9:40 a.m. revealed she provided incontinent care for Resident #2 on 10/05/16, 10/06/16, 10/10/16, and 10/11/16, and the resident had multiple loose stools on those days as well. CNA H stated she thought she notified the nurse that the resident had loose stools. An interview with LVN N on 10/11/16 at 1:55 p.m. revealed she knew Resident #2 had a prn order for loperamide A-D for diarrhea, and she thought she administered a dose to the resident on 10/10/16; however, she she stated she forgot to document it. She stated she had not given her a dose on 10/11/16 or notified the physician about the loose stools. She stated she was going to give the resident a dose of loperamide A-D at this time, and she would notify the physician about the resident's loose stools. Resident #2's October 2016 MAR reflected loperamide A-D was administered to Resident #2 on 10/11/16 at 2:06 p.m. following the interview with LVN N. An interview on 10/14/16 at 8:30 a.m. with LVN N revealed the facility was going to keep a better eye on the resident, and the facility needed to improve their communication. 2. Resident #7's MDS assessment, dated 10/12/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with her ADLs. She also required insulin injections daily. Resident #7's care plan, initiated on 11/05/13 and revised on 10/13/16, reflected the resident had a [DIAGNOSES REDACTED]. The care planned interventions included administer diabetes medications as ordered by the physician, monitor/document for side effects and effectiveness, and checking fasting serum blood sugars as ordered by the physician. Resident #7's October 2016 Order Summary Report reflected the resident was to receive Humalog Solution (insulin) per sliding scale subcutaneously before meals as follows: 70-150 = 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 5 units; 301+ = 7 units and call the physician. Resident #7's MAR for 10/01/16 through 10/13/16 the resident's blood sugar reading was 301 or greater 15 times as follows: 10/06/16 4:30 p.m. - BS 301 - 7 units of insulin administered; 10/07/16 6:00 a.m. - BS 357 - 7 units of insulin administered; 10/07/16 11:30 a.m. - BS 449 - 7 units of insulin administered; 10/07/16 4:30 p.m. - BS 597 - 7 units of insulin administered; 10/08/16 11:30 a.m. - BS 311 - 7 units of insulin administered; 10/08/16 4:30 p.m. - BS 441 - 7 units of insulin administered; 10/09/16 11:30 a.m. - BS 339 - 7 units of insulin administered; 10/09/16 4:30 p.m. - BS 365 - 7 units of insulin administered; 10/10/16 6:00 a.m. - BS 313 - 7 units of insulin administered; 10/10/16 4:30 p.m. - BS 322 - 7 units of insulin administered; 10/11/16 11:30 a.m. - BS 381 - 7 units of insulin administered; 10/11/16 4:30 p.m. - BS 407 - 7 units of insulin administered; 10/12/16 11:30 a.m. - BS 317 - 7 units of insulin administered; 10/12/16 4:30 p.m. - BS 434 - 7 units of insulin administered; and 10/13/16 11:30 a.m. - BS 334 - 7 units of insulin administered. Resident #7's Nursing Progress Notes for the period of 10/06/16 through 10/13/16 reflected the Nurse Practitioner was only notified of the resident's elevated blood sugars on 10/07/16 and 10/11/16. There was no documentation on the MAR or the Nursing Progress Notes reflecting the Nurse Practitioner or Physician was notified when Resident #7's blood sugars were 301 or greater on 10/06/16, 10/08/16, 10/09/16, 10/10/16, 10/12/16, and 10/13/16. An interview with RN D on 10/14/16 at 9:45 a.m. revealed worked the 6:00 a.m. to 6:00 p.m. shift, and she was responsible for checking Resident #7's blood sugars on 10/07/26, 10/08/16, 10/09/16, and 10/12/16. She stated she did not remember if she contacted the physician on 10/08/16 and 10/09/16 when the resident's blood sugar readings were elevated. The RN revealed the physician and nurse practitioner were aware of Resident #7's elevated blood sugars. She stated every time the physician or nurse practitioner was in the building they would ask about the resident's condition, and she would inform them that Resident #7's blood sugars remained elevated. RN D stated she called and/or notified the physician in person regarding elevated blood sugars. She stated the physician did at times order interventions, such as restarting the resident's order for Metformin and a one-time dose of two units of insulin on 10/07/16. An interview with LVN B on 10/14/16 at 9:30 a.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift, and she was responsible for checking Resident #7's blood sugars on 10/06/16 and 10/10/16. She stated she called the physician every time a resident's blood sugars were outside of parameters. When shown that Resident #7's blood sugars were 313 on the morning of 10/10/16 and 322 in the evening on 10/10/16, LVN B stated she did not recall if she had called the physician. She stated the nurses sometimes communicated with the physicians via a communication book. Review of the physician communication book revealed there was no documentation regarding Resident #7's elevated blood sugar readings. LVN B confirmed there was no documentation of Resident #7's blood sugar readings in the communication book. An interview with the DON on 10/14/16 at 10:00 a.m. revealed she thought Resident #7's sliding scale orders were to notify the physician when the resident's blood sugar readings were above 400. She stated she was unaware the order had changed since the resident readmitted to the facility. The DON stated she was aware of one instance she the resident's readmission when the resident's blood sugar was over 500, and Metformin, which had been discontinued in the hospital, was restarted. An interview with the Nurse Practitioner on 10/14/16 at 10:50 a.m. revealed she had been called a couple of times by nurses regarding Resident #7's elevated blood sugar levels. She stated she was notified on the evening of 10/12/16 when the resident's blood sugar reading was 434. She stated each time she was notified that the resident's blood sugar was elevated, she ordered an additional two units of insulin, because she did not want the resident to go into crisis. She stated any blood sugar reading over 400 was too high and needed intervention. The Nurse Practitioner revealed both she and the Physician received calls from the facility regarding the resident so she could not state whether notification was received regarding specific instances of elevated blood sugars. The facility's current Hyperglycemia policy and procedure, dated May 2007, reflected the following: .3. Review resident chart for diet order and appetite, medical orders, tests and results. 4. Notify physician of findings and results of your evaluation. Administer insulin and/or oral hyperglycemics per physician orders [REDACTED]. The facility's current Change of Condition Reporting policy and procedure, dated May 2007, reflected the following: .2. The nurse in charge is responsible for notification of physicians prior to the end of assigned shifts when a significant change in the resident's condition is noted. 3. Resident #1's MDS assessment, dated 10/14/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and resided on Hall 200. Resident #1's physician orders, dated 08/23/16, reflected the following: 1. Mirapex 0.125 mg (used to treat moderate to severe primary restless leg syndrome) by mouth every 12 hours on Sundays, Tuesdays, Thursdays, and Saturdays for restless leg syndrome. 2. Mirapex 0.125 mg by mouth twice daily on Mondays, Wednesdays, and Fridays. 3. Artificial Tears eye drops, one drop in both eyes four times daily for dry eyes. 4. Tramadol HCL 100 mg (an analgesic medication) every 6 hours as needed for pain Resident #1's physician orders, dated 08/27/16, reflected the following: 1. Senokot S tablets 8.6-50 mg (laxative medication), 2 tablets by mouth daily at bedtime for constipation. Resident #1's October 2016 MAR reflected the resident did not receive a dose of Mirapex 0.125 mg at 8:00 p.m. on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. Resident #1's October 2016 MAR reflected the resident did not receive a dose of Artificial Tears eye drops at 4:00 p.m. and 8:00 p.m. on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. Resident #1's October 2016 MAR reflected the resident did not receive a dose of Senokot S at 8:00 p.m. on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. Resident #1's October 2016 TAR reflected the resident received a dose of Tramadol HCL on the 2:00 p.m.-10:00 p.m. shift on 10/03/16, 10/04/16, 10/05/16, 10/11/16, and 10/12/16. The facility's October 2016 schedule reflected MA O, assigned to Hall 200, worked the 2:00 p.m. to 10:00 p.m. shift on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. An interview with Resident #1 on 10/13/16 at 12:20 p.m. revealed she had not received doses of her evening medications for the past two weeks. She stated MA O would no longer give them to her because she was involved in a disagreement with the CNA at the end of September 2016. An interview with Resident #1 on 10/14/16 at 12:00 p.m. revealed the resident experienced increased leg pain which she rated a seven on a scale of one to ten (one=no pain and ten=worst pain imaginable) on the evenings when she did not receive her Mirapex as ordered. She stated she asked the nurse to give her a dose of Tramadol on those days. An interview with MA O on 10/13/16 at 1:42 p.m. revealed she did not give Resident #1 her evening medications on the days she worked because the resident would scream at her to get out of the room. She stated she had not given Resident #1 her medications since she had a disagreement with the resident at the end of September 2016. MA O stated she notified RN U, LVN V, and the ADON about the Resident #1 refusing her medications. She stated she did not notify the nurse every time the resident refused her medications. An interview with RN U on 10/13/16 at 2:23 p.m. revealed she thought MA O told her about Resident #1 refusing her medication on 10/07/16, and she spoke with the resident, who agreed to take her medications. RN U revealed she was not aware of any other time when Resident #1 refused her medications. An interview with LVN V on 10/14/16 at 2:09 p.m. revealed she thought MA O notified her one time about Resident #1 refusing her medications. An interview with the facility's only ADON on 10/13/16 at 3:32 p.m. revealed she was not aware Resident #1 refused medications from MA O. She stated the nurse was supposed to be notified if a resident refused to take medications. 4. Resident #7's MDS assessment, dated 10/12/16, reflected the resident was a [AGE] year-old female, with severe cognitive impairment, who was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #7's physician orders, dated 10/13/16, reflected the following: HumaLOG Solution (Insulin Lispro (Human)) Inject as per sliding scale .301+ = 7 Units Call MD, subcutaneously before meals for Diabetes This order was initiated on 10/06/16. Resident #7's October 2016 MAR reflected an entry for HumaLOG Solution (Insulin Lispro (Human)) Inject as per sliding scale: .301+ = 7 Units Call MD, subcutaneously before meals for Diabetes The MAR reflected RN D administered seven units of Humalog on 10/12/16 at 11:30 a.m. for a blood sugar reading of 317. An observation on 10/12/16 at 12:35 p.m. revealed Resident #7 received her lunch in the dining room. Resident #20's MDS assessment, dated 08/18/16, reflected the resident was an [AGE] year-old female, with severe cognitive impairment, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #20's physician orders, date 09/27/16, reflected the following: HumaLOG Solution 100 UNIT/ML (Insulin Lispro (Human)) Inject as per sliding scale: .151-200 = 3 Units .before meals This order was initiated on 05/21/16. Resident #20's October 2016 MAR reflected an entry for HumaLOG Solution (Insulin Lispro (Human)) Inject as per sliding scale: .151-200 = 3 Units .subcutaneously before meals .for DM type 2 The MAR reflected RN D administered three units of HumaLOG on 10/12/16 at 11:30 a.m. for a blood sugar reading of 197. An observation on 10/12/16 at 12:15 p.m. revealed Resident #20 received her lunch in the dining room. An interview with RN D on 10/12/16 at 11:00 a.m. revealed she had already completed her blood sugars and sliding scale insulin administration to her residents that required them. She further revealed they were ordered for 11:30 a.m. so she could administer the insulin one hour before, so she started at 10:30 a.m. She had five residents, including Residents #7 and #20, who required sliding scale insulin. RN D stated the insulin would begin to work in 30 to 60 minutes after it was administered. She revealed lunch was served at 12:00 p.m. An interview with Nurse Practitioner E on 10/14/16 at 10:45 a.m. revealed if a resident had to wait one and a half hours to eat after sliding scale insulin was administered it was too long a period of time. An observation on 10/12/16 at 12:00 p.m. revealed a posting, in the dining room, which reflected lunch was served at 12:00 p.m. The facility's current Policy/Procedure - Nursing Clinical .Hyperglycemia dated May 2007 reflected the following: .4 .Administer insulin and/or oral hyperglycemics per physician orders [REDACTED]. The Humalog manufacterer's prescription information, revised November 2015, reflected the following: .HUMALOG is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus Administer the dose of HUMALOG .within fifteen minutes before a meal or immediately after a meal by injection . 5. Resident #12's MDS assessment, dated 09/14/16, reflected the resident was a [AGE] year-old female, with moderate cognitive impairment, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #12's Facility Transfer Orders, dated 08/25/16, reflected prednisone 20 mg (a corticosteroid medication) daily. The orders reflected to taper the prednisone in one week. Resident #12's physician orders, dated 10/13/16, reflected prednisone 20 mg daily, taper in one week on 08/31/16. This order was initiated on 08/25/16. Resident #12's August 2016 MAR reflected prednisone 20 mg was administered 08/25/16 through 08/31/16. The prednisone was not tapered on 08/31/16. Resident #12's September 2016 MAR reflected prednisone 20 mg was administered 09/01/16 through 09/30/16. The prednisone was not tapered, and a total of 30 doses were administered. Resident #12's October 2016 MAR reflected prednisone 20 mg was administered 10/01/16 through 10/13/16. The prednisone was not tapered, and a total of 13 doses were administered. Resident #12's Physician Order, dated 10/14/16, reflected prednisone 10 mg for seven days, then prednisone 5 mg every other day for seven days. An interview with facility's only ADON on 10/14/16 at 7:55 a.m. revealed when a resident admitted to the facility it was the responsibility of the charge nurse for that hall to admit the resident. This included notifying the physician, verifying the medication orders, and entering the physician orders [REDACTED]. An interview with LVN B on 10/14/16 at 8:30 a.m. revealed the charge nurse was responsible to review the medications with the physician for newly admitted residents. She stated if there was an order to taper a medication, she would definitely tell the doctor. An interview with the DON on 10/14/16 at 9:30 a.m. revealed she was not aware of the prednisone taper order for Resident #12. The DON stated new physician orders [REDACTED]. An interview with LVN A on 10/14/16 at 9:30 a.m. revealed she did not remember doing Resident 12's admission. She stated if she saw an order to taper a medication she would call the physician and get an order to clarify the tapering. The facility's current, Policy/Procedure - Nursing Clinical Medication Administration dated May 2007 reflected: .4. Read the label on the bottle/bubble pack as it is removed from the cart and check label with MAR 6. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 10/12/16, reflected the census was 73.

Based on observation, interview, and record review, the facility failed to ensure that residents were free of any significant medication errors for five (Residents #1, #2, #7, #12, and #20) of 15 residents reviewed for medications. 1. The facility failed to ensure [MEDICATION NAME] A-D was administered to Resident #2 for the treatment of [REDACTED]. 2. RN D and LVN B failed to consult with the Physician or Nurse Practitioner when Resident #7's blood sugars were 301 or greater nine times between 10/06/16 and 10/12/16 as per physician orders. 3. MA O failed to administer [MEDICATION NAME] S, and Artificial Tears eye drops to Resident #1 according to physician orders [REDACTED]. 4. RN D failed to administer sliding scale insulin at the proper time as ordered by the physician to Residents #7 and #20. 5. The facility failed to ensure clarification was obtained for an order to taper Resident #12's [MEDICATION NAME] starting on 08/31/16, which resulted in the resident continuing to receive the medication at full dose from 08/31/16 through 10/14/16. These failures placed the facility's 73 residents at risk of adverse drug reactions, decreased therapeutic benefit, and complications and/or exaceration of clinical conditions. Findings included: 1. Resident #2's MDS assessment, dated 10/04/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on 09/27/16. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was always incontinent of bladder and bowel. Resident #2's care plan, initiated on 09/14/16, reflected the resident had an alteration in gastrointestinal status due to chronic diarrhea related to disease process. One of the care planned interventions was to give the resident medications as ordered and to monitor/document side effects and effectiveness. physician progress notes [REDACTED]. Resident #2's physician orders, dated 09/27/16, reflected the following: [MEDICATION NAME] A-D ([MEDICATION NAME] A-D (antidiarrheal medication) tablet 2 mg by mouth every six hours as needed for diarrhea. Resident #2's BM (Bowel Movement) Report for 10/01/16 through 10/11/16 reflected the resident's bowel movement consistency was recorded as loose/diarrhea on the following dates and times: 10/01/16 - 4:41 a.m. 10/01/16 - 9:33 a.m. 10/01/16 - 8:00 p.m. 10/02/16 - 9:17 a.m. 10/02/16 - 7:55 p.m. 10/03/16 - 2:17 a.m. 10/04/16 - 12:10 p.m. 10/04/16 - 12:53 p.m. 10/05/16 - 9:44 a.m. 10/05/16 - 1:37 p.m. 10/05/16 - 3:37 p.m. 10/06/16 - 10:22 a.m. 10/06/16 - 1:44 p.m. 10/07/16 - 9:35 a.m. 10/07/16 - 7:47 p.m. 10/08/16 - 11:37 a.m. 10/08/16 - 8:45 p.m. 10/09/16 - 9:33 a.m. 10/09/16 - 6:42 p.m. 10/10/16 - 9:13 a.m. 10/10/16 - 10:19 a.m. 10/10/16 - 1:30 p.m. 10/11/16 - 10:07 a.m. 10/11/16 - 1:44 p.m. 10/11/16 - 1:50 p.m. Resident #2's October 2016 MAR reflected [MEDICATION NAME] A-D tablet 2 mg give two tablets by mouth every six hours as need for diarrhea, order date 09/27/16. The MAR reflected Resident #2 received [MEDICATION NAME] A-D for diarrhea on the following dates and times: 10/02/16 - 8:07 p.m. 10/09/16 - 1:08 a.m. There was no other documentation on Resident #2's MAR reflecting she was administered [MEDICATION NAME] A-D when she had loose stools on 10/01/16, 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/07/16, 10/08/16, 10/09/16, and 10/10/16. Resident #2's physician progress notes [REDACTED]. An observation of Resident #2 on 10/11/16 at 11:25 a.m. revealed the resident was in bed and incontinent of a watery, loose, yellow stool. The resident's perineal area and buttocks were red and moist with a large rash. An interview with Resident #2 on 10/11/16 at 12:30 p.m. revealed she had chronic diarrhea, and the [MEDICATION NAME] A-D worked for her to stop the diarrhea. An interview with CNA H on 10/11/2016 at 1:45 p.m. revealed she worked the 6:00 a.m. to 2:00 p.m. and Resident #2 had three bowel movement on her shift on this date and all three were bowel movement were loose. An interview with CNA H on 10/14/16 at 9:40 a.m. revealed she provided incontinent care for Resident #2 on 10/05/16, 10/06/16, 10/10/16, and 10/11/16, and the resident had multiple loose stools on those days as well. CNA H stated she thought she notified the nurse that the resident had loose stools. An interview with LVN N on 10/11/16 at 1:55 p.m. revealed she knew Resident #2 had a prn order for [MEDICATION NAME] A-D for diarrhea, and she thought she administered a dose to the resident on 10/10/16; however, she she stated she forgot to document it. She stated she had not given her a dose on 10/11/16 or notified the physician about the loose stools. She stated she was going to give the resident a dose of [MEDICATION NAME] A-D at this time, and she would notify the physician about the resident's loose stools. Resident #2's October 2016 MAR reflected [MEDICATION NAME] A-D was administered to Resident #2 on 10/11/16 at 2:06 p.m. following the interview with LVN N. An interview on 10/14/16 at 8:30 a.m. with LVN N revealed the facility was going to keep a better eye on the resident, and the facility needed to improve their communication. 2. Resident #7's MDS assessment, dated 10/12/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with her ADLs. She also required insulin injections daily. Resident #7's care plan, initiated on 11/05/13 and revised on 10/13/16, reflected the resident had a [DIAGNOSES REDACTED]. The care planned interventions included administer diabetes medications as ordered by the physician, monitor/document for side effects and effectiveness, and checking fasting serum blood sugars as ordered by the physician. Resident #7's October 2016 Order Summary Report reflected the resident was to receive Humalog Solution (insulin) per sliding scale subcutaneously before meals as follows: 70-150 = 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 5 units; 301+ = 7 units and call the physician. Resident #7's MAR for 10/01/16 through 10/13/16 the resident's blood sugar reading was 301 or greater 15 times as follows: 10/06/16 4:30 p.m. - BS 301 - 7 units of insulin administered; 10/07/16 6:00 a.m. - BS 357 - 7 units of insulin administered; 10/07/16 11:30 a.m. - BS 449 - 7 units of insulin administered; 10/07/16 4:30 p.m. - BS 597 - 7 units of insulin administered; 10/08/16 11:30 a.m. - BS 311 - 7 units of insulin administered; 10/08/16 4:30 p.m. - BS 441 - 7 units of insulin administered; 10/09/16 11:30 a.m. - BS 339 - 7 units of insulin administered; 10/09/16 4:30 p.m. - BS 365 - 7 units of insulin administered; 10/10/16 6:00 a.m. - BS 313 - 7 units of insulin administered; 10/10/16 4:30 p.m. - BS 322 - 7 units of insulin administered; 10/11/16 11:30 a.m. - BS 381 - 7 units of insulin administered; 10/11/16 4:30 p.m. - BS 407 - 7 units of insulin administered; 10/12/16 11:30 a.m. - BS 317 - 7 units of insulin administered; 10/12/16 4:30 p.m. - BS 434 - 7 units of insulin administered; and 10/13/16 11:30 a.m. - BS 334 - 7 units of insulin administered. Resident #7's Nursing Progress Notes for the period of 10/06/16 through 10/13/16 reflected the Nurse Practitioner was only notified of the resident's elevated blood sugars on 10/07/16 and 10/11/16. There was no documentation on the MAR or the Nursing Progress Notes reflecting the Nurse Practitioner or Physician was notified when Resident #7's blood sugars were 301 or greater on 10/06/16, 10/08/16, 10/09/16, 10/10/16, 10/12/16, and 10/13/16. An interview with RN D on 10/14/16 at 9:45 a.m. revealed worked the 6:00 a.m. to 6:00 p.m. shift, and she was responsible for checking Resident #7's blood sugars on 10/07/26, 10/08/16, 10/09/16, and 10/12/16. She stated she did not remember if she contacted the physician on 10/08/16 and 10/09/16 when the resident's blood sugar readings were elevated. The RN revealed the physician and nurse practitioner were aware of Resident #7's elevated blood sugars. She stated every time the physician or nurse practitioner was in the building they would ask about the resident's condition, and she would inform them that Resident #7's blood sugars remained elevated. RN D stated she called and/or notified the physician in person regarding elevated blood sugars. She stated the physician did at times order interventions, such as restarting the resident's order for [MEDICATION NAME] and a one-time dose of two units of insulin on 10/07/16. An interview with LVN B on 10/14/16 at 9:30 a.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift, and she was responsible for checking Resident #7's blood sugars on 10/06/16 and 10/10/16. She stated she called the physician every time a resident's blood sugars were outside of parameters. When shown that Resident #7's blood sugars were 313 on the morning of 10/10/16 and 322 in the evening on 10/10/16, LVN B stated she did not recall if she had called the physician. She stated the nurses sometimes communicated with the physicians via a communication book. Review of the physician communication book revealed there was no documentation regarding Resident #7's elevated blood sugar readings. LVN B confirmed there was no documentation of Resident #7's blood sugar readings in the communication book. An interview with the DON on 10/14/16 at 10:00 a.m. revealed she thought Resident #7's sliding scale orders were to notify the physician when the resident's blood sugar readings were above 400. She stated she was unaware the order had changed since the resident readmitted to the facility. The DON stated she was aware of one instance she the resident's readmission when the resident's blood sugar was over 500, and [MEDICATION NAME], which had been discontinued in the hospital, was restarted. An interview with the Nurse Practitioner on 10/14/16 at 10:50 a.m. revealed she had been called a couple of times by nurses regarding Resident #7's elevated blood sugar levels. She stated she was notified on the evening of 10/12/16 when the resident's blood sugar reading was 434. She stated each time she was notified that the resident's blood sugar was elevated, she ordered an additional two units of insulin, because she did not want the resident to go into crisis. She stated any blood sugar reading over 400 was too high and needed intervention. The Nurse Practitioner revealed both she and the Physician received calls from the facility regarding the resident so she could not state whether notification was received regarding specific instances of elevated blood sugars. The facility's current [MEDICAL CONDITION] policy and procedure, dated May 2007, reflected the following: .3. Review resident chart for diet order and appetite, medical orders, tests and results. 4. Notify physician of findings and results of your evaluation. Administer insulin and/or oral hyperglycemics per physician orders [REDACTED]. The facility's current Change of Condition Reporting policy and procedure, dated May 2007, reflected the following: .2. The nurse in charge is responsible for notification of physicians prior to the end of assigned shifts when a significant change in the resident's condition is noted. 3. Resident #1's MDS assessment, dated 10/14/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and resided on Hall 200. Resident #1's physician orders, dated 08/23/16, reflected the following: 1. [MEDICATION NAME] 0.125 mg (used to treat moderate to severe primary restless leg syndrome) by mouth every 12 hours on Sundays, Tuesdays, Thursdays, and Saturdays for restless leg syndrome. 2. [MEDICATION NAME] 0.125 mg by mouth twice daily on Mondays, Wednesdays, and Fridays. 3. Artificial Tears eye drops, one drop in both eyes four times daily for dry eyes. 4. [MEDICATION NAME] HCL 100 mg (an [MEDICATION NAME] medication) every 6 hours as needed for pain Resident #1's physician orders, dated 08/27/16, reflected the following: 1. [MEDICATION NAME] S tablets 8.6-50 mg (laxative medication), 2 tablets by mouth daily at bedtime for constipation. Resident #1's October 2016 MAR reflected the resident did not receive a dose of [MEDICATION NAME] 0.125 mg at 8:00 p.m. on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. Resident #1's October 2016 MAR reflected the resident did not receive a dose of Artificial Tears eye drops at 4:00 p.m. and 8:00 p.m. on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. Resident #1's October 2016 MAR reflected the resident did not receive a dose of [MEDICATION NAME] S at 8:00 p.m. on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. Resident #1's October 2016 TAR reflected the resident received a dose of [MEDICATION NAME] HCL on the 2:00 p.m.-10:00 p.m. shift on 10/03/16, 10/04/16, 10/05/16, 10/11/16, and 10/12/16. The facility's October 2016 schedule reflected MA O, assigned to Hall 200, worked the 2:00 p.m. to 10:00 p.m. shift on 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/10/16, 10/11/16, and 10/12/16. An interview with Resident #1 on 10/13/16 at 12:20 p.m. revealed she had not received doses of her evening medications for the past two weeks. She stated MA O would no longer give them to her because she was involved in a disagreement with the CNA at the end of September 2016. An interview with Resident #1 on 10/14/16 at 12:00 p.m. revealed the resident experienced increased leg pain which she rated a seven on a scale of one to ten (one=no pain and ten=worst pain imaginable) on the evenings when she did not receive her [MEDICATION NAME] as ordered. She stated she asked the nurse to give her a dose of [MEDICATION NAME] on those days. An interview with MA O on 10/13/16 at 1:42 p.m. revealed she did not give Resident #1 her evening medications on the days she worked because the resident would scream at her to get out of the room. She stated she had not given Resident #1 her medications since she had a disagreement with the resident at the end of September 2016. MA O stated she notified RN U, LVN V, and the ADON about the Resident #1 refusing her medications. She stated she did not notify the nurse every time the resident refused her medications. An interview with RN U on 10/13/16 at 2:23 p.m. revealed she thought MA O told her about Resident #1 refusing her medication on 10/07/16, and she spoke with the resident, who agreed to take her medications. RN U revealed she was not aware of any other time when Resident #1 refused her medications. An interview with LVN V on 10/14/16 at 2:09 p.m. revealed she thought MA O notified her one time about Resident #1 refusing her medications. An interview with the facility's only ADON on 10/13/16 at 3:32 p.m. revealed she was not aware Resident #1 refused medications from MA O. She stated the nurse was supposed to be notified if a resident refused to take medications. 4. Resident #7's MDS assessment, dated 10/12/16, reflected the resident was a [AGE] year-old female, with severe cognitive impairment, who was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #7's physician orders, dated 10/13/16, reflected the following: HumaLOG Solution (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scale .301+ = 7 Units Call MD, subcutaneously before meals for Diabetes This order was initiated on 10/06/16. Resident #7's October 2016 MAR reflected an entry for HumaLOG Solution (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scale: .301+ = 7 Units Call MD, subcutaneously before meals for Diabetes The MAR reflected RN D administered seven units of Humalog on 10/12/16 at 11:30 a.m. for a blood sugar reading of 317. An observation on 10/12/16 at 12:35 p.m. revealed Resident #7 received her lunch in the dining room. Resident #20's MDS assessment, dated 08/18/16, reflected the resident was an [AGE] year-old female, with severe cognitive impairment, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #20's physician orders, date 09/27/16, reflected the following: HumaLOG Solution 100 UNIT/ML (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scale: .151-200 = 3 Units .before meals This order was initiated on 05/21/16. Resident #20's October 2016 MAR reflected an entry for HumaLOG Solution (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scale: .151-200 = 3 Units .subcutaneously before meals .for DM type 2 The MAR reflected RN D administered three units of HumaLOG on 10/12/16 at 11:30 a.m. for a blood sugar reading of 197. An observation on 10/12/16 at 12:15 p.m. revealed Resident #20 received her lunch in the dining room. An interview with RN D on 10/12/16 at 11:00 a.m. revealed she had already completed her blood sugars and sliding scale insulin administration to her residents that required them. She further revealed they were ordered for 11:30 a.m. so she could administer the insulin one hour before, so she started at 10:30 a.m. She had five residents, including Residents #7 and #20, who required sliding scale insulin. RN D stated the insulin would begin to work in 30 to 60 minutes after it was administered. She revealed lunch was served at 12:00 p.m. An interview with Nurse Practitioner E on 10/14/16 at 10:45 a.m. revealed if a resident had to wait one and a half hours to eat after sliding scale insulin was administered it was too long a period of time. An observation on 10/12/16 at 12:00 p.m. revealed a posting, in the dining room, which reflected lunch was served at 12:00 p.m. The facility's current Policy/Procedure - Nursing Clinical .[MEDICAL CONDITION] dated May 2007 reflected the following: .4 .Administer insulin and/or oral hyperglycemics per physician orders [REDACTED]. The Humalog manufacterer's prescription information, revised November 2015, reflected the following: .HUMALOG is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus Administer the dose of HUMALOG .within fifteen minutes before a meal or immediately after a meal by injection . 5. Resident #12's MDS assessment, dated 09/14/16, reflected the resident was a [AGE] year-old female, with moderate cognitive impairment, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #12's Facility Transfer Orders, dated 08/25/16, reflected [MEDICATION NAME] 20 mg (a corticosteroid medication) daily. The orders reflected to taper the [MEDICATION NAME] in one week. Resident #12's physician orders, dated 10/13/16, reflected [MEDICATION NAME] 20 mg daily, taper in one week on 08/31/16. This order was initiated on 08/25/16. Resident #12's August 2016 MAR reflected [MEDICATION NAME] 20 mg was administered 08/25/16 through 08/31/16. The [MEDICATION NAME] was not tapered on 08/31/16. Resident #12's September 2016 MAR reflected [MEDICATION NAME] 20 mg was administered 09/01/16 through 09/30/16. The [MEDICATION NAME] was not tapered, and a total of 30 doses were administered. Resident #12's October 2016 MAR reflected [MEDICATION NAME] 20 mg was administered 10/01/16 through 10/13/16. The [MEDICATION NAME] was not tapered, and a total of 13 doses were administered. Resident #12's Physician Order, dated 10/14/16, reflected [MEDICATION NAME] 10 mg for seven days, then [MEDICATION NAME] 5 mg every other day for seven days. An interview with facility's only ADON on 10/14/16 at 7:55 a.m. revealed when a resident admitted to the facility it was the responsibility of the charge nurse for that hall to admit the resident. This included notifying the physician, verifying the medication orders, and entering the physician orders [REDACTED]. An interview with LVN B on 10/14/16 at 8:30 a.m. revealed the charge nurse was responsible to review the medications with the physician for newly admitted residents. She stated if there was an order to taper a medication, she would definitely tell the doctor. An interview with the DON on 10/14/16 at 9:30 a.m. revealed she was not aware of the [MEDICATION NAME] taper order for Resident #12. The DON stated new physician orders [REDACTED]. An interview with LVN A on 10/14/16 at 9:30 a.m. revealed she did not remember doing Resident 12's admission. She stated if she saw an order to taper a medication she would call the physician and get an order to clarify the tapering. The facility's current, Policy/Procedure - Nursing Clinical Medication Administration dated May 2007 reflected: .4. Read the label on the bottle/bubble pack as it is removed from the cart and check label with MAR 6. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 10/12/16, reflected the census was 73.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for two (Residents #3 and #2) of seven residents, who resided on one (Hall 600) of six halls, who were reviewed for bowel incontinence. 1. The facility failed to assess Resident #3, when the resident was found to have open/reddened areas on his groin and coccyx on 10/04/16. As of 10/13/16, the resident's groin, scrotum, and buttocks were excoriated with blistering and bleeding, and the resident went without treatment for [REDACTED]. 2. The facility failed to ensure [MEDICATION NAME] A-D was administered to Resident #2 for the treatment of [REDACTED]. These failures placed the eight residents, who resided on Hall 600 where Residents #2 and #3 resided, at risk for the development and/or worsening of skin breakdown, dehydration, and electrolyte imbalance. Findings included: 1. Resident #3's MDS assessment, dated 09/25/16, reflected the resident was a [AGE] year-old male readmitted to the facility on readmission on 09/25/16. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance with his ADLs. Resident #3's care plan for ADL self care performance deficit due to [MEDICAL CONDITION], initiated on 05/30/16, reflected one of the care planned interventions included, Skin Inspection: Requires Skin inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. A second care plan, initiated on 05/30/16, reflected the resident had an indwelling catheter. One of the care planned approaches included keeping the resident's skin clean and dry to promote wound healing and prevent further skin breakdown. An observation on 10/13/16 at 10:25 a.m. revealed the skin around Resident #3's scrotum, groin, and buttocks was excoriated with white blisters and open areas which bled when CNA L wiped the resident's groin during catheter care. The excoriation on the right groin fold near the resident's scrotum measured 17 cm x 4 cm (6.69 in x 1.57 in). The excoriation on the the left side measured 15 cm x 4 cm (5.90 in x 1.57 in). The excoriation to the buttock at the skin folds measured 7 cm x 3 cm (2.75 in x 1.18 in) bilaterally. An interview with CNAs L and M, at the time of this observation, revealed they would notify the charge nurse about the resident's skin. Resident #3's Nursing Progress Notes for 09/25/16 through 10/13/16 reflected there was no documentation regarding the excoriation on Resident #3's scrotum, groin, and buttocks. Resident #3's Skin Observation - Shower form, completed by CNA H on 10/04/16, reflected the resident had red and open areas on his groin and coccyx. The form was signed by RN F, the charge nurse, on 10/04/16. An interview on 10/13/16 at 1:20 p.m. with CNA H revealed Resident #3 had redness on the groin and buttocks. She stated charge nurses had signed the sheets indicating they were aware of the resident's skin problem. CNA H revealed when the charge nurse signed the sheet it meant she would follow-up by completing an assessment. An interview on 10/13/16 at 1:50 p.m. with RN F revealed Resident #3 did not have excoriation, just reddened areas caused by the resident's brief, which had been present since his admission from the hospital. An observation with RN F on 10/13/16 at 4:20 p.m. revealed Resident #3's skin was excoriated on the groin, scrotum and buttock with bleeding at the base the right scrotum and at the base of the penis and scrotum. She stated she had already gotten an order for [REDACTED]. RN F was asked about signing the Skin Observation - Shower form for Resident #3, and she stated she did not do a full assessment on the resident on 10/04/16. RN F stated she did not look at the resident's skin folds or scrotum after she signed the shower sheets. RN F admitted she signed the Skin Observation - Shower form on 10/04/16, but she did not assess the resident's skin. Resident #3's Skin Observation - Shower form, completed by CNA H on 10/06/16, reflected the resident had red and open areas on his groin and coccyx. The form was signed by LVN N, the charge nurse, on 10/06/16. Resident #3's Skin Observation - Shower form, completed by CNA H on 10/11/16, reflected the resident had red and open areas on his groin and coccyx. The form was signed by LVN N, the charge nurse, on 10/11/16. An interview on 10/13/16 at 2:50 p.m. with Nurse Practitioner T revealed neither she nor the physician were aware of Resident #3's excoriation. She stated she was never notified about the issue by the facility, but she would call the charge nurse and order medication and treatment. An interview on 10/13/16 at 4:40 p.m. with CNA H revealed the Skin Observation - Shower forms were filled out when the CNAs took the residents to be showered. CNA H reported if the CNA saw something on the resident they were supposed to fill out the form and give it to the charge nurse. An interview on 10/13/16 at 4:45 p.m. with the DON revealed she expected the nurses to do a full assessment when they saw a problem with the resident's skin. The DON stated the nurses should be following facility policy in regards to skin care. The facility's current Change in Condition Reporting policy and procedure, revised May 2007, reflected the following: .Routine Medical Change 1. All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physial and mental behavior .that are not life threatening. 2. The nurse in charge is responsible for notification of (the) physician prior to (the) end of (the) assigned shift when a significant change in (the) resident's condition is noted. .Follow-up 1. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabled (sic). 2. Resident #2's MDS assessment, dated 10/04/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on 09/27/16. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and was always incontinent of bladder and bowel. Resident #2's care plan, initiated on 09/14/16, reflected the resident had an alteration in gastrointestinal status due to chronic diarrhea related to disease process. One of the care planned interventions was to give the resident medications as ordered and to monitor/document side effects and effectiveness. physician progress notes [REDACTED]. Resident #2's physician orders, dated 09/27/16, reflected the following: [MEDICATION NAME] A-D ([MEDICATION NAME] A-D (antidiarrheal medication) tablet 2 mg by mouth every six hours as needed for diarrhea. Resident #2's BM (Bowel Movement) Report for 10/01/16 through 10/11/16 reflected the resident's bowel movement consistency was recorded as loose/diarrhea on the following dates and times: 10/01/16 - 4:41 a.m. 10/01/16 - 9:33 a.m. 10/01/16 - 8:00 p.m. 10/02/16 - 9:17 a.m. 10/02/16 - 7:55 p.m. 10/03/16 - 2:17 a.m. 10/04/16 - 12:10 p.m. 10/04/16 - 12:53 p.m. 10/05/16 - 9:44 a.m. 10/05/16 - 1:37 p.m. 10/05/16 - 3:37 p.m. 10/06/16 - 10:22 a.m. 10/06/16 - 1:44 p.m. 10/07/16 - 9:35 a.m. 10/07/16 - 7:47 p.m. 10/08/16 - 11:37 a.m. 10/08/16 - 8:45 p.m. 10/09/16 - 9:33 a.m. 10/09/16 - 6:42 p.m. 10/10/16 - 9:13 a.m. 10/10/16 - 10:19 a.m. 10/10/16 - 1:30 p.m. 10/11/16 - 10:07 a.m. 10/11/16 - 1:44 p.m. 10/11/16 - 1:50 p.m. Resident #2's October 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED] 10/02/16 - 8:07 p.m. 10/09/16 - 1:08 a.m. There was no other documentation on Resident #2's MAR indicated [REDACTED]. Resident #2's physician progress notes [REDACTED]. An observation of Resident #2 on 10/11/16 at 11:25 a.m. revealed the resident was in bed and incontinent of a watery, loose, yellow stool. The resident's perineal area and buttocks were red and moist with a large rash. An interview with CNA H on 10/11/2016 at 1:45 p.m. revealed she worked the 6:00 a.m. to 2:00 p.m. and Resident #2 had three bowel movement on her shift on this date and all three were bowel movement were loose. An interview with CNA H on 10/14/16 at 9:40 a.m. revealed she provided incontinent care for Resident #2 on 10/05/16, 10/06/16, 10/10/16, and 10/11/16, and the resident had multiple loose stools on those days as well. CNA H stated she thought she notified the nurse that the resident had loose stools. Review of Resident #2's clinical record revealed there was no documentation reflecting the nurse had been notified about Resident #2's loose stools/diarrhea. An interview with LVN N on 10/11/16 at 1:55 p.m. revealed she knew Resident #2 had a prn order for [MEDICATION NAME] A-D for diarrhea, and she thought she administered a dose to the resident on 10/10/16; however, she stated she forgot to document it. She stated she had not given her a dose on 10/11/16 or notified the physician about the loose stools. She stated she was going to give the resident a dose of [MEDICATION NAME] A-D at this time, and she would notify the physician about the resident's loose stools. Resident #2's October 2016 MAR indicated [REDACTED]. An interview on 10/14/16 at 8:30 a.m. with LVN N revealed the facility was going to keep a better eye on the resident, and the facility needed to improve their communication. 3. The Roster/Sample Matrix Form CMS-802, provided to the survey team on 10/11/16, reflected eight residents resided on Hall 600.