Every finding on record at Mitchell County Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA A) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided with care by staff who have not provided documentation of training and competency in providing care.The findings included: Record review of CNA A's personnel file reflected a date of hire of [DATE]. The last employability status check search via TULIP that was completed on [DATE] reflected CNA A's NAR status would expire on [DATE]. There were not any disciplinary action forms in the personnel file reflecting any concerns with resident care. Record review of CNA A's time punch detail dated [DATE] reflected CNA A clocked in and worked from 07:02 AM until 7:00 PM. During an interview on [DATE] at 11:00 AM, the DON stated that the ADM was no longer here. During an interview on [DATE] at 5:32 PM, the DON stated that CNA A was still working but not here today. She stated that HR was responsible for the verification and monitoring of staff licensures. The DON further stated that verifications of staff licensures all happened at the hospital, next to the facility. When asked what the potential negative outcome could be, the DON stated, It is not that they have not been trained, so it is out of compliance, they should keep it till date with the employer. I don't think it has any impact, that's my view. During a phone interview on [DATE] at 11:35 AM, HR stated that she knew CNA A and to the best of her knowledge she was still working. She stated that verifications of staff licensures were run through TULIP and outcomes communicated to the ADM, DON and ADON. HR added that both the facility's management and she were responsible for the verification and monitoring of staff licensures, and that she communicated to ADON two weeks ago about CNA A's expired license. She stated that it was both the facility and CNA A's fault not to have a current license, and she does not know if CNA A was informed about her expired license. HR stated that she did not know the potential negative outcomes but obviously believed that CNA A should have been current with her licensures. During a phone interview on [DATE] at 12:07PM, CNA A stated, I have worked for the facility for 4years and no, I am not aware of that, and I honestly didn't know it was expired. She stated that she had worked some couple of days ago and last day worked was Monday - [DATE], worked the day shift from 7:00AM -7:00PM. She further stated that she was supposed to renew her license every 2years, that the last time she did, the facility informed her that she was about to go out of date. CNA A stated that she was pretty sure that she was informed about her expired license but did not realize that it had expired and would work on that once we got off the phone. When asked what the potential negative outcome could be, CNA A stated, first, if I don't have up-to-date license then I don't have up-to-date information, I could not be following the rules or the law and that's not good. During a phone interview on [DATE] at 12:44 PM, the DON stated that ADON was on vacation.An email request on [DATE] at 12:58PM, was made for facility policy for Credentialling of Nursing Services Personnel from the DON; did not provide requested policy.

Based on interview and record review, the facility failed to ensure residents had the right to participate in the development and implementation of his or her person-centered plan of care for 13 of 13 residents (Residents #1, #2, #20 and 10 confidential residents) reviewed for comprehensive care plans.The facility failed to record any documentation inviting Resident #1 or their representative to the care plan meetings. The facility failed to record any documentation inviting Resident #2 or their representative to the care plan meetings. The facility failed to record any documentation inviting Resident #20 or their representative to the care plan meetings. The facility failed to ensure 10 confidential residents of the facility were provided with prior notice to participate in their care plan meetings. These failures could place residents at risk of not being involved in their plan of care and having their needs met. The findings include:1. Record review of Resident #1's facesheet dated 2/5/2026 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Fracture of right femur, anemia (low levels of red blood cells), pneumonia (infection that inflames the air sacs in lung), hypertension (blood forcefully pushes against artery walls), acute diastolic congestive heart failure (left ventricle becomes stiff and cannot fill properly with blood), macular corneal dystrophy (progressive genetic eye disease), history of cerebral infarction (blockage in a brain blood vessel), and history of falling. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had minimal difficulty with hearing, impaired vision and has corrective lenses. Resident #1's BIMS score was 11/15 (moderate cognitive impairment). Resident #1 had functional limitation in range of motion to one side lower extremity. Uses walker and wheelchair for mobility. Resident #1 required limited to moderate assistance for ADL's, she was continent of bladder and bowel. The active diagnosis listed was fractures and other multiple trauma. Resident #1 received PRN pain medication, rates pain 5/10. Resident #1was 62 inches, 145 pounds and received a mechanically altered therapeutic diet. Resident #1 required surgical wound care, applications of nonsurgical dressings other than to feet, and application of dressings to feet. Resident #1 is took an antibiotic, opioid, and antiplatelet. Resident #1 received Occupational Therapy and Physical Therapy. Resident #1's overall goal was to be discharged to the community. There was an active discharge plan already occurring for the resident to return to the community. Record review of Resident #1's care plan initiated on 2/17/2026 addressed Resident #1's triggered concern areas from the admission MDS dated [DATE], but did not reveal any documentation of a IDT or care plan meeting. Record review of Resident #1's progress notes and assessments did not reveal any documentation of an IDT or care plan meeting between the dates 2/5/2026 through 4/28/2026. During an interview on 4/27/2026 at 9:26 AM with Resident #1 on whether she had participated in a care plan/IDT meeting to discuss her care and discharge plans. Resident #1 voiced she did not think so. During an interview on 4/28/2026 at 9:30 AM with Resident #1 and a family member revealed the facility communicated with the family member for any updates or orders. The family member voiced that he had probably talked to everyone individually, but not as part of a care plan/IDT meeting.2. Record review of Resident #2's facesheet dated 4/25/2026 revealed a [AGE] year-old male who was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #2 had diagnoses which included: Dementia (progressive decline in cognitive function), altered mental status (sudden or gradual change in brain function), chronic viral hepatitis C (long-lasting liver infection), hyperlipidemia (high levels of fatty or waxy compounds in the blood), depressive disorder (mental illness causing persistent sadness), post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing a terrifying event), polyneuropathy (damage to multiple nerves causing numbness, tingling, or muscle weakness), osteoporosis (bone disease where density decreases), urethral fistula (abnormal connection between the urethra and skin or other organ), and traumatic brain injury (sudden bump, blow, jolt that disrupts normal brain function). Record review of Resident #2' Quarterly MDS, dated [DATE], revealed Resident #2 had impaired vision and had corrective lenses. Resident #2's BIMS score was 5/15 (severe cognitive impairment). Resident #2 used a wheelchair for mobility. Resident #2 required extensive assistance for ADL's. Resident #2 was frequently incontinent of bladder and had an ostomy for bowel. Active diagnosis was non-traumatic brain dysfunction. Resident #2 received scheduled and prn pain medication. Resident #2 had two falls with no injury and one fall with injury (except major) since the previous assessment. Resident #2 was 72 inches, 146 pounds and received mechanically altered therapeutic diet. Resident #2 had skin tears and moisture associated skin damage with applications of nonsurgical dressings and applications of ointments/medications other than to feet. Resident #2 took an antidepressant and antibiotic. Resident #2 did not wish to return to the community. Record review of Resident #2's care plan initiated on 10/27/2025 addressed Resident #2's triggered concern areas from the Quarterly MDS dated [DATE], but did not reveal any documentation of a IDT or care plan meeting. Record review of Resident #2's progress notes and assessments did not reveal any documentation of a IDT or care plan meeting between the dates 2/26/2026 through 4/28/2026. During a phone interview on 4/27/26 at 1:10 PM with Resident #2's family member it was revealed the facility was good to contact him for any changes. The family member stated he had not been invited or had he attended any care plan/IDT meeting regarding Resident #2's care. 3. Record review of Resident #20's facesheet dated 1/19/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #20 had diagnoses which included: Dementia (progressive decline in cognitive function), acute kidney failure (rapid often reversible loss of kidney function), acquired absence of specified parts of digestive tract (refers to the partial or complete surgical removal of digestive organs), cholecystitis (gallbladder inflammation), atrial fibrillation (rapid, irregular and, disorganized heartbeat from the hearts upper chambers), arthritis (inflammation or degeneration of joints), type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce enough causing high blood sugar), insomnia (difficulty falling or staying asleep), depressive disorder (mental illness causing persistent sadness), hypertension (blood forcefully pushes against artery walls), and gastro-esophageal reflux disease (stomach acid frequently flows back into the esophagus causing discomfort). Record review of Resident #20's Quarterly MDS, dated [DATE], revealed Resident #20 had impaired vision and had corrective lenes. Resident #20 had a BIMS score of 6/15 (severe cognitive impairment). Resident #20 used a wheelchair for mobility. Resident #20 required extensive assistance for ADL's. Resident #20 was incontinent of bladder and bowel. Resident #20 's active diagnosis was medically complex conditions. Resident #20 received scheduled pain medication. Resident #20 was 60 inches, 135 pounds, and received a mechanically altered therapeutic diet. Resident #20 had moisture associated skin damage with applications of nonsurgical dressings. Resident #20 took seven days of insulin injections and took an antidepressant. Resident #20 did not wish to return to the community. Record review of Resident #20's's care plan initiated on 9/4/2025, addressed Resident #20's triggered concern areas from the Quarterly MDS dated [DATE], but did not reveal any documentation of a IDT or care plan meeting. Record review of Resident #20's progress notes and assessments did not reveal any documentation of a IDT or care plan meeting between the dates 2/26/2026 through 4/28/2026. During an interview with Resident #20's family member on 4/28/2026 it was revealed she had never been invited to a care plan/IDT meeting to discuss Resident #20's care. Interview at an undisclosed dated and disclosed time revealed 10 confidential residents who stated they did not know what a care plan meeting was. They stated they were not invited to a care plan meeting and did not know what a care plan meeting was for. During an interview on 4/28/2026 at 12:45 PM with the MDS Coordinator revealed they did not send letters or have care plan meetings. The IDT team got together to discuss the plan of care, then the DON would call the families with any updates. During an interview on 4/28/2026 at 1:15 PM with the DON revealed they did get the IDT team together and went over the residents care plan. Usually, IDT team members would give input during the morning meeting. The DON stated then she called the family and gave them the whole spill of that every 92 days there was a Quarterly assessment, then the next one is the annual assessment. The DON told the family member/responsible party for the residents at those times the IDT team got together to go over the plan of care. The DON stated she told the family member/responsible party if they would like to be here they could schedule a meeting to discuss it. The DON stated 9 out of 10 times they did not want to attend because they were out of town or there was a doctor appointment or something. The DON stated when COVID-19 happened they could not have the meetings and were doing it over the phone, so they just kept doing it that way. The DON stated she would look to see if there was any documentation when she notified the families. The DON voiced that their EMR program was basic, and she did not have anywhere to document her notes, so she noted it on paper. The DON stated they did not send letters to invite residents or family members to a care plan meeting. The DON stated she communicates with the family members with any updates or changes in that residents care. During an interview on 04/28/2026 at 1:58 PM with the Administrator it was revealed when she first started working at the facility she asked the MDS nurse about the care plan meeting and she told her she did not do them, but the DON notified the families with any updates. The Administrator voiced the DON told her during COVID-19 they could not do them, so they did them by phone, and they never started it back. Regarding the importance of having care plan meetings, the Administrator voiced it was important to notify the resident/family of any changes to their plan of care and a chance for them to talk to the IDT meeting for any questions or concerns. Maybe they were full code and now want to be a DNR, or maybe diet preferences changed, a chance to check on vaccines, just a chance to go over everything. The Administrator voiced she had always had care plan meetings in other facilities where she had worked.Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised March 2022, revealed: 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. participate in the planning process;b. identify individuals or roles to be included;c. request meetings;d. request revisions to the plan of care;e. participate in establishing the expected goals and outcomes of care.f. participate in determining the type, amount, frequency and duration of care;g. receive the services and/or items included in the plan of care; andh. see the care plan and sign it after significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences.6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.

Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality and the facility failed to protect and promote the rights of 7 of 20 confidential residents reviewed for resident rights. The facility failed to ensure staff were not on their personal cell phones while providing care, which included assisting residents with their showers. This failure could place residents at risk for a diminished quality of life and loss of dignity and self-worth.Findings include: Interview at an undisclosed date and time revealed seven confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. The seven confidential residents stated the use of cell phones by CNAs occurred on every shift. Confidential residents also stated staff utilized their cell phones while feeding residents during meals; residents stated the use of the cell phones while feeding residents forced those residents to have significant wait times between bites. The seven confidential residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 04/28/26 at 2:15pm, the DON stated residents should be provided with privacy during resident care; the staff's attention should be 100% on the Resident. She stated all staff were trained in privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the DON. She stated staff were monitored by sporadic rounds completed by the DON and the ADON. She stated cell phones should never be used in patient care areas, cell phones should not be utilized anywhere Residents were visible. She stated the potential negative outcome could be feeling ignored and loss of dignity. During an interview on 4/28/2026 at 3:33pm, the ADM stated staff should only be focused on Residents while performing care. The ADM stated all staff were trained on resident rights, dignity, and cell phone usage during the on boarding process and in-services. She stated cell phones should only be used during breaks; personal calls were not allowed while staff were on the clock. She stated cell phones should be kept in the breakroom. Staff were monitored for cell phone use by rounding completed by the ADM and the DON. The ADM stated the potential negative outcome for Residents, if staff used their cell phones while performing care, was Residents could feel ignored. Record review of the facility's policy dated October 2025 titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a dignified existence to be treated with respect, kindness, and dignityt. privacy and confidentiality

Based on observation, interview, and record review, the facility failed to make information on how to file a grievance or complaint available to the residents for 9 of 10 confidential residents reviewed for grievances. The facility failed to ensure 9 of 10 residents were provided, through postings in prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life. Findings include: In Interviews and Record Review at an undisclosed date and time, 9 of 10 confidential residents stated they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. The residents stated they did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Observations of prominent postings on 04/28/2026 at 3:00pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Interview with the ADM on 04/28/2026 at 3:35pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was available on a shelf on the wall in the entryway hallway and at the nurses' station. The ADM stated the Activities Director completed Grievance forms during monthly, resident council meetings when concerns were vocalized by Residents. The ADM stated staff also complete Grievance forms for some complaints that were discussed with them face to face with residents. The ADM stated she assigned the Grievance to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution is documented on the Grievance form, and the completed form is submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook for 3 plus years. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance. The ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council; the ADM agreed the availability of the Grievance forms, the Grievance procedure, and procedure for submitting a Grievance form anonymously should be explained to Residents at admission and continually discussed in monthly Resident Council meetings. Record Review of the Grievance policy on 04/28/2026 at 2:27pm; reflected a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Record Review of the Grievance Policy last updated in April 2017 reflected: Policy Statement:All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. Policy Interpretation and Implementation: The ADM has assigned the responsibility of grievance investigation to the grievance officer. Upon receiving a grievance, the grievance officer will investigate the allegations. The department director will be notified pf the nature of the complaint. The grievance officer will record and maintain all grievances on the Resident Grievance Log. The Grievance form will be filed with the administrator. The resident or person filing the grievance on behalf of the resident will be informed of the findings of the investigation. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations.

Based on observation, interview and record review, the facility failed to provide food and drink that was palatable, attractive and at a safe and appetizing temperature for one of one kitchen. A. Resident #8, #11, #13, #32 voiced concerned of cold food, flavor and/or texture.B. Five of the 9 foods sampled on the meal tray were cold.C. One of the 9 foods sampled on the meal tray was mushy.D. One of the 9 foods sampled on the meal tray was sticky. E. One of the 9 foods sampled on the meal tray was chunky. These failures could affect the forms of food provided in the facility (regular, mechanical chopped and pureed) and could result in a decline in residents' consumption of food and residents to have unwanted weight loss. The findings included: On 04/26/2026 during initial tour of facility, four Residents (#8, #11, #13, #32) voiced concerns about the food. During an interview on 04/26/2026 at 1:22 PM, Resident #32 was asked how the food was and she responded by saying It is bad, I mean greasy, no seasoning, no taste, is cold, never hot. She stated the kitchen is horrible, they can't cook, and she ate in her room and in the dining hall. During an interview on 04/26/2026 at 4:02 PM, Resident #13 was asked how the food was and she stated, The food is not good, no texture, no varieties, not even hot and I am tired of Mexican food and chicken. She further added, the vegetable today was overcooked, and I do eat both in my room and at the dining hall. During an interview on 04/26/2026 at 4:26 PM, Resident #11 was asked how the food tasted and he stated, I don't eat it, it is of poor quality, I eat sandwiches, you have to see it a few days, to understand and I do eat in my room. He further stated, I understand that they are under budget. During an interview on 04/27/2026 at 9:28 AM, Resident #8 was asked how the food was and she responded by saying I have trouble with mine, they get my dislikes, no variety. I do eat in my room, and it is cold, the chicken is so dry. A sample tray was requested on 04/27/2026 at 10:02 AM, of all the food forms served including the alternate plate and requested to have the sample trays delivered after the last hall tray was delivered. The sample tray on 04/27/2026 was delivered to the survey room at 11:43 AM. Sample tray findings found by the survey team and [NAME] A were the following: FOOD ITEMS Taste, Temperature, TextureRegular [NAME] MushyMechanical vegetable ColdMechanical [NAME] Cold/stickyPuree Chicken Cold/chunkyPuree vegetable Cold/no flavorPuree [NAME] Cold During an interview on 04/28/2026 at 10:26 a.m., [NAME] A stated, I have worked here for three and half years now, whoever is cooking the meal that day is responsible for monitoring of temperature, texture and flavor and I am not sure why the meal were not palatable, I don't have any reason for that. She stated that the kitchen middle steamtable was not working for a while now, I have spoken to the ADM and DM, both said they will send somebody. She further stated, I have trained myself, and have never seen the food palatability policy. She stated, because of the age the residents are, with health concerns such meals could cause food illness, and could be fatal over a long period of time. During an interview on 04/28/2026 at 11:14 a.m., [NAME] B stated, I am responsible for monitoring of food temperature, texture and flavor and honestly don't know why the meals were not palatable, we are mostly worried about getting the meals out quick. She stated that maybe the meals were not served fast enough to the residents, and the kitchen middle steam table was not working properly for about a month now, and I think the vendor is waiting for the parts, when asked why the meals were cold. She further stated, yes I have been trained but have not come across food palatability policy before, and the residents wouldn't like such meal which will end up affecting their health. During a phone interview on 04/28/2026 at 11:57 a.m., the RD stated, that will be the cooks, that were responsible, and I am not sure why, surely that food should be palatable for residents to consume. The RD stated that, No, I don't know why the meals were cold, yes the steamtable issue was brought to my attention, and the DM is working on that to get it fixed. When asked about staff training, she stated, again that would be a good question for the DM. She further stated, such meals could cause the residents not to eat resulting in weight loss or malnutrition. She stated, nobody has directly told me about issues regarding food varieties, but I know that they are working on getting new menus but not sure when. During an interview on 04/28/2026 at 12:27 p.m., the ADM stated that will be the DM that is responsible for ensuring that all meals were palatable, but I am not sure why, I know the RD is telling me everything is good, the palatability and consistency are good, I think we could do more training on that. She further stated, we do have food palatability policy, and I don't know if the kitchen staff have seen one. She stated that the negative outcome of serving residents such meals could be fatal. She further stated, to me I looked at the menu, and it is not the same every day, it is not true regarding varieties, we give residents two choices. During an interview on 04/28/2026 at 1:01 p.m., the DM stated, every kitchen staff is responsible for ensuring that all meals were palatable, but I am the overall and I think the kitchen staff rushed cooking the food and not checking for food palatability and consistency before plating, the staff failed to follow recipes, and that is not acceptable. He further stated, The only thing that is possible is they are not turning in the meals on time after putting it on the serving line, in addition there is a lot of airflow and I don't recall coming across food palatability policy. He further admitted that one steamtable compartment was not working and work order had already been turned in. He stated serving such meals, definitely cause residents not to eat resulting to weight loss. Record review of the facility's policy and procedure titled, Food Palatability, undated, reflected the following: Policy Statement: The facility is committed to providing meals that are palatable, visually appealing, and served at appropriate temperatures, while meeting each resident's dietary needs and preferences. Policy Guidelines: 1, Food Quality & Taste Taste testing will be conducted routinely by dietary staff prior to service.Meals shall be prepared using standardized recipes to ensure consistent flavor and quality.2, Appearance & PresentationMeals shall be attractively plated with attention to color, contrast, and portion size.Pureed foods shall be molded or presented to resemble original food items when possible3, Temperature Control Hot foods shabby served hot and cold food served cold.Food temperatures shall comply with state and federal food safety guidelines at times of service.Delays in mail service shall be minimized to preserve quality.4, Texture & ConsisitencyFoods shop meat prescribed diet orders (e.g., pureed, minced, soft).Textured-modified food shall maintain moisture and flavor to enhance palatability.Thickened liquids should be prepared to correct consistency and serve promptly.8, Staff TrainingDietary staff shall receive training on food preparation techniques that enhance flavor and presentation.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the garbage can used for food waste was covered unless in use. These failures could place residents at risk for food-borne illness and cross contamination.The findings included: During kitchen tour observations on 04/26/2026 that began at 10:39 a.m. and concluded at 11:09 a.m., revealed the following: Garbage can, next to food prepping table, was uncovered and not in use. Walk-in refrigerator revealed the following: -What resembled hamburger burns, and lettuce in different clear plastic bags, all with no use by date. Walk-in Freezer revealed the following: -What resembled chicken breast patty, mixed vegetable, and grilled chicken meat burgers in different clear plastic bags, all with no use by date. During an interview on 04/28/2026 at 10:26 a.m., [NAME] A stated, I am responsible for putting the labels and dating (use by date) on all food items, and also whoever put in the food items in there, while the DM is responsible for monitoring the labels and dating of all food items.She stated that because nobody gets written up for their mistakes, no discipline when something is wrong and the kitchen staff are not taking things serious because they think they can get away with it, and I have been trained on labelling and dating of food items. She further stated that the garbage can next to the food prepping table was supposed to be covered all times, unless in use and that could cause cross contamination, which would make the residents sick. During an interview on 04/28/2026 at 11:14 a.m., [NAME] B stated, I have worked here for 2years now and I am responsible for putting the labels and dating (use by date) on all food items, including all the kitchen staff and the DM is responsible for monitoring the labelling and dating of all the food items, and I have come across the food storage & kitchen sanitation policies. [NAME] B stated, honestly I might have been rushing, and I forgot to put up the dates and labels. She further stated that the garbage can next to the food prepping table should have a lid over it. She stated that, the food items with no use by date could have been expired, alongside the uncovered garbage container, would make the residents sick due to food contamination. During a phone interview on 04/28/2026 at 11:57 a.m., the RD stated, that will be all the kitchen staff, that were responsible for dating (use by date) and labelling the food items, and further stated garbage can, should be covered if not in use. The RD stated, the kitchen staff must have missed them due to the pressure of working in the kitchen. She further stated all the kitchen staff, and herself were responsible for monitoring the labelling and dating of all the food items in the kitchen. When asked if the staff have been trained on such tasks, the RD stated, yes I conducted an in-service on that recently either a month or 2 months ago, but not sure if they have come across the food storage and kitchen policies. She further stated that she was not sure why those food items had no use by date on them. The RD stated that food items not labeled or dated, alongside the opened garbage can, could potentially cause food borne illness to the residents. During an interview on 04/28/2026 at 12:27 p.m., the ADM stated all the kitchen staff were responsible including the DM for dating and labelling of all food items in the kitchen. Yes, the no use by date is very important and added it could cause food poisoning to the residents. She further stated that, the kitchen staff were all trained on such task, and I am thinking it is an oversight. I would say that the DM was responsible for monitoring that. When asked about the open garbage can, the ADM stated No, the garbage can, should have lid if not in use, that is unsanitary and could cause food contamination. During an interview on 04/28/2026 at 1:01 p.m., the DM stated, everyone in the kitchen is responsible for putting the date (use by date) and labelling of all food items, there is no excuse for it, all the food items should have dates. He stated, oh yes they were all trained on that and have come across food storage and kitchen policies, it would be me that is responsible for monitoring the dating and labelling of all the food items in the kitchen, it will definitely cause the residents to be sick when served undated or unlabeled food items. He further stated that the garbage can, should have lid, the can is supposed to be covered if not in use, such failure could lead to food contamination. Record review of the facility's policy and procedure titled, Food Receiving and Storage, revised November 2022, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Refrigerated/Frozen StorageAll foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Record review of the facility policy and procedure titled, Sanitation, revised November 2022, reflected the following: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 6 residents (Residents #20) reviewed for advanced directives. The facility failed to ensure Resident #20 who was listed as DNR (Do Not Resuscitate), had an Out-of-Hospital Do Not Resuscitate form that did not have missed required information. These failures could place residents at risk of not having their end of life wishes honored and incomplete records.Findings include: Resident #20 Record review of Resident #20's, undated, face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included Dementia (irreversible that causes mental deterioration), Acute Kidney Failure (rapid loss of kidney function), and Type 2 Diabetes (high blood sugar). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #20's physician order summary, dated [DATE], reflected the following order: DNR-Do Not Resuscitate dated [DATE]. Record review of Resident #20's care plan, dated [DATE], reflected care plan for DNR. Record review of Resident #20's DNR form dated [DATE] reflected the physician did not print his name following his signature, and his license number was not present. During an interview on [DATE] at 3:05pm with the BOM, she stated the DNR was not valid if it's not filled out correctly. She stated she and the ADM were responsible for ensuring DNRs were completed correctly. She verified missing information on DNR for Residents #20. She stated there was no system for monitoring DNRs for accuracy. She stated the reason the DNR's were not complete was human error. She stated she was trained on DNRs. The BOM stated the potential negative outcome for residents if a DNR was not completed correctly was the family may be upset that CPR was performed on their loved one. During an interview on [DATE] at 3:35PM with the ADM, she stated the DNR was not valid if not filled out correctly. She stated the DON was responsible for making sure the DNR was completed accurately. She stated they did not have a system to monitor DNR for accuracy. She stated the DON should be reviewing the OOH DNRs for accuracy. She verified missing information on the DNR for Resident #20. She stated she did not know why the information was missing. She stated the potential negative outcome was the Resident's end of life wishes may not be honored. She stated she was trained in how to complete DNR and her expectations were for them to be filled out completely and be correct. Record review of the Social Services Policies and Procedures Advanced Directives (Revised [DATE]) reflected the following: Policy Advance Directives will be respected with state law and facility policy. Upon admission, the resident will be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital. The DNR orders will remain in effect until the resident or legal surrogate provides the facility with a signed and dated request to end the DNR order. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the residents wish to make changes in such directives. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes to clarify and adhere to the resident's wishes. Inquiries concerning do not resuscitate orders/requests should be referred to the administrator, director of nurses, or the social services director.

Based on interview and record review, the facility failed to ensure residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days for 2 of 20 (Resident #21 and #40) residents reviewed for unnecessary medications.The facility failed to ensure Resident #21 was free from unnecessary anxiolytic medication (prescription drugs that treat anxiety disorder symptoms, such as fear, dread, and physical tension, by balancing brain chemicals or calming the nervous system ) and failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 9/19/2025 had a stop date and did not extend beyond 14 days. The facility failed to ensure Resident #40 was free from unnecessary anxiolytic medication and failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 10/01/2024 had a stop date to ensure the medication did not extend beyond 14 days. This failure placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs. Findings include:Resident #21Record review of Resident #21's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #21 had a medical history of UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (represents a stable cognitive decline where the specific type is not determined, and no significant psychiatric or behavioral issues are present), TYPE 1 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY (a chronic autoimmune condition where the immune system destroys insulin-producing beta cells, with nerve damage often caused by diabetes), and CEREBRAL INFARCTIO (tissue death caused by a severe reduction in brain blood flow due to arterial blockage). Record review of Resident #21's quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS score of 8 which indicated Resident #21 had moderate cognitive impairment. Section I- Active Diagnoses section of the MDS did not reveal Resident #21 had anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia or post-traumatic stress disorder. Section O- Special Treatment, Procedures and Programs section revealed resident had received Hospice care. Record review of Resident #21's care plan revealed a focus dated 10/09/2025 for I [Resident #21] receive anxiolytic medications for restlessness, anxiousness. I am receiving hospice care. Care plan goal revealed The resident [Resident #21] will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date, last revised 4/15/2026. Care plan interventions revealed Administer Lorazepam Intensol 0.25-0.5ml Q4hr (every four hours) prn (as needed) as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift) .Record review of Resident #21's physician orders with a start date of 9/19/2025 revealed Lorazepam Intensol Oral Concentrate 2mg/mL give .25mL by mouth every 4 hours as needed for MILD TO MODERATE ANXIETY OR AGITATION and Lorazepam Intensol Oral Concentrate 2mg/mL give .50 mL by mouth every 4 hours as needed for MILD TO MODERATE ANXIETY OR AGITATION. Record review of Resident #21's MAR for February 2026 did not reveal any administration of Lorazepam. The MAR for March 2026 revealed Resident #21 received Lorazepam 0.50mL on 3/22, 3/23, and 3/25. The MAR for April 2026 revealed Resident #21 received Lorazepam .25mL on 4/14/2026. Resident #40 Record review of Resident #40's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #40 had a medical history of shortness of breath, delirium due to known physiological conditions (fluctuating disturbance in attention, awareness, and cognition) and dementia (decline in cognitive function) .unspecified severity, with mood disturbance (a mental health condition that primarily affects your emotional state. They can cause persistent and intense sadness, elation and/or anger). Record review of Resident #40's quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS score of 6 which indicated Resident #40 had severe cognitive impairment. Section I- Active Diagnoses section of the MDS did not reveal Resident #40 had anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia or post-traumatic stress disorder. Section O- Special Treatment, Procedures and Programs section revealed resident had received Hospice care. Record review of Resident #40's care plan revealed a focus dated 08/09/2025, The resident [Resident #40] uses psychotropic medications with the potential for adverse side effects. Interventions for Resident #40 revealed Administer .Lorazepam 0.25-1ml Q2hr (every two hours) prn (as needed) as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Record review of Resident #40's physician orders with a start date of 10/01/2024 revealed the following orders; Lorazepam Conc [concentrate] 2mg/mL Give 0.25ml sublingually (medication is placed under the tongue to dissolve) every 2 hours as needed for ANXIETY AND RESTELSSNESS, Lorazepam Conc 2 MG/ML Give 0.5 ml sublingually every 2 hours as needed for ANXIETY AND RESTLESSNESS Lorazepam Conc 2 MG/ML Give 0.75 ml sublingually every 2 hours as needed for ANXIETY AND RESTLESSNESS Lorazepam Conc 2 MG/ML Give 1ml sublingually every 2 hours as needed for ANXIETY AND RESTLESSNESS. Record review of Resident #40's MAR for February, March and April of 2026 did not reveal any administered Lorazepam doses. During an interview on 4/26/2026 at 3:50pm with Resident #40's family representative, they stated they were aware of Resident #40 having an order for Lorazepam and it was used to treat her anxiety. She stated she had been educated on the side effects of the medication and had no concerns about the order. She stated she was aware the medication was as needed and she was okay with that. During attempted interviews with Resident #21 on 4/27/2026 at 1:35pm and 4/28/2026 at 12:31pm, Resident #21 was confused and unable to answer questions. During an interview on 4/27/2026 at 2:09pm with the DON, she stated the pharmacist from the hospital usually reviewed the resident's' medication regimen for unnecessary medication. She stated PRN psychotropic medication should not go past 14 days except if the resident was on hospice and she believed that was the only exception. She stated Resident #21 and Resident #40 were on hospice and hospice had originally ordered the Lorazepam for comfort. She stated there were different dosages on the Lorazepam, in order for staff to titrate up if needed but they would administer the lowest dose first and go up as needed every two to three hours depending on the order. She stated Resident #21 and Resident #40 did not have the 14 day stop date because they were on hospice, but she was aware that if any resident had a PRN psychotropic medication, it required a stop date. She stated a potential negative outcome of residents not having a 14 day stop date on PRN psychotropic medication could be residents getting medication they don't need. She stated PRN psychotropic medications are audited monthly and reviewed for stop dates. During an interview on 4/28/2026 at 10:25am with the ADM, she stated the DON is responsible for ensuring residents PRN psychotropic are reviewed for stop dates. She stated if a resident does not have a stop date after 14 days, the nurses and DON should be notifying the physician and discontinue the medication or to reassess the need for the medication. She stated a potential negative outcome of not having the 14 day stop date on PRN psychotropic medication could be the facility not being in compliance, and a danger to the residents. She stated the pharmacist from the hospital comes to the facility once a month and does medication reviews. She stated she was not aware Resident #21 and Resident #40 did not have a stop date to their Lorazepam. Record review of facility policy titled Psychotropic Medication Use last revised February 2025 revealed; PRN Medication 1. Psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 3. PRN orders for psychotropic medications are limited to 14 days.a. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order.b. For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.

Based on observation, interview, and record review, the facility failed to 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 for 2 out of 4 residents (Resident #20 and Resident #1) observed for perineal care. 1. CNA A failed to change gloves or utilize hand hygiene prior to putting a clean brief under Resident #20. 2. CNA B failed to utilize hand hygiene prior to putting on a clean pair of gloves before assisting Resident #1 to stand to pull up her brief and pants. This failure could result in residents contracting infections or spreading infections to others by direct contact with contaminated surfaces. Findings include: Resident #20: Record review of Resident #20's facesheet dated 1/19/2024 revealed resident is a [AGE] year-old female who admitted to the facility on [DATE], with a readmission on [DATE] with a primary diagnosis of Dementia (progressive decline in cognitive function). Record review of Resident #20's Quarterly MDS dated [DATE] revealed resident's BIMS score was 6/15 (severe cognitive impairment). Resident #20 was always incontinent of bladder and bowel. Observation on 4/27/26 at 9:12 AM, CNA A had turned Resident #20 to her right side and cleaned residents buttock of bowel movement. CNA A removed glove to left hand only and applied glove to the left hand only without utilizing hand hygiene. CNA A continued to clean Resident #20's buttocks. CNA A grabbed the clean brief and placed it underneath Resident #20 and assisted with fastening the brief. CNA A did not change gloves or use hand hygiene before putting the clean brief under Resident #20. During an interview on 4/27/2026 at 3:10 PM with CNA A who stated the infection preventionist was the DON or ADON. She stated she had been trained on incontinence care, and her last skills checkoff was approximately 1 month ago. She stated she was aware she had not changed her gloves after cleaning Resident #20's bottom but had gotten nervous. She stated she had changed the glove to the left hand only because there was stool on it and she did not want to get it on the resident. She stated a potential negative outcome of not changing gloves and using hand hygiene is contaminating the residents and could cause skin breakdown or infections. Resident #1: Record review of Resident #1's facesheet dated 2/5/2026 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of fracture of right femur. Record review of Resident #1's admission MDS dated [DATE] revealed resident's BIMS score was 11/15 (moderate cognitive impairment). Resident #1 was continent of bladder and bowel. Observation on 4/27/2026 at 2:00 PM CNA B voiced Resident #1 was in the bathroom on the toilet. After cleaning Resident #1's front side then back side, CNA B removed gloves and put on a new pair of gloves without using hand sanitizer or washing hands. CNA B assisted Resident #1 to stand and then pulled up brief and pants. Interview on 4/27/2026 at 3:20 PM CNA B regarding observation of peri-care on Resident #1, CNA B voiced she should have used hand sanitizer prior to putting on a new pair of gloves, saying she was nervous and just missed doing it. CNA B voiced she had been checked off on peri-care about a week ago. CNA B voiced that the ADON would demonstrate peri-care, then she will watch them repeat the demonstration, and give them feedback or suggestions. CNA B stated a potential negative outcome of not doing hand hygiene could be to spread infection to the resident. Interview on 4/27/2026 at 4:00 PM with the ADON revealed she is also the Infection Preventionist. ADON reported that she already knew there was a problem, because a couple of the CNA's had reported what they had done, and she told them that was not right. ADON voiced her expectations for peri-care is to knock on door, talk to the resident, wash hands, gather items. She also suggests having another staff help that can stay clean, so when the other staff is finishing care, the clean one can start with the brief, while the staff who was cleaning can remove gloves and utilize hand hygiene before assisting with the brief. ADON voiced she tells her staff one wipe per swipe: in front down sides, then the middle, backside one wipe per swipe. Remove gloves and utilize hand hygiene. ADON showed me the check-off sheet she uses with staff. Record Review of Observation and Documentation of Policy Demonstration: Has date and what direct care staff member was observed giving perineal care based on facility policy and procedure for perineal care. 1) The facility policy and procedure were followed: Yes or No. 2) Direct care staff member was observed demonstrating proper handwashing based on facility policy and procedure for handwashing: Yes or No. 3) Direct care staff member was observed demonstrating proper transfer technique based on facility policy and procedure for transferring: Yes or No. If any question is answered no, there is a question: If No, was proper procedure reviewed until performed properly: Yes or No. Record review of facility policy titled Standard Precautions with the last revision date of September 2022 revealed: Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Standard precautions include the following practices: Hand HygieneHand hygiene refers to handwashing with soap (anti-microbial) or the use of alcohol-based hand rub (ABHR), which does not require access to waterHand hygiene is performed with ABHR or soap and water: (5) after removing gloves. GlovesGloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material. d. Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. f. Gloves are changed as necessary, during care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).i. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.

Based on observation, interview, and record review, the facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements. in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to ensure canned foods were not expired and dented. 2. The kitchen staff member failed to use proper hand washing while preparing eating utensils. 3. The facility failed to label and properly date foods. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on [DATE] beginning at 09:07 AM during initial observation of the kitchen: Observed the following in the storage panty: 1. 1 can Sweetened Condensed milk (14 oz) with a dent. 2. 2 cans Velvet Evaporated milk; vitamin added (12 oz) dented 3. 4 boxes of Ritz crackers (3.4 oz.) with an expiration of [DATE]. 4. 3 bags (1 lbs.) of Fritos (chips) with an expiration date [DATE]. 5. 2 boxes of white chocolate pudding with an expiration date of [DATE]. 6. 1 zip top sandwich baggie with contents that looked like quarter baggie of coffee grounds, with no label with a date as ,d+[DATE] but no year. 7. 2 packages of Ranch Dressing with an expiration date of [DATE]. 8. 1 can of green chili peppers with the expiration date of [DATE]. During an observation on [DATE] at 10:15 AM, revealed the Dishwasher was observed wrapping silverware in napkins while touching the forks and spoons on the end that went in the mouth without washing her hands and they had no gloves on. During an observation on [DATE] at 9:22 AM, revealed a quarter amount of butter was left out on the counter unwrapped and unattended, for approximately thirty-minutes. During an observation on [DATE] at 10:34 AM, revealed the Dishwasher was observed again wrapping silverware in napkins while touching the forks and spoons on the end that went in the mouth without washing her hands and had no gloves on. During an interview on [DATE] at 10:41 AM, the dishwasher stated that she did not know why she was not wearing gloves or did not wash her hands to wrap the silverware and stated that she just did. The dishwasher stated that she had been trained to wash her hands and wear gloves prior to wrapping the silverware. She stated that the manager was responsible for overseeing the training. The dishwasher stated that their training consisted of in-services every couple of weeks. The dishwasher stated that by not wearing gloves or washing her hands while wrapping the utensils it could spread germs and infections. During an interview on [DATE] at 11:10 AM, the Kitchen Manager stated that he was responsible for the training of the staff and had just recently trained on washing hands, last week. The Kitchen Manager stated that he had not realized that there were expired foods in the storage room. He stated that all staff were responsible for helping to clear out the expired foods, but mainly it was his responsibility to make sure that all expired foods are cleared out of the pantry. He stated that staff were to bring the expired foods to his office so he can properly waste them. The Kitchen Manager stated that for the butter that was left out unattended it should have been put up in the refrigerator as soon as it was done being used. The Kitchen Manager stated that the Dishwasher that was observed wrapping the silverware, should have washed her hands and put on gloves. He stated that all staff had been trained through in-services and meetings. He stated that he had covered those topics with the staff several times and he would now resort to disciplinary actions. The Kitchen Manager stated that the negative potential outcome would have been the spread of germs, food poisoning, cross contamination, and foodborne illnesses. During an interview on [DATE] at 11:21 AM the he Dietary Manager stated that she would expect food to be properly disposed if they were outside of the expirations date because it could cause illnesses. The Dietary Manager stated that anyone handling silverware or utensils should properly wash their hands and use gloves because it could cause germs to spread to residents and cause a decline in their health. The Dietician Manager stated that she could be in-serviced on these particular topics. During an interview on [DATE] at 11:43 AM the Administrator stated that she expected staff to follow the policy for all situations especially handling foods and utensils. The Administrator stated that the dietary manager was responsible for training. The Administrator stated that the negative outcome was that it could have affected residents' health. During an interview on [DATE] at 11:50 AM the Administrator stated that she could not find a policy related to expired canned goods. Record review of the FDA Food Code 2022, revised [DATE] reflected the following: Food Codes: ,d+[DATE].11-Personal Cleanliness: FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean. ,d+[DATE].12 (A) Cleaning Procedure: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S ,d+[DATE].12 and Subpart ,d+[DATE]. ,d+[DATE].14 When to wash: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms. (D) After coughing, sneezing, using a handkerchief or disposable tissue, using Tobacco Products, eating, or drinking. (E) After handling soiled Equipment or Utensils. (H) Before donning gloves to initiate a task that involves working with Food. ,d+[DATE] Food Labeling: (A) Food Packaged in a Food Establishment, shall be labeled as specified in Law, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) The common name of the Food, or absent a common name, an adequately descriptive identity statement. Record review of the facility policy, titled Food Receiving and Food Storage, revised [DATE] reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date) such foods are rotated using a first in-first out system. Record review of the facility policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised [DATE] reflected the following: Policy Statement: Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illnesses. Policy Interpretation: All employees who handle, prepares, or serves food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food to residents. Hand Washing/ Hand Hygiene: a. after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.). c. whenever entering or re-entering the kitchen. d. before coming in contact with any food surfaces. f. after handling soiled equipment or utensils. Gloves and Direct Food Contact: 9. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed, and gloves are replaced. a. after direct contact with resident. d. between handling soiled and clean dishes. 10. The use of disposable gloves does not substitute for proper handwashing. 12. Gloves are used when serving residents who are on transmission-based precautions. 14. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.

Based on interviews and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 4 days out of 33 days (1/25/25, 1/26/25, 2/8/25 and 2/9/25) reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 1/25/25, 1/26/25, 2/8/25 and 2/9/25. This deficient practice could place residents at risk of not receiving adequate care. Findings included: During an interview on 02/19/25 at 9:48 AM, RN B stated she was an RN. She said she worked every other weekend. As an RN, she had the ability to pronounce death. She stated they were also in the facility if the LVN needs guidance. She said there were times when an LVN may not be able to get a catheter in but will ask for assistance. During an interview on 02/19/25 at 10:27 AM, RN C stated occasionally, she worked the weekends. She stated she had not in a while, but if she did, she clocked in. She stated as an RN, she could pronounce death. She stated if there was an IV, the RN would start them. She stated she does not believe that they did IVs in their facility. She stated the RN assists the LVN with decision-making in critical situations. She stated LVNs could not complete or create a care plan for the residents. She stated if the resident did not feel comfortable the RN could help comfort and be available to the residents. During an interview on 02/19/25 at 3:22 PM, the DON stated she had been trained on the RN coverage policy. The DON stated the purpose of having an RN in the facility was to provide continuous daily care. She stated the RN was there so that they could oversee the shift. She stated the RN could pronounce death if someone passed away. She stated the RN can oversee the care the LVN and CNAs provide. She said the PNO of not having an RN in the facility, according to the policy, was that if something went wrong, they would not be present to give professional oversight. She stated she was unaware of any uncovered days. She stated the system to monitor RN coverage was the ADON ensured it was covered. If there is no coverage, the ADON needed to get an agency and find someone to cover. The DON stated if the ADON could not find coverage and she (the DON) was available, she would come in. She stated she was not available to come in on the days identified. During an interview on 02/19/25 at 3:55 PM, the ADM stated she was familiar with the facility policy regarding RN coverage. She stated the purpose was that it was a state requirement. She stated the PNO of not following the state requirement regarding RN coverage was they would be out of compliance. She stated the LVN can do only so much. She stated the RN could pronounce death. She stated the RN can guide LVNs in the decision-making process. She stated she was unaware of any uncovered days until 02/19/25 when she looked at the time sheets. She stated her system to monitor RN coverage relied on the DON. She stated she had not been trained on the expectations but had read the policy. She stated she expected the policy to be followed. She stated the DON was responsible for ensuring that the facility had the appropriate RN coverage. She stated there was no RN coverage because an RN volunteered to help but then called in. She did not specify the date. She stated if they did not have coverage, they could call agency help. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the RN coverage policy. She stated she was unsure of the purpose of having an RN every day for 8 consecutive hours. She stated she was unsure what additional duties or assessments an RN can do vs what an LVN can do outside of pronouncing death. She stated she was unaware of multiple days that were uncovered. She stated she was aware of just one day. She stated she had a volunteer, but the volunteer called in. She stated as a result of the call in, she did not think she made any additional effort to cover the shift. She said they needed to call the agency nurses if they could not find RN coverage. She stated this had been mentioned before but when the volunteer did not come in, she did not think of calling agency. She stated it is typically unsuccessful when they attempt to get an RN at the last minute. She stated the system she used to monitor RN coverage was that every other weekend was always covered, and she typically had no issues covering the alternate weekend. She stated if it is not covered then they attempt to find coverage. She stated she had been trained that the facility had to have RN coverage 7 days a week for 8 consecutive hours. She stated she expected the facility to have RN coverage 7 days a week for 8 consecutive hours. She sated she was responsible for making the schedule. She stated she did not have a reason the four days did not have RN coverage for 8 consecutive hours. Record review of RNB, C, P and Q time sheets for the time period of 1/17/25-02/18/25 revealed there was no RN coverage for 1/25/25, 1/26/25, 2/8/25 and 2/9/25. Record review of facility policy, Director of Nursing Services, dated August 2022, revealed: Policy Statement The nursing services department is under the direct supervision of a registered nurse. Policy Interpretation and Implementation The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: overseeing standards of nursing practice; coordinating nursing services with other resident services; recruiting and retaining the number and skill levels of nursing personnel necessary to meet the nursing care needs of each resident; Record review of facility policy, Departmental Supervision, dated August 2022, revealed: Policy Statement The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation A licensed nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven (7) days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse is designated as a charge nurse on each shift. A licensed nurse may be a licensed practical nurse (LPN), licensed vocational nurse (LVN), or registered nurse (RN). A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A registered nurse (RN) is employed as the director of nursing services (DNS). The DNS is on duty a minimum of 40 hours per week. Record review of facility policy, Staffing, Sufficient and Competent Nursing, dated August 2022, revealed: Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

43344 Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 14 residents (Resident #10, #24, #27, #34, #36 and #39) reviewed for care plans in that: The facility failed to ensure that Resident #10's care plan was revised, updated and individualized with interventions and goals to address Resident #10's vison and communication. The facility failed to ensure that Resident #24's care plan was revised, updated and individualized with interventions and goals to address Resident #24's vision and communication. The facility failed to ensure that Resident #27's care plan was revised, updated and individualized with interventions and goals to address Resident #27's vision and urinary incontinence. The facility failed to ensure that Resident #34's care plan was revised, updated and individualized with interventions and goals to address Resident #34's vision. The facility failed to ensure that Resident #36's care plan was revised, updated and individualized with interventions and goals to address Resident #36's vision. The facility failed to ensure that Resident #39's care plan was revised, updated and individualized with interventions and goals to address Resident #39's vison, communication, urinary incontinence and psychosocial wellbeing. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns. Findings included: Resident #10 Record review of Resident #10's face sheet, dated 02/19/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), . Record review of Resident #10's Comprehensive MDS, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 4, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 03. Visual Function 04. Communication Section B0200. Hearing Coded 1= Minimal difficulty= difficulty in some environments. B0800 Ability to understand others- Coded 1= Usually understands= misses some part/intent of message but comprehends most conversation. B1000. Vision - coded 1 =impaired - sees large print, but not regular print in newspapers/books. B1200 Corrective Lenses: Yes. Record review of Resident #10's care plan, dated 07/15/24, revealed no care plan for visual function or communication. Record review of Resident #10's Physician Order's, dates 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 07/02/24 Start Date 10/01/24) During an interview on 02/20/25 at 9:17 AM, LVN A stated when talking to Resident #10, staff must speak to her in her right ear and speak loudly. She said she learned this through trial and error. She also stated that Resident #10 wears glasses. During an interview on 02/20/25 at 9:18 AM, RN C stated staff must speak in Resident #10's right ear. She said she learned this through trial and error. She noticed Resident #10 would answer more questions on her right side. During an interview on 02/20/25 at 9:19 AM, Resident #10 could not provide any information regarding her vision and communication ability. Observed on 02/20/25 at 9:19 AM, Resident #10 had her glasses on and had a puzzle book in her lap. Resident #24 Record review of Resident #24's face sheet, dated 02/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer (memory loss) and schizophrenia (chronic mental illness). Record review of Resident #24's Comprehensive MDS, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 5, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication Section B0200. Hearing Coded 1= Minimal difficulty= difficulty in some environments. B0700. Ability to understands others. Coded 1= Usually understands- misses some part. intent of message but comprehends most conversation. B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1000. Corrective Lenses: No Record review of Resident #24's care plan, dated 07/19/24, revealed no care plan for visual function and communication. During an interview on 02/20/25 at 10:34 AM, Resident #24 did not provide any additional information regarding his ability to communicate and vision. He stated he could communicate and see. During an interview on 02/20/25 at 10:35 AM, CNA L stated Resident #24 can be demanding and usually communicates in a demanding manner. She also stated Resident #24 can be hostile. She said she practices asking him politely, which usually works even if he was communicating in a demanding manner. She stated that she knew this by working with him but did not know what a care plan was. She said that she believes Resident #24 can see well. Resident #27 Record review of Resident #27's face sheet, dated 02/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Parkinson's (brain disorder that worsens), constipation (infrequent or uncomfortable bowel movements) and lack of coordination. Resident #27's face sheet revealed that his code status was full code. Record review of Resident #27's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 06. Urinary Incontinence Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1000. Corrective Lenses: Yes. Section H-Bowel and Bladder. H0300. Urinary Continence Coded 3=Always incontinent (no episodes of continent voiding). H0400. Bowel Continence Coded 3=Always incontinent (no episodes of continent Bowel Movement) Record review of Resident #27's care plan, dated 01/06/25, revealed no care plan for visual function or urinary incontinence. During an interview on 02/20/25 at 10:30 AM, Resident #27 stated he wore glasses and needed them. He stated he could clean them, but preferred staff do so because they do a better job than he does. He stated that he had three pairs of glasses. He stated he can go to the restroom by himself and does not need any help but likes to have help sometimes when he goes to the restroom. During an interview on 02/20/25 at 11:10 AM, CNA K stated regarding Resident #27, they must assist him in the restroom all the time. She said he used his briefs most of the time but can assist when standing. She stated Resident #27 had dementia, but she typically goes by what the resident says if they tell her any information about themselves. She stated Resident #27 wears glasses, and he cleans his glasses. Resident #34 Record review of Resident #34's face sheet, dated 02/20/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include anxiety, dementia, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), depression, muscle weakness, pain, heart disease, and hypertension (high blood pressure). Record review of Resident #34's Admission's Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 7, which indicated the resident's cognition was impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. Record review of Resident #5's care plan, dated 11/24/24, revealed no care plan for visual function. Record review of Resident #34's Care Plan on 02/19/2025 at 9:50 AM, revealed: Resident #34 was at risk for injuries due to falls due to confusion and weakness. I have impaired vision and wear glasses. I require moderate assist for transfers. I use a walker when ambulating. The goals indicated that Resident #34 would not have injuries due to falls in the next 90 days. The interventions stated: ensure that Resident #34 is wearing glasses, and they are clean, provide a well-lit room to enhance vision. During an interview with Resident #34 on 2/20/2025 at 11:32 AM. Resident #34 stated that she had not been to the eye doctor in a while but does not remember how long it had been. Resident #34 stated that she can see out of her glasses. Resident #34 stated that she can clean her own glasses. Resident #34 stated that she had brought her glasses from home. Resident #34 stated Resident #36 Record review of Resident #36's face sheet, dated 02/19/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, headache, and dizziness. Record review of Resident #36's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C score revealed a score of 14, which indicated the resident's cognition was not impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 03. Visual Function Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1200. Corrective Lenses: Yes Record review of Resident #36's care plan, dated 05/27/24, revealed no care plan for visual function. During an interview on 02/20/25 at 9:13 AM, Resident #36 stated she wore glasses only when she completed her puzzles. She said that she was independent and can clean her glasses. She stated she had multiple pairs and liked to have them match her clothing. Resident #36 stated that when she does not wear her glasses and attempts to do puzzles or read, she gets a headache. Resident #39 Record review of Resident #39's face sheet, dated 02/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include depressive episodes, dysphasia (swallowing difficulties), cognitive communication deficit (a difficulty in communication that arises from an impairment in cognitive functions), reduced mobility, and aphasia difficulty in communicating). Record review of Resident #39's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C BIMS revealed a score of 06, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 06. Urinary Incontinence 07. Psychosocial Well-Being Section B0600. Speech Clarity Coded 1 Unclear Speech- slurred or mumbled words. B0700 Makes self understood Coded 3= Rarely/never understood. B0800 Ability to Understand Others Coded 1 Usually understands= misses some part/intent of message but comprehends most conversation. B1000. Vision - coded 2 = Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. B1200 Corrective lenses: No. Section H-Bowel and Bladder. H0300. Urinary Continence Coded 3=Always incontinent (no episodes of continent voiding). H0400. Bowel Continence Coded 3=Always incontinent (no episodes of continent Bowel Movement) Record review of Resident #39's care plan, dated 09/12/24, revealed no care plan for visual function, communication, urinary incontinence, and psychosocial wellbeing. Record review of Resident #39's Physician Order's, dates 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 08/25/23 Start Date 10/01/24). During an interview on 02/20/25 at 9:08 AM, CNA K stated regarding Resident #39, they figured it out regarding communicating with him. She stated when he gets mad because they do not understand him, she returns and tries again later. She stated she knows to do this because of her certified nurse aide experience. She stated not many staff can communicate with him. She stated Resident #39 used briefs and required total assistance from the staff. She stated Resident #39 does not get sad but gets angry often and does not want to do activities. She stated the staff had to tread lightly with Resident #39. During an interview on 02/20/25 at 9:10 AM, Resident #39 could not speak. He pointed at his TV and his nightstand. During an interview on 02/18/25 at 11:42 AM, Resident #39 could not answer any questions. He had a tough time communicating. After a few attempts to communicate with Resident #39, he became frustrated and waved the investigator out of his room. Resident #39 could not answer questions about his communication preference, vision, psychosocial well-being, and urinary. During an interview on 02/19/25 at 3:00 PM, the MDS Coordinator, stated she was familiar with the care plan policy regarding missing care plans. She stated that a care plan was when there was an identified problem or things that the resident needed to work on. The MDS Coordinator stated there was a goal set and then they (staff and resident) would see if the resident could meet the goal. She stated the PNO of the care plan was not accurate or up to date because the resident could not get proper care. She stated the PNO for a resident who required a vision care plan, and they did not have it, was that the resident could lose their vision if they were not receiving the proper treatment. She stated the PNO for a resident who required a urinary care plan and did not have it was that they could have issues with skin integrity. She stated the PNO for a resident that required a communication care plan, and they did not have it, the resident may be overlooked. Staff would not know to take their time and wait for the resident to communicate if that was the case. She stated the resident's communication could get worse, and the resident could become depressed. She stated the PNO for a resident that required a psychosocial well-being care plan, and they did not have it, so there may not be adequate monitoring for the resident. The MDS Coordinator stated she was unaware of any missing care plans. She stated that the system to monitor care plans was she would put the assessment date on the calendar as the MDS Coordinator. She stated after she completed the MDS assessment she is unsure what happened with the resident care plans. She stated she did not collaborate with the DON regarding the creation/revision and did not know how the care plan connected to the MDS assessment. She stated she had been trained on how to do the MDS assessment but had no training regarding care plans. She said she expected all resident care plans to be updated and accurate. She stated the DON was responsible for the care plans. She stated she was responsible for the MDS assessment, and if there were missing care plans, she did not have a reason. She stated she believed the MDS assessment pulled information from the care plan. She stated the DON creates the CAAs, and she does not deal with section V (CAAs) of the MDS assessment. During an interview on 02/19/25 at 3:22 PM, the DON stated she had been trained on the care plan policy. She stated that the resident plan's purpose was to provide continuous care, so all staff knew what was happening with the resident. She stated if there were any missing care plans, then the PNO, which is the resident, may not get the care they need. She stated the care plan is created based on what was triggered on the MDS assessment (section V). She stated the PNO for a resident who required a vision care plan, and if they did not have it, it could impact their falls. She stated the PNO for a resident who required a urinary care plan, and they did not have it, was that the resident could have skin breakdown. She stated the PNO for a resident that required a communication care plan, and they did not have it, the resident will not be able to be understood and may not understand who is speaking with them. She stated the PNO for a resident that required a psychosocial well-being care plan, and they did not have it, the resident may feel down and may not get out of their room, and it could lead to depression. She stated she was unaware of any missing resident care plans. She stated her system to monitor care plans was that she sometimes would combine triggered care areas to ensure that she had them all care planned. She stated she had been trained on how to complete care plans. She stated that she expected all care plans to be updated and accurate. She stated that as the DON, she was responsible for resident care plans. She stated she did not have a reason for missing care plans as she believed all care plans had been created according to Section V of the MDS assessment. During an interview on 02/19/25 at 3:55 PM, the ADM stated regarding the accuracy and creation of resident care plans, she was familiar with the facility policy. She stated the resident care was to inform staff about the resident care and family information. She said the PNO of not having accurate and triggered care plans was the resident may not receive the care they should be receiving. She stated the PNO for a resident who required a urinary care plan, and they did not have the staff would not know if the resident was incontinent. She stated the PNO for a resident that required a communication care plan, and they did not have it was the staff may not know if they had any assistive devices to help them communicate. She stated the PNO for a resident who required a psychosocial well-being care plan and did not have it, the staff may not know if there were any services the resident will need to attend or if there were medications they were required to have. The staff may not know if the resident is acting out of character. She stated she was unaware of any residents missing care plan. She stated the system to monitor resident care plans was they were discussed in morning meetings and that it may be on the dashboard in the EMR (PCC). She stated since she is not a nurse, she may not have access to this information. She stated she had not had specific training on resident care plans but had always consulted with the DON. She stated she expected all care plans to be updated and accurate. She stated the DON was responsible, and the only reason she could think of why there were missing care plans was that they were transitioning from one EMR to another. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the facility policy regarding resident care plans. She stated that the purpose of resident care plans was that they were detailed plans of care. Ashe stated that the resident's care plan was tailored to each resident. She stated that everyone used the care plan to provide care. She stated that the PNO was if the care plan was not updated and accurate, the resident may not receive the care they need. She stated the PNO for a resident that required a vision care plan, and they did not have it the resident would not get the care that they needed. She stated the PNO for a resident who required a communication care plan and did not have it, staff would be unable to communicate with the resident or provide the communication devices they may need. She stated the PNO for a resident who required a urinary care plan and did not have it then placed the resident at risk for skin breakdown. She stated the PNO for a resident that needed a psychosocial well-being care plan, and they did not have it she was unsure what the negative outcome would be for the resident. She stated she was unaware of any residents missing any triggered care plans. She stated she did not know the system they used to monitor the care plans. She stated she had not been trained on how to create care plans. She stated the DON was responsible for care plans and was unsure why there would be any missing ones. Record review of facility policy, Care Area Assessments, dated November 2019, revealed: Policy Statement Care area assessments (CAAs) are used to help analyze data obtained from the MDS and to develop individualized care plans. Triggered care areas are evaluated by the interdisciplinary team to determine the underlying causes, potential consequences and relationships to other triggered care areas. Document interventions on the care plan: Include specific interventions, including those that address common causes of multiple issues; and Include recommendations for monitoring and follow-up timeframes CAA documentation explains the basis for the care plan. This documentation should include: causes and contributing factors for the triggered care areas; the nature of the condition or issue (i.e., What exactly is the problem and why is it a problem?); complications contributing to (or caused by) the care area; risk factors related to the condition; Record review of facility policy, Care Planning, dated March 2022, revealed: Policy Statement The interdisciplinary team is responsible for the development of resident care plans. Resident care plans are developed according to the timeframes and criteria established by S483.21. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Record review of facility policy, Comprehensive Assessments, dated March 2022, revealed: Policy Statement Comprehensive assessments are conducted to assist in developing person-centered care plans. Annual Assessment: Its completion dates (MDS/CAA(s)/ care plan) depend on the most recent comprehensive and past assessments ' ARDs and completion dates. Completed assessments are maintained in the residents active record for a minimum of 15 months. These assessments are used to develop, review and revise the residents comprehensive care plan. Record review of facility policy, Goals and Objectives, Care Plans, dated April 2009, revealed: Record review of facility policy, , date/revised, revealed: Policy Statement Care plans shall incorporate goals and objectives that lead to the residents highest obtainable level of independence. Policy Interpretation and Implementation Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Care plan goals and objectives are derived from information contained in the residents comprehensive assessment and: are resident oriented; are behaviorally stated; are measurable; and contain timetables to meet the residents needs in accordance with the comprehensive assessment. Goals and objectives are entered on the residents care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.

Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 14 residents (Resident #35 and Resident #41) reviewed for resident rights. The facility failed to ensure RN C provided privacy during wound care for Resident #35 and Resident #41. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Resident #35 Record review of Resident 35's face sheet, dated 02/18/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (a syndrome of weight loss, poor nutrition, and inactivity that affects older adults), anxiety, dementia (memory loss that interferes with daily life), stage 2 pressure ulcer to left buttock, and hypertension (high blood pressure). Record review of Resident #35's current physician's orders, with a start date of 01/21/25, revealed an order to cleanse stage II pressure ulcer to left buttock with wound cleanser and apply zinc daily. Record review of Resident #35's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident's cognition was mildly impaired. Section M-Skin Conditions revealed a stage 2 pressure ulcer that was present upon admission. Record review of Resident #35's comprehensive care plan dated 02/10/25 revealed the resident was admitted to the facility with a Stage II pressure injury to the left buttock. Interventions included: Administer treatments as ordered and monitor for effectiveness. During a wound care observation on 02/18/25 at 12:33 PM for Resident #35, RN C failed to fully pull the privacy curtain and close the window blind before performing wound care to the resident's left buttock, which placed the resident at risk of bodily exposure to the hallway and facility exterior. Resident #35's bed position was nearest the window and there was a roommate occupying the other bed in the room. During an interview on 02/20/25 at 11:33 AM, RN C stated she did not completely pull the curtain or close the window blind prior to performing wound care for Resident #35. She stated blinds and curtains should always be closed during personal care to provide privacy to the resident. RN C stated she just didn't see that the blind was open and stated staff attempt to work in a timely manner when providing personal care to Resident #35 because he gets agitated if we take too long. She stated she had been trained by nursing administration to provide privacy during personal care. RN C stated a potential negative outcome for failure to provide privacy during personal care would be that the resident's mental health could be negatively affected, the resident could suffer shame or lose trust in staff. Resident #41 Record review of Resident 41's face sheet, dated 02/18/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include age-related cognitive decline, chronic kidney disease, weakness, macular degeneration (an eye disease that causes vision loss), and hypertension (high blood pressure). Record review of Resident #41's significant change MDS, dated [DATE], revealed a BIMS score of 06, which indicated the resident's cognition was moderately impaired. Section M-Skin Conditions revealed a stage 2 pressure ulcer that was present upon admission. Record review of Resident #41's current physician's orders, with a start date of 12/14/24, revealed an order to cleanse stage II wound to the sacrum (area above the tailbone) with wound cleanser and apply ordered treatment and dressing daily. During a wound care observation on 02/18/25 at 12:56 PM for Resident #41, RN C failed to fully pull the privacy curtain and close the window blind before performing wound care to the resident's sacrum, which placed the resident at risk of bodily exposure to the hallway and facility exterior. Resident #41's bed position was nearest the window and there was a roommate occupying the other bed in the room. During an interview on 02/20/25 at 11:35 AM, RN C stated she did not completely pull the curtain or close the window blind prior to performing wound care for Resident #41. She stated she should have closed the curtain and window blind before she began wound care for Resident #41, but she was concentrating on the steps of proper wound care and forgot. She stated she had been trained by nursing administration to provide privacy during personal care. RN C stated a potential negative outcome for failure to provide privacy during personal care would be that the resident's mental health could be negatively affected, the resident could suffer shame or lose trust in staff. During an interview on 02/25/25 at 11:38 AM with the ADM, she stated she was not aware that staff were not providing privacy to residents during personal care. She stated the door, privacy curtain and window blinds should be closed during personal care to provide as much privacy as possible to the resident. She stated her expectation of staff was that they always provide privacy to residents during personal care by following the facility policies for dignity and privacy and closing doors, curtains, and blinds. The ADM stated a potential negative outcome for failure to provide privacy during care was that the resident would not have the privacy they desire. Record review of the facility's policy titled; Dignity, date revised February 2021 revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are always treated with dignity and respect. . 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interviews, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 14 residents (Resident #39) reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication, Trazadone, administered to Resident #39 for depressive episodes. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Finding included: Record review of Resident #39's face sheet, dated 02/19/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include depressive episodes, dysphasia (swallowing difficulties), cognitive communication deficit (a difficulty in communication that arises from an impairment in cognitive functions), reduced mobility, and aphasia difficulty in communicating). Record review of Resident #39's Comprehensive MDS, dated [DATE], revealed: Section C BIMS score revealed a score of 06, which indicated the resident's cognition was severely impaired. Section N-Medications [N0415] High Risk Drug Classes: Use and Indication revealed Resident #39 was taking an antidepressant. Record review of Resident #39's care plan, dated 09/12/24, revealed Resident #39 received antidepressant medications with the potential for drug-related adverse side effects like nausea, dizziness, drowsiness, dizziness, dry mouth, diarrhea, upset stomach, or trouble sleeping. Record review of Resident #39's Physician Order's, dates 02/18/25, revealed: Trazadone 100 MG; give 1 tablet by mouth one time a day for depressive episodes (Order date 08/25/23; Start date 10/01/24) Record review of Resident #39's Medication administration Record, February 2025, revealed: Resident #39 received Trazadone 100 MG; give 1 tablet by mouth one time a day for depressive episodes from 02/01/25-02/17/25. During an interview on 02/19/25 at 3:00 PM, the MDS Coordinator, stated she was familiar with the facility policy regarding medication consent. She stated the PNO was the facility could get sued. She stated the residents or family could allege that a medication was given that was not effective. She stated the purpose was to receive consent to administer the medication. She stated that consent should be obtained before then. The MDS Coordinator stated she was unaware of any residents missing medication consents. She stated the system to monitor medication consents was as soon as a doctor gave an order, the nurse should do the paperwork immediately. She stated there were instances where they will get verbal consent from the resident or the family, but they get all consents in writing as soon as possible. She stated if verbal consent had been obtained, it would be documented in the resident's EMR. The MDS Coordinator stated she expected all consents (written/verbal) should be obtained as soon as the doctor order was given. She stated all the nurses who receive orders were responsible. She stated if there were any missed medication consents, she did not have a reason it was not obtained. During an interview on 02/19/25 at 3:22 PM, the DON stated regarding medication consents, she was familiar with the facility policy and the purpose of medication consents was to make sure that everyone (resident and their family) was aware of the medication and that they were permitted to receive it. She said the PNO of not obtaining medication consent was that staff could end up giving the resident a medication that they do not want or may even receive medication to which they were allergic. The DON stated she was unaware of any residents who did not have medication consent for psychotropic medications. She stated the system to monitor medication consents was that the ADON or the MDS Coordinator will go through and ensure everything is up to date for all residents. She stated she, as the DON, would follow up. She stated she would also go through the resident medication consents when she is thinning their physical charts. She stated that she had been trained that all psychotropic medications required a consent before administering the medication. She stated she expected all appropriate medications to have the required consents. She stated she did not have a reason for the missing medication consents. She stated the nurse present when the medication is ordered was responsible for ensuring that the consents were obtained. During an interview on 02/19/25 at 3:55 PM, the ADM stated she was familiar with the facility's policy regarding medication consents. She stated the purpose of medication consent was if staff were going to administer psychotropic medications, they would have permission/consent from the resident and family. She said the PNO of not obtaining medication consent before administration was the facility would be liable if the resident could not make decisions. She stated it could be detrimental if the resident does not get the correct medication. She stated she was unaware of any residents who did not have the appropriate medication consent. She stated her system to monitor medication consent for psychotropic medications was that she relied on the DON. She stated she had not had specific training on obtaining medication consent because she is the administrator. She stated the nursing staff was responsible and did not have a reason it was not done if it was not done. She stated that she expected all appropriate psychotropic medications to have consents before administration. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the facility's policy on medication consents for psychotropic medications. She stated the purpose of obtaining consent was to ensure families and the residents knew what they were getting and the potential side effects. She stated the PNO was something bad could happen to the resident, or they could have a decline in health. She stated she was unaware of any residents not having medication consent until it was brought to her attention by the investigator. She stated the system to monitor consent for psychotropic medications was the nurse that receives the order would get the consent. She stated if the resident came into the facility with the medication, the admission nurse would obtain the consent. She stated she had been trained to obtain written consent before the administration of psychotropic medications. She stated she expected all appropriate medications to have an appropriate consent if applicable. She stated the nurses were responsible for getting consent and that she did not have a reason any resident consent was not obtained. During an interview on 02/20/25 at 9:10 AM, Resident #39 could not speak. He could not provide any information regarding administration of psychotropic medications. Record review of facility policy, Psychotropic Medication Use, dated July 2022, revealed: Policy Statement Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation A Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: Anti psychotics Anti-anxiety medications Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: Indications for use Dose Duration Adequate monitoring for efficacy and adverse consequences Preventing, identifying and responding to adverse consequences Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. Record review of facility policy, Resident Rights, revised February 2021, revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Be informed of, and participate in, his or her care planning and treatment

Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 14 residents (Resident #27) whose records were reviewed for code status. The facility failed to obtain a DNR order and update the EMR for Resident #27 based on his completed DNR, dated [DATE]. This failure could place residents at risk for having their end of life wishes dishonored, and of having CPR performed against their wishes. Findings included: Record review of Resident #27's face sheet, dated [DATE], revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Parkinson's (brain disorder that worsens), constipation (infrequent or uncomfortable bowel movements) and lack of coordination. Resident #27's face sheet revealed that his code status was full code. Record review of Resident #27's Comprehensive MDS, dated [DATE], revealed: Section C BIMS score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 06. Urinary Incontinence Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1000. Corrective Lenses: Yes. Section H-Bowel and Bladder. H0300. Urinary Continence Coded 3=Always incontinent (no episodes of continent voiding). H0400. Bowel Continence Coded 3=Always incontinent (no episodes of continent Bowel Movement) Record review of Resident #27's care plan, dated [DATE], revealed no care plan for visual function or urinary incontinence. Resident #27 had a care plan stating he did not want CPR and a goal of having an order for no CPR accepted/followed daily for the next 90 days. The intervention included to ensure all of Resident #27's needs are being met, ensure that all staff understand his no CPR status and having a OOH-DNR on file. Record review of Resident #27's OOH-DNR, dated [DATE], revealed that Family Member D declared as an agent in a Medical Power of Attorney on [DATE] that on the behalf of Resident #27 that she did not want any resuscitation measures to be initiated or continued. The OOH-DNR was valid with the medical power of attorney, notary and doctor's signature. During an interview on [DATE] at 9:23 AM, Resident #27 stated he knew what a DNR was. He said it was tough to answer the question about his preference. He was unable to report if he had a DNR in place. During an interview on [DATE] at 9:34 AM, LVN A stated regarding if a resident code (the resident was experiencing a cardiac arrest, where their heart had stopped beating, requiring immediate life-saving measures like CPR from a medical team) they would call for assistance from other staff. She stated that they had not had anyone code in a while. She stated whether a resident wanted CPR or was a DNR status, they, as the nurses, should know. She stated the first place that she would look was the computer. She stated there was a list of residents who wished to receive CPR at the nurse's station, but it had been moved. She stated Resident #27 was a full code and would require CPR. Observed LVN A on [DATE] at 9:35 AM, looked in Resident #27 EMR and reported he was a resident listed as full code status. No observation of a list of residents who wished to be a DNR was observed at the nurses' station on [DATE]. During an interview on [DATE] at 9:48 AM, RN B stated if someone coded, it is their duty to determine their code status. She said there was a list of residents wishing to receive CPR at the nurses' station. She stated that she had been a nurse at the facility since [DATE], and no one had coded. She said staff could find residents' code status on the computer and the list at the nurses' station. She stated Resident #27's code status was full, which meant they would perform CPR. Observed RN B on [DATE] at 9:49 AM, look in Resident #27's EMR and report that his code status was full code. During an interview on [DATE] at 9:56 AM, the MDS Coordinator stated if a resident codes, they will immediately check to see their code status. She stated the first place would be the computer. She stated if they did not have the information on the computer, she was unsure where the second place would be. She said the PNO for the resident, if the correct code status were not administered, was they, as the staff, may give the resident CPR, and this could make the family mad. She stated there could be many issues. She stated they could bring the resident back, which may not be what they wanted. She stated it was a violation of the resident's rights. During an interview on [DATE] at 10:27 AM, RN C stated if a resident coded, they immediately check to see if they were full code (Required CPR). She stated they would check the computer first and then the grey physical charts. She stated if those two do not coincide or the information was inconsistent, trying to find the correct answer could delay treatment. She stated the staff would have to have the correct information to start the correct code. She stated the PNO was the facility could receive a lawsuit. She stated the resident and or the family would not be happy. She stated if it were her, she would not be happy if the incorrect treatment was performed. She stated the computer was the first place to look, and the charge nurse was responsible for relaying the information on the code status. During an interview on [DATE] at 10:27 AM, Family Member D stated she still wanted the DNR in place. She stated she could not remember who helped her complete the paperwork, but that is a wish and desire of hers and her family. She said she had medical power of attorney, and it states no matter the capacity of his mental status, she could make medical decisions for Resident #27. She stated Resident #27 thinks he can walk and cannot, and his mental status fluctuates. During an interview on [DATE] at 3:22 PM, the DON stated she if a resident codes, and they have DNR code status, she does not expect CPR to be administered. She stated if the resident is a full code, she expected CPR to be administered. She stated the code status in the physical chart and the computer (EMR). She stated that the charge nurse would typically go to the physical chart, but all information should be consistent. Regarding DNR documentation, she was familiar with the facility policy. She stated not having consistent information in the EMR, physical charts, and care plan could affect all involved. She said the PNO of not having the correct code status was if it is not consistent or accurate, a resident could receive the wrong treatment. She said she was unaware of any residents who did not have the correct code status. She stated the system to monitor consistency in code status information was to check all residents' information every quarter. She stated by doing this, they had not identified any inconsistencies. She stated that she expected all information regarding code status to be consistent and accurate. She stated she did not have a reason Resident #27 EMR reflected he was a full code, and the remainder of his information reflected that he was a DNR. She said she was responsible for ensuring that this information was correct. During an interview on [DATE] at 3:55 PM, the ADM stated if a resident codes, she expected her staff to know the resident's code status. She stated each resident's code status was in the EMR. She stated after the staff checks the EMR, they should be able to provide appropriate care. She stated the code status should also be kept in the hard chart. She stated the information should be consistent and accurate. The ADM stated she was familiar with the policy regarding DNR and the accuracy of information regarding code status. She stated the PNO of if code status was inaccurate or inconsistent across platforms, the resident's health and life could be affected. She stated the purpose of having consistent information across facility platforms was that, potentially, the resident's wishes may not be met. She stated she was unaware of residents whose code status was inconsistent across all facility platforms, such as the EMR, care plan, and physical charts. She stated she had been trained that code status should be updated and accurate. She stated the ADON was responsible for updating the resident's EMR and maintaining DNR accuracy. During an interview on [DATE] at 4:48 PM, the ADON stated that the nurse should get a crash cart if a resident coded. She stated the nurse could look in the computer in the resident's EMR to determine their code status. She stated that if there is an advance directive, the attached DNR should be there for staff viewing. She stated she expected all code status information to be consistent across facility platforms, such as the EMR, care plan, and physical chart. She stated the DON was responsible for ensuring that all information across the facility platforms was consistent regarding resident code status. She stated she did not have a reason the information was not consistent for Resident #27. Record review of facility policy, Advance Directives, dated [DATE], revealed: Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Definitions Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Determining Existence of Advance Directive If the Resident Has an Advance Directive If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care. The attending physician is not required to write orders for which he or she has an ethical or conscientious objection. The residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Facility staff are not required to provide care that conflicts with an advance directive. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised (as necessary) by his/her legal counsel in this state before the facility may honor such directives. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on 1 of 1 medication cart (cart for hall 100) reviewed for pharmaceutical services. The facility failed to ensure the medication cart for hall 100 did not contain expired medication. This failure could place residents at risk of not receiving prescribed medications as ordered and receiving medications that are less effective or have altered composition. The findings included: An observation 02/19/25 at 9:11 AM of the medication cart for hall 100 with RN B revealed a bottle of expired over-the-counter medication. The medication was labeled: Acetaminophen 500 mg/Diphenhydramine HCl 25 mg and had an expiration date of 11/2024. RN B confirmed that the date of the medication was past the manufacturer's expiration date. During an interview on 02/19/25 at 9:20 AM, RN B stated there should not be expired medication on the medication cart. She stated she did not know why the medication cart contained expired medication. She stated it was the responsibility of the nursing staff to check the cart for expired medications. RN B stated she had only been employed by the facility for a couple of months and was not sure how often the carts were audited by nursing administration for proper medication storage. RN B stated a potential negative outcome for expired medication on the cart would be that a resident could have an adverse reaction or may not receive the therapeutic effect of the ordered medication. During an interview on 02/20/25 at 10:05 AM the DON stated she was not aware that the medication cart contained expired medication. She stated it was the responsibility of the nursing staff on duty to assure expired medications were removed from the medication cart. The DON stated staff were trained and carts were monitored through periodic cart audits conducted by the pharmacy consultant and nursing administration. She stated her expectation of staff was to monitor carts and assure expired medications were removed from the medication cart for destruction. The DON stated a potential negative outcome for expired medication on the cart was that medications may lose potency and the resident would not get the full effect of the medication. During an interview on 02/20/25 at 10:51 AM the ADM stated she was not aware that there was an expired medication on the medication cart. She stated nursing staff and nursing administration were responsible to assure expired medications were removed from the cart. She stated her expectation of staff was to monitor expiration dates of medications and to follow policy at all times. The ADM stated a potential negative outcome of expired medication on the cart was that a resident's health could be negatively affected if an expired medication were administered. Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed: Policy Interpretation and Implementation Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 1 medication carts (medication cart for Hall 100), reviewed for medication storage. The medication cart assigned to Hall 100 contained loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered, receiving medications that are less effective or have altered composition, and drug diversions. The findings included: On 2/19/25 at 9:11 AM an observation of the medication cart for Hall 100 was conducted with RN B. Two loose pills were found in the drawer of the medication cart. RN B placed the pills in a dispensing cup and the ADON identified the medications as Furosemide 40 mg (1 tablet) and Cyclobenzaprine 10 mg (1 tablet). RN B destroyed the loose pills by placing them in the sharps container on the medication cart. During an interview on 02/19/25 at 9:20 AM, RN B stated there should not be loose pills on the medication cart. She stated she was not sure why the medication cart contained loose pills. She stated it was her responsibility to check the cart for proper medication storage each time when reporting for duty. RN B stated she received training on proper medication storage through her nursing education. She stated she had only been employed by the facility for a couple of months and was not aware of how often training on proper medication storage was provided by the facility. RN B stated she was trained by nursing administration to assure medication blister packs were kept in hard plastic sleeves in the drawers of the cart to reduce the risk of loose medications. RN B stated a potential negative outcome of loose medications on the cart would be that a resident may miss a scheduled dose of medication. During an interview on 02/20/25 at 10:05 AM the DON stated she was not aware that there were loose pills on the medication cart. She stated it was the responsibility of the nurse on duty as well as nursing administration to assure medications were stored properly on the medication cart. The DON stated staff were trained and carts were monitored through periodic cart audits conducted by the pharmacy consultant and nursing administration. She stated her expectation of staff was to keep medications secured by monitoring carts and assuring pill packs were in protective plastic covers to prevent medications from falling out of blister packs. The DON stated a potential negative outcome for loose pills on the cart was that medications may lose potency and the resident would not get the full effect of the medication. During an interview on 02/20/25 at 10:51 AM the ADM stated she was not aware that there were loose pills on the medication cart. She stated the nurse on duty and nursing administration were responsible to assure medications were stored properly on the cart. She stated her expectation of staff for proper storage of medications was to follow policy at all times. The ADM stated a potential negative outcome for failure to properly store medications was that medications could be more easily accessed, placing the facility at risk of drug diversions and residents could receive the wrong medications. Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed: Policy Interpretation and Implementation Medication Storage 1. Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. . 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 4 residents (Residents #35, and Resident #151) and 2 of 4 staff (RN C and CNA E) reviewed for infection control. RN C failed to sanitize her hands between gloves changes during wound care for Resident #35. CNA E failed to wear PPE during catheter care for Resident #151 who was on EBP. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #35 Record review of Resident 35's face sheet, dated 02/18/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (a syndrome of weight loss, poor nutrition, and inactivity that affects older adults), anxiety, dementia (memory loss that interferes with daily life), stage 2 pressure ulcer to left buttock, and hypertension (high blood pressure). Record review of Resident #35's current physician's orders, with a start date of 01/21/25, revealed an order to cleanse stage 2 (partial thickness skin loss) pressure ulcer to left buttock with wound cleanser and apply zinc daily. Record review of Resident #35's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident's cognition was mildly impaired. Section M-Skin Conditions revealed a stage 2 pressure ulcer that was present upon admission. Record review of Resident #35's comprehensive care plan dated 02/10/25 revealed the resident was admitted to the facility with a stage 2 pressure injury to the left buttock. Interventions included: Administer treatments as ordered and monitor for effectiveness. During a wound care observation on 02/18/25 at 12:33 PM for Resident #35, revealed RN C entered the room, washed her hands, and put on a gown and gloves. RN C explained the procedure to Resident #35 then assisted him to roll to his left side. RN C removed the dressing to the resident's left buttock and placed it in the trash. RN C then removed her gloves, put on new gloves and cleansed the resident's wound, according to the physician's orders. RN C placed a new dressing to the wound and repositioned the resident for comfort. RN C did not sanitize her hands between the glove change. During an interview on 02/18/25 at 1:19 PM, RN C stated she did not sanitize her hands between the glove change. She stated hand hygiene should be performed each time gloves were changed during wound care. RN C stated she realized she failed to sanitize her hands after she had already changed her gloves and continued with wound care. She stated she forgot to set her bottle of hand sanitizer on the prepped table, which would have reminded her to sanitize her hands. RN C stated she was trained on hand hygiene through in-services conducted by nursing administration annually and as needed. RN C stated a potential negative outcome of failure to sanitize hands between glove changes was that bacteria could be spread from resident to resident and wounds could become infected. Resident #151 Record review of Resident 151's face sheet, dated 02/18/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a disorder of the central nervous system that affects movement), dementia, hypertension (high blood pressure), anxiety, and overactive bladder (a disorder of bladder function that causes the sudden need to urinate). Record review of Resident #151's current physician's orders, with a start date of 02/03/25, revealed an order to change Foley catheter monthly and provide catheter care daily on each shift. Record review of Resident #151's admission MDS, dated [DATE], Section H-Bowel and Bladder revealed the resident had an indwelling catheter. During a perineal care and catheter care observation on 02/18/25 at 1:36 PM for Resident #151, revealed CNA E entered the room, washed her hands, and put on gloves. CNA E explained the procedure to Resident #151 then performed female perineal care and catheter care. CNA E repositioned the resident in bed, removed her gloves and washed her hands. CNA E did not put a gown on prior to performing care for the resident. A sign was observed above Resident #151's bed which reflected a gown and gloves were required while performing direct care for the resident. During an interview on 02/18/25 at 1:54 PM, CNA E stated she did not put a gown on prior to performing perineal care and catheter care for Resident #151. She stated she should have worn a gown while performing care because the resident had a catheter. CNA E stated a resident on EBP would require staff to wear a gown and gloves while performing care in order to prevent bacteria from entering wounds and catheters. She stated staff were informed of a resident being on EBP through the report given at shift change. She stated, Most of the time, there is a sign in the room that tells us if we need to put on a gown. CNA E stated she had been trained on EBP through in-services conducted by the ADON. CNA E stated a potential negative outcome for failure to use proper PPE on a resident on EBP would be that the resident could get an infection. During an interview on 02/20/25 at 10:05 AM the DON stated she was not aware that staff were not following proper hand hygiene and EBP protocol. She stated hand hygiene should be performed after each glove change and a gown and gloves should be used when caring for a resident on EBP. She stated it was the responsibility of nursing administration to assure staff were properly trained on hand hygiene and EBP through in-services conducted periodically at the facility. The DON stated her expectation of staff was to follow protocol for hand hygiene and EBP at all times. The DON stated a potential negative outcome for failure to observe proper hand hygiene and EBP protocol would be cross-contamination and the spread of infection. During an interview on 02/20/25 at 10:51 AM the ADM stated she was not aware that staff were not following proper hand hygiene and EBP protocol. She stated it was the responsibility of nursing administration to assure staff were properly trained on hand hygiene and EBP. The ADM stated her expectation of staff was to always follow protocol for hand hygiene and EBP by sanitizing hands and wearing proper EBP when necessary. The ADM stated a potential negative outcome for failure to observe proper hand hygiene and EBP protocol would be that residents and employees were at higher risk of infection. Record review of the facility-provided in-service, dated 03/27/24, revealed: Subject: New State Guidelines for Residents with wounds, feeding tubes and catheters. The document was signed by 28 staff members and had a memorandum attached from the Centers for Medicare and Medicaid Services with a subject of Enhanced Barrier Precautions in Nursing Homes. Record review of the facility-provided policy, date revised March 2024, titled Enhanced Barrier Precautions revealed: Policy Statement Enhanced Barrier Precautions (EBP's) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment {PPE} is changed before caring for another resident. . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing).

Based on the interview and record review the facility failed to provide each resident or the resident's representative education regarding pneumococcal immunization and failed to document evidence of receiving, refusal, or education regarding pneumococcal immunization, for 2 of 14 residents (Residents #10 and #39). The facility failed to document the influenza immunization status for Resident #10 The facility failed to document the influenza immunization status for Resident #39 This failure placed residents who wanted but did not receive the pneumococcal vaccine, who are at risk for infections and decreased quality of life. Findings included: Resident #10 Record review of Resident #10's face sheet, dated 02/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss). Record review of Resident #10's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 4, which indicated the resident's cognition was severely impaired. Section O [O0250] Influenza Vaccine revealed Resident #10 did not receive the influenza vaccine in the facility because she was not in the facility. Record review of Resident #10's Physician Order's, dated 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 07/02/24 Start Date 10/01/24). Record review of Resident #10's progress notes dated 10/01/24-02/18/25, did not reveal any documentation indicating that the resident had received or refused the influenza vaccination. During an interview on 02/20/25 at 9:19 AM, Resident #10 could not provide any information regarding whether the flu immunization had been offered or refused. Resident #39 Record review of Resident #39's face sheet, dated 02/19/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include depressive episodes, dysphasia (swallowing difficulties), cognitive communication deficit (a difficulty in communication that arises from an impairment in cognitive functions), reduced mobility, and aphasia difficulty in communicating). Record review of Resident #39's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severely impaired. Section O [O0250] Influenza Vaccine revealed Resident #39 did not receive the influenza vaccine in the facility and no reason was given. Record review of Resident #39's Physician Order's, dates 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 08/25/23 Start Date 10/01/24). Record review of Resident #39's progress notes dated 10/01/24-02/18/25, did not reveal any documentation indicating that the resident had received or refused the influenza vaccination. During an interview on 02/18/25 at 11:42 AM, Resident #39 could not answer any questions. Resident #39 could not answer questions about whether he had been offered or refused immunizations. During an interview on 02/19/25 at 3:00 PM, the MDS Coordinator stated she was familiar with the facility's immunization policy. She stated the purpose of offering immunizations to residents was so they could fight illnesses. The MDS Coordinator said the PNO of not offering necessary immunizations was the residents could get sick and pass illnesses to other residents. The MDS Coordinator stated she was unaware of residents not being offered the influenza (flu) immunization. She stated the system to monitor immunizations was that the ADON headed the process. She stated they were provided a list of names and then went down the list. She stated they do the flu shots in October or November. She stated she had been trained that all immunizations were offered upon admission and during the applicable seasons. She stated she expected all residents to be offered immunizations. She stated she did not have a reason if any immunizations were not offered but that the ADON was responsible. During an interview on 02/19/25 at 3:22 PM, the DON stated regarding resident immunizations she was familiar with the facility policy. She stated the purpose for offering and administering resident immunizations was that it helped prevent the flu. She stated she was unaware of any resident missing immunizations or not being offered until 2/19/25. She stated the system to monitor resident immunizations was the ADON normally kept up with it since she was the infection prevention nurse. She stated she had been trained to offer all applicable immunizations, such as flu, TB, and COVID-19. She stated she did not have a reason the flu immunization was not offered to Resident #10 and Resident #39. She stated she and the ADON were responsible for resident immunizations. During an interview on 02/19/25 at 3:55 PM, the ADM stated regarding resident immunizations she was familiar with the policy but only a little. She stated she read the policy. She stated the purpose of offering residents immunizations was to give them a choice of what they want regarding preventative care. She stated it was the resident's right to choose. She stated the PNO of not offering or administering their choice in preventative care was the residents would not be able to decide what they wanted for preventative care. She stated she was unaware of residents who had not been offered or received their flu shot. She stated the system to monitor resident immunizations was the ADON kept up with it. She stated she had not had specific training but read the policy. She stated the ADON was responsible for resident immunizations. The ADM stated she did not know why resident immunizations were not offered or administered. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the resident immunization policy. She stated the purpose of offering or administering immunizations was so that residents could receive their immunizations if they wanted them. She stated the PNO for not offering or administering the flu immunization was so the resident would not get the flu. She stated she was unaware that Residents #10 and #39 had no flu vaccines. She stated the system that she used to monitor resident immunizations was that she would make a list. She said she would then give it to the nurses so they could offer and administer the immunization. She stated they offered upon admission, and starting in October, they began with flu immunizations. She stated last year (2024), most residents received their flu immunizations in November and late December because of a wave of sickness that occurred in October. She stated even if the resident was admitted after December 2024, the resident would have still been offered the flu shot. She stated she had been trained on resident immunizations and expected all residents to be offered immunizations upon admission and in the appropriate seasons. She stated she, as the ADON, was responsible, and there was no reason the two residents (Resident #10 and #39) had not received their flu shot or been offered. Record review of facility policy, Director of Nursing Services, dated August 2022, revealed: Policy Statement The nursing services department is under the direct supervision of a registered nurse. Policy Interpretation and Implementation The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: overseeing standards of nursing practice; coordinating nursing services with other resident services; recruiting and retaining the number and skill levels of nursing personnel necessary to meet the nursing care needs of each resident; Record review of facility policy, Resident Rights , revised February 2021, revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Be informed of, and participate in, his or her care planning and treatment Record review of facility policy, Influenza Vaccine , dated March 2022, revealed: Policy Statement All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives) Policy Interpretation Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident has already been immunized. Residents admitted between October 1st and March 31st shall be offered the vaccine within 5 working days of the resident admission to the facility. A resident refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention recommendations at the time of the vaccination.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 1 out of 48 days (12/25/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following day: 12/25/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 01/16/24 revealed there were three RNs employed at the facility. Record review time sheet for the DON dated 01/16/24 revealed no hours worked for 12/25/23. Record review time sheet for RN A dated 01/16/24 revealed no hours worked for 12/25/23. Record review time sheet for RN B dated 01/16/24 revealed no hours worked for 12/25/23. During an interview on 01/18/24 at 8:42 AM, the DON she stated she works Monday through Friday 08:00 AM to 05:00 PM. The DON stated she did not work on 12/25/23 because she was off for vacation. The DON stated she did not know why the facility did not have RN coverage as the ADM is the one who schedules for RN coverage. The DON stated it was unknown what the potential negative outcome could be because they are close to the hospital if they needed help. During an interview on 01/18/24 at 8:07 AM, the ADM stated she did not know why the facility did not have RN coverage for 12/25/23. The ADM stated maybe agency was scheduled and did not show up, she was not sure. The ADM stated the potential negative outcome to the residents could be RN responsibilities could not be performed and it was detrimental to the residents. During an interview on 01/18/24 at 12:45 PM, the ADM stated the facility did not have a policy regarding RN coverage.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when the resident experienced a significant change in physical condition for 1 resident (Resident #2) of 16 residents reviewed for change of condition. The facility failed to immediately consult with Resident #2's primary care physician when Resident #2, who had a history of [REDACTED]. On [DATE] at 1:05 a.m., Resident #2 was found to have no respirations or pulse and pronounced deceased at 1:50 a.m. by the Justice of the Peace. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure to immediately consult with a resident's primary care physician when a resident experienced a change in condition could affect all 61 residents in the facility. This failure could result in serious medical complications, a decline in condition and the need for hospitalization or death. The findings included: Resident #2 Record Review of Resident #2's face sheet, dated [DATE], revealed she was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The face sheet identified Resident #2's physician as Physician C. Record Review of Resident #2's admission MDS (Minimum Data Set) dated [DATE] revealed she had moderate difficulty with hearing. She had clear speech, usually makes self-understood and sometimes has the ability to understand others. A BIMS (Brief Interview of Mental Status) could not be performed due to resident was unable to complete the interview. The MDS indicated Resident #2 had moderately impaired cognitive skills. MDS revealed Resident #2 was noted to always be incontinent of bowel and was totally dependent on one person to physically assist with toileting. The MDS dated [DATE] revealed Resident #2 had not received pain medication in the 5 days prior to the assessment and was unable to answer if pain present. MDS revealed Resident #2 displayed other behavioral symptoms (verbal/vocal symptoms or disruptive sounds) not directed toward others 1 to 3 days of the review period. Record Review of Resident #2's Care plan dated [DATE] revealed she has the potential for pain related to stiff joints, impaired mobility and pressure ulcer with a goal she will have pain level no greater than 2 on pain scale of ,[DATE] daily for the next 90 days. Interventions included monitor for signs/symptoms such as grimacing, guarding, frequent complaints of pain, moaning, crying, etc. Notify charge nurse/Physician as needed of signs/symptoms of pain or increased complications of pain, Administer [MEDICATION NAME] 650mg every 4 hours as needed as ordered per physician and utilize PAINAD assessment tool. Record Review of Resident #2's History and Physical, dated [DATE], by Physician D revealed she had 2 falls while at her home resulting in her being weak and unable to get up even with assistance. Past Surgical history included previous abdomen surgery for [REDACTED].#2's abdomen to be soft, nontender, no rebound, guarding or rigidity noted. According to the Mayo Clinic signs and symptoms of bowel obstruction can include Crampy abdominal pain that comes and goes, Loss of appetite, Constipation, Vomiting, Inability to have a bowel movement or pass gas, Swelling of the abdomen. The Mayo Clinic recommended that Because of the serious complications that can develop from intestinal obstruction (bowel obstruction), seek immediate medical care if you have severe abdominal pain or other symptoms of intestinal obstruction. http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc- 463 (accessed on [DATE]) Record Review of Resident #2's Discharge Summary from Hospital B dated [DATE] revealed she was to be discharged to (the facility) with condition at discharge noted as physically and emotionally stable. Discharge follow-up appointments included to follow-up with Physician C in 2 weeks; please call to schedule an appointment. Record Review of Resident #2's facility clinical record revealed an Exit Care Patient Information Packet from Hospital B dated [DATE]. The Exit Care packet revealed seek medical care if you have abdominal pain and it increases or stays in one area (localizes) .Make sure you understand these instructions, will watch your condition and will get help right away if you are not doing well or get worse. Record Review of Resident #2's Nurses' Admission Nursing Assessment, dated [DATE], and completed by LVN A revealed Resident #2's condition on admission was she was alert and required 2 person assist with transfers, utilized a wheelchair for ambulation, poor hearing bilaterally, clear communication, needs assistance for eating, dependent for shower, grooming, dressing and shampoo. LVN A noted Resident #2 was not continent of bowel and last bowel movement was [DATE]. The nurse's admission record identified Resident #2's pulse as 96 and irregular, her respirations as 16, her temperature as 98.1, and her blood pressure as ,[DATE]. General Skin condition was noted to be warm and dry with pressure ulcer noted to coccyx. Review of Resident #2's Nurses Admission Nursing Assessment did not reveal any documentation regarding abdominal distention or abdominal bulging. Record Review of Resident #2's Nurses' Notes revealed the following entries: [DATE] 5:57 p.m., admitted this 85 yr (year) old female . for services of Physician C .Resident is alert upon admission. Family member present upon admission. Resident is hoh (hard of hearing). Diet mech (mechanical) soft Signed by LVN A In an interview on [DATE] at 4:30 p.m., LVN A said CNA's did not report anything different with Resident #2. She said on admission, Resident #2 refused to eat but would drink. She said sometimes Resident #2 was a feeder. She said Resident #2 would yell help me, help me but couldn't specify what help she needed. She said there was nothing abnormal noted to abdomen. She said in report it came up that Resident #2 had four bulging areas which was toward the end of her life in the last week or so. She said she did not witness Resident #2 crying, holding her abdomen. [DATE] at 9:37 p.m., .Speech is clear and is able to voice her wants and needs. Resident is HOH (hard of hearing) and does not see well .Bowel sounds x 4 quadrants with no abdominal distention noted .Final dose of antibiotic administered has voiced no needs at this time . Signed LVN E (No additional nurse's notes related to bowel issues prior to [DATE].) [DATE] at 9:24 p.m., .Awake, alert in bed .poor appetite needs to be fed during meals abdominal distended where the hernias are present. Resident continues to yell out help when approached resident does not say anything else. No Distress noted at this time . Signed LVN C [DATE] at 12:38 p.m., Resident was being wheeled to D/R (Dining room) and noted abd (abdomen) distended with 4 bulging sores to abdomen. She states no when asked if stomach hurts her. She is only concerned about laying back down and hollers that often. Called Physician A (facility's Medical Director, not Resident #2's physician) and left message that one of Physician B's (not Resident #2's physician) residents needed to be checked on. Waiting for answer from Physician A Signed LVN D In an interview on [DATE] at 1:40 p.m., LVN D said Resident #2 had not had a bowel movement in a while and said several things were tried. She said when Resident #2 was admitted she would moan but then started yelling. She said Resident #2 would drink water but refused snacks. She said Resident #2 would let you know she was hurting by facial grimacing and answering yes or no when asked if she was in pain. She said she communicated her changes by communicating in change of shift report. She said she called Physician A (facility's Medical Director but not the primary care physician for Resident #2) on [DATE] but he did not call back. She said nurses are to fax a note to the physician if needing to notify physician of a change in condition of a resident. She said she did not realize Physician A or B was not the physician for Resident #2 because she didn't check the medical chart to see who the physician was. After reviewing her nurses note entries, LVN D said she did not realize at the time what was going on with Resident #2. [DATE] at 9:46 p.m., .speech is clear and is able to voice wants and needs .Bowel Sounds x 4 quadrants with no abdominal distention noted has voiced no needs at this time . Signed LVN E Record Review of Resident #2 nurses notes revealed the following entry; [DATE] at 9:57 a.m., resting in bed with eyes closed, no s/sx (signs or symptoms) of pain/discomfort noted, abdomen remains distended and several buldged (sp) areas to mid abdomen remain . Signed LVN G In an interview on [DATE] at 11:05 a.m., LVN G said on [DATE] CNA showed her Resident #2 had 2 bulging areas above umbilicus and 1 below umbilicus. She said her abdomen was distended but soft and was non-tender when palpated. She said Resident #2 did not appear in pain when touched. She said resident #2 would yell out a lot but never was in pain but would request water to drink. She said did not notify physician of bulging areas or of abdominal distention. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 9:31 p.m., Resident continues to have 4 buldging (sp) areas to abdomen with abdominal distention. Physician C has been notified. Signed LVN E [DATE] at 1:05 a.m., Abd (abdomen) distended when palpating abd res (resident) yells ouch. ABD firm/distended. Checked for impaction. Noted Res to have x 2 very small round hard formed stools. [MEDICATION NAME] 10mg one sup. (Suppository) given rectally. Also noted umbilical buldging (sp). Will continue to monitor. Incontinent of bladder with check performed q (every 2 hrs (hours) and prn (as needed) with peri care given after each episode. T/R (turn/reposition) q 2 hours. Side rails up for safety. Call light in reach. Signed LVN F [DATE] at 1:15 a.m., [MEDICATION NAME] 10mg sup (suppository) one rectally prn For constipation noted to have x2 hard balls in rectum. ABD (abdomen) distended/painful to touch. Signed LVN F [DATE] at 1:17 a.m., Also noted sluggish bowel sound in left lower quad (quadrant). Signed LVN F In an interview on [DATE] at 1:55 p.m., LVN F said Resident #2 was hard of hearing but could answer questions appropriately at times to make her needs known. She said Resident #2 had an area of distention then it progressed to full blown distention. She said Resident #2 was unable to clearly state where she was hurting, but could respond yes or no. She said she was always requesting water. She said she documented her findings in the nurse's notes and would communicate to other shifts via the communication log. She said when CNA's reported any changes in condition of a resident, she would assess the resident and notify the physician via fax. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 4:40 p.m., . BS (bowel sounds) x 4 hypoactive, abdomen distended, nontender on palpation, possible hernia noted around the umbilical region. Resident denies any pain . No stool noted. Signed RN A [DATE] at 11:08 a.m., Resident has been in bed all day with a low grade temp. noted of 99.4 was turned and repositioned. She hollers out for help constantly and hollers out in pain when moved. She continues to have distended abd (abdomen) and 4 knots noted to abdomen. Signed LVN D [DATE] at 1:32 p.m., .Abdomen is soft, observed 4 large soft rounded knots around umbilical region. No discomfort reported by patient on palpation of this area. Bowel sounds are present but hypoactive. Pericare done q (ever) 2 h (hours) and PRN (as needed). Resident continues to have poor po (by mouth) intake with fluids and meals. Signed RN A [DATE] at 9:49 p.m., At 4:20 pm residents stomach continues to be very distended and has had no results from laxative given on the previous day. Administered MOM (Milk of Magnesia) and one [MEDICATION NAME] to try to obtain a bowel movement. At this time 9:48 pm she has had no results. At 8:40 pm resident continuously saying ow. Administered 2 Tylenol for discomfort and repositioned her. At this time she is resting quietly. Signed LVN E In an interview on [DATE] at 4:20 p.m., LVN E said Resident #2 usually hollered help but one day she hollered ow. She said in shift report she was told resident #2 had a suppository and was constipated. She said she assessed her and noted she had bowel sounds and bulging around umbilicus. She said she palpated her abdomen but didn't feel anything abnormal She thought she should give resident something by mouth and rectally to get her going. She said she documented in the nurses notes she notified Physician C but she did not notify him. She said a nurse from a previous shift/day had notified Physician C. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:11 a.m., Res (resident) yelled all shift for help or wanting a drink of water, res has taken 200 cc H2O (water). Voiding QS (quantity sufficient) with peri care given after each episode. No BMS (bowel movements) this shift. Continues to have sluggish bowel sounds with several buldging (sp) areas around umbilical area. Signed LVN F In an interview on [DATE] at 3:43 p.m., LVN F said Resident #2 yelled out a lot on [DATE] and [DATE] but nothing unusual. She said she worked at night with her and when Resident #2 was awake, she was hollering. She said she noticed Resident #2 to have abdominal distention and hypoactive bowel sounds with 3 or so knots noted around umbilicus area. She said she called Physician C but no answer. She said she gave her a [MEDICATION NAME] suppository due to hard round stools but didn't have anything to give her by mouth for constipation. She said she documented on the medication administration record and nurses notes of the [MEDICATION NAME] suppository being administered. She also documented on the 24 hour nursing report for nurses to know to follow-up for effectiveness. She said in report she was notified of Resident #2 having abdominal distention. [DATE] at 3:11 a.m., .Abdomen remains distended. Bowel sounds are present to left upper and lower quadrant. Bilateral lower quads are sluggish. Resident only voided a small amount of urine thus far. Resident holding lower abdomen and was noted with facial grimacing. She has had no results for [MEDICATION NAME] sup thus far. She has been afebrile. She is HOH but will answer staff when we speak loudly by her ear. Signed LVN H [DATE] at 7:21 a.m., 0624 Resident continues to have abdominal distention at this time. Bowels have not moved this shift. Fluids are encouraged and resident will yell out that she does not want fluids.[MEDICATION NAME] sup (suppository) administered rectally. Will relinquish effectiveness to oncoming shift. Signed LVN H In an interview on [DATE] at 3:47 p.m., LVN H said Resident #2 had a hard time with fluid intake and staff feeding her. LVN H said several CNA's had reported to her Resident #2's abdomen was distended. She said when she was having stomach problems, she wouldn't eat or drink and she progressively took in less. She said on an assessment of Resident #2 she noted sluggish bowel sounds and lumps where umbilical hernia that became more pronounced as abdomen became distended and she charted in the nurse's notes her findings. LVN H said she did not notify a physician of changes in Resident #2. She said she told the oncoming shift to follow-up. Record Review of faxed note to Physician C dated [DATE] (This was faxed on Saturday outside physician C's normal operating hours) regarding Resident #2 with message that abd sl (abdomen slightly) firm/distended. Also noted abd buldging (sp) below umbilical, checked resident for impaction, noted x 2 small hard roll stool. Gave res (resident) a [MEDICATION NAME] 10mg supp. rectally without results. Res complained of pain when palpating abdomen. She has nothing more to give on [MEDICATION NAME]. What do you want me to do? I tried calling you this am on both numbers, they went to voice mail. Signed LVN F. Physician C replied on [DATE] with order to try fleet's enema. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:02 p.m., .She continues to have distended abdomen and 4 bulging areas from ABD. (Abdomen). All area's are soft and when pressed down they will sink in. No c/o (complaints of) discomfort to area. She refused to eat breakfast and lunch. Drank nothing. When in bed will request water constantly. New order for a fleet's enema. Signed LVN D In an interview on [DATE] at 10:30 a.m., LVN D said Resident #2 had one knot at umbilical area on admission. On [DATE] she had 4 knots around umbilical area. She said she placed a call into Physician A on [DATE] but did not document it but informed the following shift in report. She said she did not look at the clinical record to know that Physician C was Resident #2's physician and not physician A. She said on [DATE] she attempted Tylenol for pain but resident #2 wouldn't take it. She said she did not administer the Fleets enema to Resident #2 due to she had a small and medium bowel movement on [DATE]. She said if she gives a prn (as needed) medication and it is ineffective, she faxes the physician for an alternate treatment. She said Resident #2 would holler out and when asked what she needed she wanted a drink. She said she was not aware resident #2 did not have a bowel movement for 5 days. Record Review of Resident #2 nurses notes revealed the following entry: [DATE] at 11:05 p.m., Resident was hallering (sp) continuously, repositioned still hallering (sp) abdominal distended checked for impaction bowel soft, placed 18 Fr. Foley cath (catheter) 1400 mi (milliliters) dark colored urine in return called Physician C to notify of resident's urine retention Physician C ordered to leave foley cath in place. Signed LVN C (No documentation of Physician C being informed of Resident #2's continued abdominal issues.) In an interview on [DATE] at 1:30 p.m., LVN C said CNA's reported to her Resident #2's abdomen was distended. In report with previous shift, it was reported Resident was constipated. She said LVN D reported she checked Resident #2 and felt soft BM or felt something soft. LVN C said Resident #2 had been like that for 2 days. LVN C said she inserted a catheter into Resident #2's bladder and resident soaked brief, bedding and she waited then unclamped catheter and obtained 1500ml of urine. She said CNA's reported to her Resident #2 had yelled out for 2 days. She said day shift nurse had administered a fleet's enema to Resident #2 on [DATE]. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 2:31 a.m., .No abdominal distention noted at this time No bowel movement noted thus far. Will continue to monitor. Signed LVN H Observation on [DATE] at 10:10 a.m., Resident #2 was in bed, hollering out milk. Staff turned resident on her right side for nurse to cleanse wound to coccyx and apply dressing. Resident denied pain when asked by nurse. Foley catheter intact with clear yellow urine (approximately 100ml) in bed. Resident was transferred from bed to geri chair by two staff. Observation on [DATE] at 10:15 a.m., Resident #2 was sitting in geri chair while staff changed linens on her bed. Resident continues to moan Oh CNA offered health shake and resident #2 took 3 sips then refused. Observation on [DATE] at 12:01 p.m., Resident #2 remains sitting in the geri chair and moaning Oh Observation on [DATE] at 12:15 p.m., Resident #2 remains sitting in the geri chair and continues to call out Oh Observation on [DATE] at 12:19 p.m., Resident #2 attempting to feed resident. Drank 2 sips of water, ate 3 bites of pork but spit all 3 bites out. Refused to eat corn or beans. Resident is requesting milk. Observation on [DATE] at 12:25 p.m., Resident #2 took 10 sips of milk then said enough, stop. Observation on [DATE] at 07:30 a.m., Resident #2 in bed with eyes closed, moaning. (No additional nurse's notes related to Resident #2's abdominal issues prior to [DATE]) [DATE] at 11:14 a.m., .Resident yelling as if in pain. Tylenol 650mg adm (administered) for s/s (signs/symptoms) pain or discomfort .Will continue to monitor. Signed LVN I (No documentation of follow-up for effectiveness of Tylenol) In an interview on [DATE] at 10:55 a.m., LVN I said Resident #2 would yell out Help me. She said on [DATE] she administered Tylenol to Resident #2. It calmed her. She said in report she heard abdomen was bigger due to [MEDICAL CONDITION] and once foley catheter was placed abdomen went down. She said she had not notified the physician of any changes to Resident #2. (No additional nurse's notes related to Resident #2's abdominal issues) Observation on [DATE] at 12:45 p.m., Resident #2 sitting up in geri chair in room. She was awake, moaning, leaning to the right in her chair. Staff notified and resident transferred to bed by two staff. Observation on [DATE] at 3:00 p.m., Resident #2 in bed, moaning out Oh . Her son in room at bedside. Record Review of Resident #2's nurses notes revealed the following entries: [DATE] documented at 6:58 a.m., 0105 This LVN entered resident's room and noted resident with no respirations at this time. NO chest expansion noted at this time. Resident was pale. Skin is still warm to touch. OU fixed and open at this time. No pulse noted at this time. Signed LVN H [DATE] documented at 7:04 a.m., 0115 Police department called at this time and was notified of resident having no vitals. Stated that JP (Justice of Peace) would be notified and funeral home would be called by PD (Police Department). Signed LVN H [DATE] documented at 7:06 a.m., 0140 JP here at this time and taken to resident's room by this LVN. 0150 Resident pronounced at this time. Signed LVN H In an interview on [DATE] at 8:30 a.m., DON said resident #2 passed away around 1:30 a.m. this morning. She said she went to sleep and was gone. Record Review of Resident #2's BM (bowel movement) and Size Roster from [DATE] through [DATE] revealed Resident #2 did not have a bowel movement between [DATE] to [DATE]. Resident #2 only had one small BM on [DATE], one small BM and one medium BM on [DATE] and one small on [DATE]. Record review of Resident #2's admission physician orders [REDACTED]. Resident #2 had orders for [MEDICATION NAME] 325mg 2 po (=650mg) prn q 4 hours prn pain, Milk of Magnesia ,[DATE] ml po prn for indigestion (not ordered as a laxative), [MEDICATION NAME] ([MEDICATION NAME]) 10mg sup 1 rectally prn for no BM in 3 days, May give SS (soap suds) enema prn constipation and may digitally check and remove BM from rectum per licensed nurse prn. Record Review of Resident #2's Medication Administration Record for [DATE] revealed she received [MEDICATION NAME] 325mg 2 tabs (=650mg) on [DATE] at 1:26 a.m., [DATE] at 8:40 a.m. and [DATE] at 9:56 a.m. Resident #2 received Milk of Magnesia ,[DATE] milliliters for indigestion on [DATE] at 4:20 p.m. Resident #2 also received [MEDICATION NAME] 10mg sup one rectally for no Bowel movement in 3 days on [DATE] at 1:15 a.m., [DATE] at 4:20 p.m. and [DATE] at 6:25 a.m. [DATE] at 6:07 p.m., Medication follow-up ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective Signed LVN E [DATE] at 1:26 a.m., [MEDICATION NAME] 325mg 2 po (by mouth) (=650mg) Q (every) 4 .Has been yelling Help Signed LVN F [DATE] at 3:24 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) Q 4, Medication was not effective Signed LVN F [DATE] at 9:47 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) q (every) 4) Medication was effective; Resting at this time. Signed LVN E [DATE] at 1:26 a.m., Medication follow-up (Milk of Magnesia ,[DATE] ml (milliliters) po prn for indi) Medication was not effective. Signed LVN H [DATE] at 1:27 a.m., Medication Follow-up - ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective. Signed LVN H Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message for lab values signed by LVN J. Physician C replied noted with no date of reply. In an interview on [DATE] at 1:55 p.m., LVN J said on admission Resident #2 spoke a lot. She said she would holler hey. She said the abdominal swelling resolved by placement of foley catheter. She said Resident #2 would holler to let you know if she was hurting. Record Review of Resident #2's laboratory report dated [DATE] revealed a White Blood Cell count of 21.4 (high) with normal referenced at 4XXX,[DATE].0. Laboratory report initialed by Physician C. According to the Mayo Clinic a high white blood cell count can indicate an increased production of white blood cells to fight an infection. http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym- 611 (accessed on [DATE]) Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message new resident arrived this evening signed by LVN A. Physician C signed note on [DATE]. In an interview on [DATE] at 12:40 p.m., Physician C said facility staff notified him of resident #2's admission, of her not voiding so he ordered a foley catheter and need for [MEDICATION NAME] suppository as needed for constipation. He said he was not informed by facility staff regarding Resident #2's abdomen being distended or that [MEDICATION NAME] prn (as needed) medications were ineffective. He said if a medication doesn't work (ineffective) the staff should call him back. He said if he had been notified of Resident #2's abdomen being distended, bulging areas noted to abdomen, altered bowel sounds, etc. he would have sent her to emergency room for further evaluation. He said he wasn't sure if the nurses at the facility were not communicating or what. He said it didn't sound like Resident #2 received appropriate care. He said he was on call the day Resident #2 expired but was not notified of her passing. In an interview on [DATE] at 4:30 p.m., Physician C said he was contacted regarding Resident #2's need for foley catheter but was not contacted regarding any urinary symptoms. He said he came to the facility today to see his residents but was asked to leave and come back later when state was gone so he left the facility. Record Review of Facility 24 hour reports regarding Resident #2 revealed [DATE] - 7am/3pm Physician A was called due to abdomen distended and 4 new bulging areas [DATE] - 3pm/11pm Continues to have 4 bulging areas [DATE] - 11pm/7am left lower quadrant noted with sluggish bowel sounds, others absent at this time. Abdomen firm/distended. [MEDICATION NAME] given suppository/rectum; 3pm/11pm noted hollered out several times only wanted water [DATE] - 11pm/7am yelled all shift, 0126 [MEDICATION NAME] 325mg 2 tabs given, WBC (White Blood Cells) are 21.4 normal 4XXX,[DATE].0; 7am/3pm abdomen distention plus 4 knots noted; 3pm/11pm administered sup plus MOM (Milk of Magnesia)= no results yet 2 Tylenol at 840 [DATE] - 11pm/7am MOM/Suppository given ,[DATE] no results; 7am/3pm N.O. (new order) for Fleets Enema had a small BM; 3pm/11pm Placed 18 Fr. Foley 1400 ml dark urine order to keep foley in place, call family please [DATE] - no entries regarding abdominal issues [DATE] - 7am/3pm did not eat breakfast, 10 x drinks of milk at lunch, been yelling out all morning, foley cath; 3pm/11pm foley cath draining to bedside no other issues [DATE] - 11pm/7am no problems, staff did encourage fluids; 7am/3pm no problems; 3pm/11pm No problems, resident passed away. In an interview on [DATE] at 4:05 p.m., DON said she reviewed nurse's notes for Resident #2. She said Resident #2 had two areas on her abdomen on admission. She said in the moment you don't fit it together but reading her nurses notes, you see the pattern of issues. She said the nurses notified Physician C of all the changes and she had the faxes to prove it. She said the nurses did tell Physician C of the changes in Resident #2. She said on the Admission Nursing Assessment, the nurse should document the two areas on her abdomen on the skin condition section. Admission Nursing Assessment was reviewed with DON and the two areas were not documented on the skin condition section of the Admission Nursing Assessment. DON said looking back over nurses notes for Resident #2, it makes sense for the concern but at the time you don't see it. In an interview on [DATE] at 1:55 p.m., CNA A said Resident #2 could understand what was said to her and she could answer you with yes or no. He said she wasn't much on eating but would drink milk. He said Resident #2 would holler out help but a few days prior to her death, she seemed to holler for help less but still called out. He said she didn't verbalize if in pain but if she was asked if in pain, she could answer yes or No. He said he reported to the nurses that Resident #2 was hollering out and also when she didn't eat but could not remember which nurse he reported this to. In an interview on [DATE] at 3:45 p.m., DON said Resident #2 would let you know she was hurting by facial grimacing and hollering out. She said when Resident #2 was asked what she needed, she would deny needing anything. She said a fax was sent to her physician for Milk of Magnesia, Fleets enema for no bowel movement in ,[DATE] days then after med given she had bowel movements. In an interview on [DATE] at 3:50 p.m., ADON said a CNA reported to her (unknown date) when Resident #2 had a knot on her abdomen. She said she assessed the area and it was soft and located in her right upper quadrant. She said Resident #2 hollered almost continuously but if asked if she was in pain, would deny pain. She said to determine what Resident #2 needed, you had to ask yes or no questions. In an interview on [DATE] at 1:53 p.m., CNA D said Resident #2 would yell help all day. She said Resident #2 had 3 bumps on belly. She had the nurse to look at them and was told the resident was admitted with them. She said the 3 bumps looked like little hernias. She said they were soft, like pudding in a balloon. She said she reported to the nurses that Resident #2 would cry daily and that she thought something was wrong with her. In an interview on [DATE] at 10:35 a.m., CNA E said Resident #2 would holler out as if she was in pain. She said she would give her water but resident would refuse water at times. CNA E said Resident #2's abdomen had been distended. She said she notified LVN H and LVN F that resident wasn't urinating, was refusing liquids and appeared in pain. She said she worked the night Resident #2 passed away and nothing out of the ordinary was noted with her. In an interview on [DATE] at 10:45 a.m., CNA F said lumps were present on tummy when admitted . She said Resident #2 would call out help and ouch on admission. She said she would ask Resident #2 if she was in pain and she would say yes and point to abdomen. She said

Based on observation, interview and record review, the facility failed to ensure resident were free from neglect for 1 resident (Resident #2) of 16 residents reviewed for neglect. The facility failed to provide appropriate interventions when Resident #2 who had a history of [REDACTED]. On [DATE] at 1:05 a.m., Resident #2 was found to have no respirations or pulse and pronounced deceased at 1:50 a.m. by the Justice of the Peace. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure to thoroughly assess, monitor, and provide appropriate medical interventions for residents could affect all 61 residents in the facility, and could result in serious medical complications, decline in condition and the need for hospitalization or death. The findings included: Resident #2 Record Review of Resident #2's face sheet, dated [DATE], revealed she was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The face sheet identified Resident #2's physician as Physician C. Record Review of Resident #2's admission MDS (Minimum Data Set) dated [DATE] revealed she had moderate difficulty with hearing. She had clear speech, usually makes self-understood and sometimes has the ability to understand others. A BIMS (Brief Interview of Mental Status) could not be performed due to resident was unable to complete the interview. The MDS indicated Resident #2 had moderately impaired cognitive skills. MDS revealed Resident #2 was noted to always be incontinent of bowel and was totally dependent on one person to physically assist with toileting. The MDS dated [DATE] revealed Resident #2 had not received pain medication in the 5 days prior to the assessment and was unable to answer if pain present. MDS revealed Resident #2 displayed other behavioral symptoms (verbal/vocal symptoms or disruptive sounds) not directed toward others 1 to 3 days of the review period. Record Review of Resident #2's Care plan dated [DATE] revealed she has the potential for pain related to stiff joints, impaired mobility and pressure ulcer with a goal she will have pain level no greater than 2 on pain scale of ,[DATE] daily for the next 90 days. Interventions included monitor for signs/symptoms such as grimacing, guarding, frequent complaints of pain, moaning, crying, etc. Notify charge nurse/Physician as needed of signs/symptoms of pain or increased complications of pain, Administer [MEDICATION NAME] 650mg every 4 hours as needed as ordered per physician and utilize PAINAD assessment tool. Record Review of Resident #2's History and Physical, dated [DATE], by Physician D revealed she had 2 falls while at her home resulting in her being weak and unable to get up even with assistance. Past Surgical history included previous abdomen surgery for [REDACTED].#2's abdomen to be soft, nontender, no rebound, guarding or rigidity noted. According to the Mayo Clinic signs and symptoms of bowel obstruction can include Crampy abdominal pain that comes and goes, Loss of appetite, Constipation, Vomiting, Inability to have a bowel movement or pass gas, Swelling of the abdomen. The Mayo Clinic recommended that Because of the serious complications that can develop from intestinal obstruction (bowel obstruction), seek immediate medical care if you have severe abdominal pain or other symptoms of intestinal obstruction. http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc- 463 (accessed on [DATE]) Record Review of Resident #2's Discharge Summary from Hospital B dated [DATE] revealed she was to be discharged to (the facility) with condition at discharge noted as physically and emotionally stable. Discharge follow-up appointments included to follow-up with Physician C in 2 weeks; please call to schedule an appointment. Record Review of Resident #2's facility clinical record revealed an Exit Care Patient Information Packet from Hospital B dated [DATE]. The Exit Care packet revealed seek medical care if you have abdominal pain and it increases or stays in one area (localizes) .Make sure you understand these instructions, will watch your condition and will get help right away if you are not doing well or get worse. Record Review of Resident #2's Nurses' Admission Nursing Assessment, dated [DATE], and completed by LVN A revealed Resident #2's condition on admission was she was alert and required 2 person assist with transfers, utilized a wheelchair for ambulation, poor hearing bilaterally, clear communication, needs assistance for eating, dependent for shower, grooming, dressing and shampoo. LVN A noted Resident #2 was not continent of bowel and last bowel movement was [DATE]. The nurse's admission record identified Resident #2's pulse as 96 and irregular, her respirations as 16, her temperature as 98.1, and her blood pressure as ,[DATE]. General Skin condition was noted to be warm and dry with pressure ulcer noted to coccyx. Review of Resident #2's Nurses Admission Nursing Assessment did not reveal any documentation regarding abdominal distention or abdominal bulging. Record Review of Resident #2's Nurses' Notes revealed the following entries: [DATE] 5:57 p.m., admitted this 85 yr (year) old female . for services of Physician C .Resident is alert upon admission. Family member present upon admission. Resident is hoh (hard of hearing). Diet mech (mechanical) soft Signed by LVN A In an interview on [DATE] at 4:30 p.m., LVN A said CNA's did not report anything different with Resident #2. She said on admission, Resident #2 refused to eat but would drink. She said sometimes Resident #2 was a feeder. She said Resident #2 would yell help me, help me but couldn't specify what help she needed. She said there was nothing abnormal noted to abdomen. She said in report it came up that Resident #2 had four bulging areas which was toward the end of her life in the last week or so. She said she did not witness Resident #2 crying, holding her abdomen. [DATE] at 9:37 p.m., .Speech is clear and is able to voice her wants and needs. Resident is HOH (hard of hearing) and does not see well .Bowel sounds x 4 quadrants with no abdominal distention noted .Final dose of antibiotic administered has voiced no needs at this time . Signed LVN E (No additional nurse's notes related to bowel issues prior to [DATE].) [DATE] at 9:24 p.m., .Awake, alert in bed .poor appetite needs to be fed during meals abdominal distended where the hernias are present. Resident continues to yell out help when approached resident does not say anything else. No Distress noted at this time . Signed LVN C [DATE] at 12:38 p.m., Resident was being wheeled to D/R (Dining room) and noted abd (abdomen) distended with 4 bulging sores to abdomen. She states no when asked if stomach hurts her. She is only concerned about laying back down and hollers that often. Called Physician A (facility's Medical Director, not Resident #2's physician) and left message that one of Physician B's (not Resident #2's physician) residents needed to be checked on. Waiting for answer from Physician A Signed LVN D In an interview on [DATE] at 1:40 p.m., LVN D said Resident #2 had not had a bowel movement in a while and said several things were tried. She said when Resident #2 was admitted she would moan but then started yelling. She said Resident #2 would drink water but refused snacks. She said Resident #2 would let you know she was hurting by facial grimacing and answering yes or no when asked if she was in pain. She said she communicated her changes by communicating in change of shift report. She said she called Physician A (facility's Medical Director but not the primary care physician for Resident #2) on [DATE] but he did not call back. She said nurses are to fax a note to the physician if needing to notify physician of a change in condition of a resident. She said she did not realize Physician A or B was not the physician for Resident #2 because she didn't check the medical chart to see who the physician was. After reviewing her nurses note entries, LVN D said she did not realize at the time what was going on with Resident #2. [DATE] at 9:46 p.m., .speech is clear and is able to voice wants and needs .Bowel Sounds x 4 quadrants with no abdominal distention noted has voiced no needs at this time . Signed LVN E Record Review of Resident #2 nurses notes revealed the following entry; [DATE] at 9:57 a.m., resting in bed with eyes closed, no s/sx (signs or symptoms) of pain/discomfort noted, abdomen remains distended and several buldged (sp) areas to mid abdomen remain . Signed LVN G In an interview on [DATE] at 11:05 a.m., LVN G said on [DATE] CNA showed her Resident #2 had 2 bulging areas above umbilicus and 1 below umbilicus. She said her abdomen was distended but soft and was non-tender when palpated. She said Resident #2 did not appear in pain when touched. She said resident #2 would yell out a lot but never was in pain but would request water to drink. She said did not notify physician of bulging areas or of abdominal distention. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 9:31 p.m., Resident continues to have 4 buldging (sp) areas to abdomen with abdominal distention. Physician C has been notified. Signed LVN E [DATE] at 1:05 a.m., Abd (abdomen) distended when palpating abd res (resident) yells ouch. ABD firm/distended. Checked for impaction. Noted Res to have x 2 very small round hard formed stools. [MEDICATION NAME] 10mg one sup. (Suppository) given rectally. Also noted umbilical buldging (sp). Will continue to monitor. Incontinent of bladder with check performed q (every 2 hrs (hours) and prn (as needed) with peri care given after each episode. T/R (turn/reposition) q 2 hours. Side rails up for safety. Call light in reach. Signed LVN F [DATE] at 1:15 a.m., [MEDICATION NAME] 10mg sup (suppository) one rectally prn For constipation noted to have x2 hard balls in rectum. ABD (abdomen) distended/painful to touch. Signed LVN F [DATE] at 1:17 a.m., Also noted sluggish bowel sound in left lower quad (quadrant). Signed LVN F In an interview on [DATE] at 1:55 p.m., LVN F said Resident #2 was hard of hearing but could answer questions appropriately at times to make her needs known. She said Resident #2 had an area of distention then it progressed to full blown distention. She said Resident #2 was unable to clearly state where she was hurting, but could respond yes or no. She said she was always requesting water. She said she documented her findings in the nurse's notes and would communicate to other shifts via the communication log. She said when CNA's reported any changes in condition of a resident, she would assess the resident and notify the physician via fax. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 4:40 p.m., . BS (bowel sounds) x 4 hypoactive, abdomen distended, nontender on palpation, possible hernia noted around the umbilical region. Resident denies any pain . No stool noted. Signed RN A [DATE] at 11:08 a.m., Resident has been in bed all day with a low grade temp. noted of 99.4 was turned and repositioned. She hollers out for help constantly and hollers out in pain when moved. She continues to have distended abd (abdomen) and 4 knots noted to abdomen. Signed LVN D [DATE] at 1:32 p.m., .Abdomen is soft, observed 4 large soft rounded knots around umbilical region. No discomfort reported by patient on palpation of this area. Bowel sounds are present but hypoactive. Pericare done q (ever) 2 h (hours) and PRN (as needed). Resident continues to have poor po (by mouth) intake with fluids and meals. Signed RN A [DATE] at 9:49 p.m., At 4:20 pm residents stomach continues to be very distended and has had no results from laxative given on the previous day. Administered MOM (Milk of Magnesia) and one [MEDICATION NAME] to try to obtain a bowel movement. At this time 9:48 pm she has had no results. At 8:40 pm resident continuously saying ow. Administered 2 Tylenol for discomfort and repositioned her. At this time she is resting quietly. Signed LVN E In an interview on [DATE] at 4:20 p.m., LVN E said Resident #2 usually hollered help but one day she hollered ow. She said in shift report she was told resident #2 had a suppository and was constipated. She said she assessed her and noted she had bowel sounds and bulging around umbilicus. She said she palpated her abdomen but didn't feel anything abnormal She thought she should give resident something by mouth and rectally to get her going. She said she documented in the nurses notes she notified Physician C but she did not notify him. She said a nurse from a previous shift/day had notified Physician C. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:11 a.m., Res (resident) yelled all shift for help or wanting a drink of water, res has taken 200 cc H2O (water). Voiding QS (quantity sufficient) with peri care given after each episode. No BMS (bowel movements) this shift. Continues to have sluggish bowel sounds with several buldging (sp) areas around umbilical area. Signed LVN F In an interview on [DATE] at 3:43 p.m., LVN F said Resident #2 yelled out a lot on [DATE] and [DATE] but nothing unusual. She said she worked at night with her and when Resident #2 was awake, she was hollering. She said she noticed Resident #2 to have abdominal distention and hypoactive bowel sounds with 3 or so knots noted around umbilicus area. She said she called Physician C but no answer. She said she gave her a [MEDICATION NAME] suppository due to hard round stools but didn't have anything to give her by mouth for constipation. She said she documented on the medication administration record and nurses notes of the [MEDICATION NAME] suppository being administered. She also documented on the 24 hour nursing report for nurses to know to follow-up for effectiveness. She said in report she was notified of Resident #2 having abdominal distention. [DATE] at 3:11 a.m., .Abdomen remains distended. Bowel sounds are present to left upper and lower quadrant. Bilateral lower quads are sluggish. Resident only voided a small amount of urine thus far. Resident holding lower abdomen and was noted with facial grimacing. She has had no results for [MEDICATION NAME] sup thus far. She has been afebrile. She is HOH but will answer staff when we speak loudly by her ear. Signed LVN H [DATE] at 7:21 a.m., 0624 Resident continues to have abdominal distention at this time. Bowels have not moved this shift. Fluids are encouraged and resident will yell out that she does not want fluids.[MEDICATION NAME] sup (suppository) administered rectally. Will relinquish effectiveness to oncoming shift. Signed LVN H In an interview on [DATE] at 3:47 p.m., LVN H said Resident #2 had a hard time with fluid intake and staff feeding her. LVN H said several CNA's had reported to her Resident #2's abdomen was distended. She said when she was having stomach problems, she wouldn't eat or drink and she progressively took in less. She said on an assessment of Resident #2 she noted sluggish bowel sounds and lumps where umbilical hernia that became more pronounced as abdomen became distended and she charted in the nurse's notes her findings. LVN H said she did not notify a physician of changes in Resident #2. She said she told the oncoming shift to follow-up. Record Review of faxed note to Physician C dated [DATE] (This was faxed on Saturday outside physician C's normal operating hours) regarding Resident #2 with message that abd sl (abdomen slightly) firm/distended. Also noted abd buldging (sp) below umbilical, checked resident for impaction, noted x 2 small hard roll stool. Gave res (resident) a [MEDICATION NAME] 10mg supp. rectally without results. Res complained of pain when palpating abdomen. She has nothing more to give on [MEDICATION NAME]. What do you want me to do? I tried calling you this am on both numbers, they went to voice mail. Signed LVN F. Physician C replied on [DATE] with order to try fleet's enema. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:02 p.m., .She continues to have distended abdomen and 4 bulging areas from ABD. (Abdomen). All area's are soft and when pressed down they will sink in. No c/o (complaints of) discomfort to area. She refused to eat breakfast and lunch. Drank nothing. When in bed will request water constantly. New order for a fleet's enema. Signed LVN D In an interview on [DATE] at 10:30 a.m., LVN D said Resident #2 had one knot at umbilical area on admission. On [DATE] she had 4 knots around umbilical area. She said she placed a call into Physician A on [DATE] but did not document it but informed the following shift in report. She said she did not look at the clinical record to know that Physician C was Resident #2's physician and not physician A. She said on [DATE] she attempted Tylenol for pain but resident #2 wouldn't take it. She said she did not administer the Fleets enema to Resident #2 due to she had a small and medium bowel movement on [DATE]. She said if she gives a prn (as needed) medication and it is ineffective, she faxes the physician for an alternate treatment. She said Resident #2 would holler out and when asked what she needed she wanted a drink. She said she was not aware resident #2 did not have a bowel movement for 5 days. Record Review of Resident #2 nurses notes revealed the following entry: [DATE] at 11:05 p.m., Resident was hallering (sp) continuously, repositioned still hallering (sp) abdominal distended checked for impaction bowel soft, placed 18 Fr. Foley cath (catheter) 1400 mi (milliliters) dark colored urine in return called Physician C to notify of resident's urine retention Physician C ordered to leave foley cath in place. Signed LVN C (No documentation of Physician C being informed of Resident #2's continued abdominal issues.) In an interview on [DATE] at 1:30 p.m., LVN C said CNA's reported to her Resident #2's abdomen was distended. In report with previous shift, it was reported Resident was constipated. She said LVN D reported she checked Resident #2 and felt soft BM or felt something soft. LVN C said Resident #2 had been like that for 2 days. LVN C said she inserted a catheter into Resident #2's bladder and resident soaked brief, bedding and she waited then unclamped catheter and obtained 1500ml of urine. She said CNA's reported to her Resident #2 had yelled out for 2 days. She said day shift nurse had administered a fleet's enema to Resident #2 on [DATE]. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 2:31 a.m., .No abdominal distention noted at this time No bowel movement noted thus far. Will continue to monitor. Signed LVN H Observation on [DATE] at 10:10 a.m., Resident #2 was in bed, hollering out milk. Staff turned resident on her right side for nurse to cleanse wound to coccyx and apply dressing. Resident denied pain when asked by nurse. Foley catheter intact with clear yellow urine (approximately 100ml) in bed. Resident was transferred from bed to geri chair by two staff. Observation on [DATE] at 10:15 a.m., Resident #2 was sitting in geri chair while staff changed linens on her bed. Resident continues to moan Oh CNA offered health shake and resident #2 took 3 sips then refused. Observation on [DATE] at 12:01 p.m., Resident #2 remains sitting in the geri chair and moaning Oh Observation on [DATE] at 12:15 p.m., Resident #2 remains sitting in the geri chair and continues to call out Oh Observation on [DATE] at 12:19 p.m., Resident #2 attempting to feed resident. Drank 2 sips of water, ate 3 bites of pork but spit all 3 bites out. Refused to eat corn or beans. Resident is requesting milk. Observation on [DATE] at 12:25 p.m., Resident #2 took 10 sips of milk then said enough, stop. Observation on [DATE] at 07:30 a.m., Resident #2 in bed with eyes closed, moaning. (No additional nurse's notes related to Resident #2's abdominal issues prior to [DATE]) [DATE] at 11:14 a.m., .Resident yelling as if in pain. Tylenol 650mg adm (administered) for s/s (signs/symptoms) pain or discomfort .Will continue to monitor. Signed LVN I (No documentation of follow-up for effectiveness of Tylenol) In an interview on [DATE] at 10:55 a.m., LVN I said Resident #2 would yell out Help me. She said on [DATE] she administered Tylenol to Resident #2. It calmed her. She said in report she heard abdomen was bigger due to [MEDICAL CONDITION] and once foley catheter was placed abdomen went down. She said she had not notified the physician of any changes to Resident #2. (No additional nurse's notes related to Resident #2's abdominal issues) Observation on [DATE] at 12:45 p.m., Resident #2 sitting up in geri chair in room. She was awake, moaning, leaning to the right in her chair. Staff notified and resident transferred to bed by two staff. Observation on [DATE] at 3:00 p.m., Resident #2 in bed, moaning out Oh . Her son in room at bedside. Record Review of Resident #2's nurses notes revealed the following entries: [DATE] documented at 6:58 a.m., 0105 This LVN entered resident's room and noted resident with no respirations at this time. NO chest expansion noted at this time. Resident was pale. Skin is still warm to touch. OU fixed and open at this time. No pulse noted at this time. Signed LVN H [DATE] documented at 7:04 a.m., 0115 Police department called at this time and was notified of resident having no vitals. Stated that JP (Justice of Peace) would be notified and funeral home would be called by PD (Police Department). Signed LVN H [DATE] documented at 7:06 a.m., 0140 JP here at this time and taken to resident's room by this LVN. 0150 Resident pronounced at this time. Signed LVN H In an interview on [DATE] at 8:30 a.m., DON said resident #2 passed away around 1:30 a.m. this morning. She said she went to sleep and was gone. Record Review of Resident #2's BM (bowel movement) and Size Roster from [DATE] through [DATE] revealed Resident #2 did not have a bowel movement between [DATE] to [DATE]. Resident #2 only had one small BM on [DATE], one small BM and one medium BM on [DATE] and one small on [DATE]. Record review of Resident #2's admission physician orders [REDACTED]. Resident #2 had orders for [MEDICATION NAME] 325mg 2 po (=650mg) prn q 4 hours prn pain, Milk of Magnesia ,[DATE] ml po prn for indigestion (not ordered as a laxative), [MEDICATION NAME] ([MEDICATION NAME]) 10mg sup 1 rectally prn for no BM in 3 days, May give SS (soap suds) enema prn constipation and may digitally check and remove BM from rectum per licensed nurse prn. Record Review of Resident #2's Medication Administration Record for [DATE] revealed she received [MEDICATION NAME] 325mg 2 tabs (=650mg) on [DATE] at 1:26 a.m., [DATE] at 8:40 a.m. and [DATE] at 9:56 a.m. Resident #2 received Milk of Magnesia ,[DATE] milliliters for indigestion on [DATE] at 4:20 p.m. Resident #2 also received [MEDICATION NAME] 10mg sup one rectally for no Bowel movement in 3 days on [DATE] at 1:15 a.m., [DATE] at 4:20 p.m. and [DATE] at 6:25 a.m. [DATE] at 6:07 p.m., Medication follow-up ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective Signed LVN E [DATE] at 1:26 a.m., [MEDICATION NAME] 325mg 2 po (by mouth) (=650mg) Q (every) 4 .Has been yelling Help Signed LVN F [DATE] at 3:24 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) Q 4, Medication was not effective Signed LVN F [DATE] at 9:47 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) q (every) 4) Medication was effective; Resting at this time. Signed LVN E [DATE] at 1:26 a.m., Medication follow-up (Milk of Magnesia ,[DATE] ml (milliliters) po prn for indi) Medication was not effective. Signed LVN H [DATE] at 1:27 a.m., Medication Follow-up - ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective. Signed LVN H Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message for lab values signed by LVN J. Physician C replied noted with no date of reply. In an interview on [DATE] at 1:55 p.m., LVN J said on admission Resident #2 spoke a lot. She said she would holler hey. She said the abdominal swelling resolved by placement of foley catheter. She said Resident #2 would holler to let you know if she was hurting. Record Review of Resident #2's laboratory report dated [DATE] revealed a White Blood Cell count of 21.4 (high) with normal referenced at 4XXX,[DATE].0. Laboratory report initialed by Physician C. According to the Mayo Clinic a high white blood cell count can indicate an increased production of white blood cells to fight an infection. http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym- 611 (accessed on [DATE]) Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message new resident arrived this evening signed by LVN A. Physician C signed note on [DATE]. In an interview on [DATE] at 12:40 p.m., Physician C said facility staff notified him of resident #2's admission, of her not voiding so he ordered a foley catheter and need for [MEDICATION NAME] suppository as needed for constipation. He said he was not informed by facility staff regarding Resident #2's abdomen being distended or that [MEDICATION NAME] prn (as needed) medications were ineffective. He said if a medication doesn't work (ineffective) the staff should call him back. He said if he had been notified of Resident #2's abdomen being distended, bulging areas noted to abdomen, altered bowel sounds, etc. he would have sent her to emergency room for further evaluation. He said he wasn't sure if the nurses at the facility were not communicating or what. He said it didn't sound like Resident #2 received appropriate care. He said he was on call the day Resident #2 expired but was not notified of her passing. In an interview on [DATE] at 4:30 p.m., Physician C said he was contacted regarding Resident #2's need for foley catheter but was not contacted regarding any urinary symptoms. He said he came to the facility today to see his residents but was asked to leave and come back later when state was gone so he left the facility. Record Review of Facility 24 hour reports regarding Resident #2 revealed [DATE] - 7am/3pm Physician A was called due to abdomen distended and 4 new bulging areas [DATE] - 3pm/11pm Continues to have 4 bulging areas [DATE] - 11pm/7am left lower quadrant noted with sluggish bowel sounds, others absent at this time. Abdomen firm/distended. [MEDICATION NAME] given suppository/rectum; 3pm/11pm noted hollered out several times only wanted water [DATE] - 11pm/7am yelled all shift, 0126 [MEDICATION NAME] 325mg 2 tabs given, WBC (White Blood Cells) are 21.4 normal 4XXX,[DATE].0; 7am/3pm abdomen distention plus 4 knots noted; 3pm/11pm administered sup plus MOM (Milk of Magnesia)= no results yet 2 Tylenol at 840 [DATE] - 11pm/7am MOM/Suppository given ,[DATE] no results; 7am/3pm N.O. (new order) for Fleets Enema had a small BM; 3pm/11pm Placed 18 Fr. Foley 1400 ml dark urine order to keep foley in place, call family please [DATE] - no entries regarding abdominal issues [DATE] - 7am/3pm did not eat breakfast, 10 x drinks of milk at lunch, been yelling out all morning, foley cath; 3pm/11pm foley cath draining to bedside no other issues [DATE] - 11pm/7am no problems, staff did encourage fluids; 7am/3pm no problems; 3pm/11pm No problems, resident passed away. In an interview on [DATE] at 4:05 p.m., DON said she reviewed nurse's notes for Resident #2. She said Resident #2 had two areas on her abdomen on admission. She said in the moment you don't fit it together but reading her nurses notes, you see the pattern of issues. She said the nurses notified Physician C of all the changes and she had the faxes to prove it. She said the nurses did tell Physician C of the changes in Resident #2. She said on the Admission Nursing Assessment, the nurse should document the two areas on her abdomen on the skin condition section. Admission Nursing Assessment was reviewed with DON and the two areas were not documented on the skin condition section of the Admission Nursing Assessment. DON said looking back over nurses notes for Resident #2, it makes sense for the concern but at the time you don't see it. In an interview on [DATE] at 1:55 p.m., CNA A said Resident #2 could understand what was said to her and she could answer you with yes or no. He said she wasn't much on eating but would drink milk. He said Resident #2 would holler out help but a few days prior to her death, she seemed to holler for help less but still called out. He said she didn't verbalize if in pain but if she was asked if in pain, she could answer yes or No. He said he reported to the nurses that Resident #2 was hollering out and also when she didn't eat but could not remember which nurse he reported this to. In an interview on [DATE] at 3:45 p.m., DON said Resident #2 would let you know she was hurting by facial grimacing and hollering out. She said when Resident #2 was asked what she needed, she would deny needing anything. She said a fax was sent to her physician for Milk of Magnesia, Fleets enema for no bowel movement in ,[DATE] days then after med given she had bowel movements. In an interview on [DATE] at 3:50 p.m., ADON said a CNA reported to her (unknown date) when Resident #2 had a knot on her abdomen. She said she assessed the area and it was soft and located in her right upper quadrant. She said Resident #2 hollered almost continuously but if asked if she was in pain, would deny pain. She said to determine what Resident #2 needed, you had to ask yes or no questions. In an interview on [DATE] at 1:53 p.m., CNA D said Resident #2 would yell help all day. She said Resident #2 had 3 bumps on belly. She had the nurse to look at them and was told the resident was admitted with them. She said the 3 bumps looked like little hernias. She said they were soft, like pudding in a balloon. She said she reported to the nurses that Resident #2 would cry daily and that she thought something was wrong with her. In an interview on [DATE] at 10:35 a.m., CNA E said Resident #2 would holler out as if she was in pain. She said she would give her water but resident would refuse water at times. CNA E said Resident #2's abdomen had been distended. She said she notified LVN H and LVN F that resident wasn't urinating, was refusing liquids and appeared in pain. She said she worked the night Resident #2 passed away and nothing out of the ordinary was noted with her. In an interview on [DATE] at 10:45 a.m., CNA F said lumps were present on tummy when admitted . She said Resident #2 would call out help and ouch on admission. She said she would ask Resident #2 if she was in pain and she would say yes and point to abdomen. She said she would drink Ensure, milk and water. She said her abdomen was big but got bigger and bigger as time progressed. She said she notified LVN F (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibited neglect for 1 resident (Resident #2) of 16 residents reviewed for neglect. The facility failed to provide appropriate interventions when Resident #2 who had a history of [REDACTED]. On [DATE] at 1:05 a.m., Resident #2 was found to have no respirations or pulse and pronounced deceased at 1:50 a.m. by the Justice of the Peace. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure to implement the facility's policies and procedures that prohibited neglect, and to assess, monitor, and provide appropriate medical interventions for residents could affect all 61 residents in the facility. This failure could result in serious medical complications, decline in condition and the need for hospitalization or death. The findings included: Review of Abuse policy (undated) revealed Residents of the facility are protected from any verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion .Definitions Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident does not receive or receives a lack of care in one or more areas (e.g. absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces). Resident #2 Record Review of Resident #2's face sheet, dated [DATE], revealed she was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The face sheet identified Resident #2's physician as Physician C. Record Review of Resident #2's admission MDS (Minimum Data Set) dated [DATE] revealed she had moderate difficulty with hearing. She had clear speech, usually makes self-understood and sometimes has the ability to understand others. A BIMS (Brief Interview of Mental Status) could not be performed due to resident was unable to complete the interview. The MDS indicated Resident #2 had moderately impaired cognitive skills. MDS revealed Resident #2 was noted to always be incontinent of bowel and was totally dependent on one person to physically assist with toileting. The MDS dated [DATE] revealed Resident #2 had not received pain medication in the 5 days prior to the assessment and was unable to answer if pain present. MDS revealed Resident #2 displayed other behavioral symptoms (verbal/vocal symptoms or disruptive sounds) not directed toward others 1 to 3 days of the review period. Record Review of Resident #2's Care plan dated [DATE] revealed she has the potential for pain related to stiff joints, impaired mobility and pressure ulcer with a goal she will have pain level no greater than 2 on pain scale of ,[DATE] daily for the next 90 days. Interventions included monitor for signs/symptoms such as grimacing, guarding, frequent complaints of pain, moaning, crying, etc. Notify charge nurse/Physician as needed of signs/symptoms of pain or increased complications of pain, Administer [MEDICATION NAME] 650mg every 4 hours as needed as ordered per physician and utilize PAINAD assessment tool. Record Review of Resident #2's History and Physical, dated [DATE], by Physician D revealed she had 2 falls while at her home resulting in her being weak and unable to get up even with assistance. Past Surgical history included previous abdomen surgery for [REDACTED].#2's abdomen to be soft, nontender, no rebound, guarding or rigidity noted. According to the Mayo Clinic signs and symptoms of bowel obstruction can include Crampy abdominal pain that comes and goes, Loss of appetite, Constipation, Vomiting, Inability to have a bowel movement or pass gas, Swelling of the abdomen. The Mayo Clinic recommended that Because of the serious complications that can develop from intestinal obstruction (bowel obstruction), seek immediate medical care if you have severe abdominal pain or other symptoms of intestinal obstruction. http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc- 463 (accessed on [DATE]) Record Review of Resident #2's Discharge Summary from Hospital B dated [DATE] revealed she was to be discharged to (the facility) with condition at discharge noted as physically and emotionally stable. Discharge follow-up appointments included to follow-up with Physician C in 2 weeks; please call to schedule an appointment. Record Review of Resident #2's facility clinical record revealed an Exit Care Patient Information Packet from Hospital B dated [DATE]. The Exit Care packet revealed seek medical care if you have abdominal pain and it increases or stays in one area (localizes) .Make sure you understand these instructions, will watch your condition and will get help right away if you are not doing well or get worse. Record Review of Resident #2's Nurses' Admission Nursing Assessment, dated [DATE], and completed by LVN A revealed Resident #2's condition on admission was she was alert and required 2 person assist with transfers, utilized a wheelchair for ambulation, poor hearing bilaterally, clear communication, needs assistance for eating, dependent for shower, grooming, dressing and shampoo. LVN A noted Resident #2 was not continent of bowel and last bowel movement was [DATE]. The nurse's admission record identified Resident #2's pulse as 96 and irregular, her respirations as 16, her temperature as 98.1, and her blood pressure as ,[DATE]. General Skin condition was noted to be warm and dry with pressure ulcer noted to coccyx. Review of Resident #2's Nurses Admission Nursing Assessment did not reveal any documentation regarding abdominal distention or abdominal bulging. Record Review of Resident #2's Nurses' Notes revealed the following entries: [DATE] 5:57 p.m., admitted this 85 yr (year) old female . for services of Physician C .Resident is alert upon admission. Family member present upon admission. Resident is hoh (hard of hearing). Diet mech (mechanical) soft Signed by LVN A In an interview on [DATE] at 4:30 p.m., LVN A said CNA's did not report anything different with Resident #2. She said on admission, Resident #2 refused to eat but would drink. She said sometimes Resident #2 was a feeder. She said Resident #2 would yell help me, help me but couldn't specify what help she needed. She said there was nothing abnormal noted to abdomen. She said in report it came up that Resident #2 had four bulging areas which was toward the end of her life in the last week or so. She said she did not witness Resident #2 crying, holding her abdomen. [DATE] at 9:37 p.m., .Speech is clear and is able to voice her wants and needs. Resident is HOH (hard of hearing) and does not see well .Bowel sounds x 4 quadrants with no abdominal distention noted .Final dose of antibiotic administered has voiced no needs at this time . Signed LVN E (No additional nurse's notes related to bowel issues prior to [DATE].) [DATE] at 9:24 p.m., .Awake, alert in bed .poor appetite needs to be fed during meals abdominal distended where the hernias are present. Resident continues to yell out help when approached resident does not say anything else. No Distress noted at this time . Signed LVN C [DATE] at 12:38 p.m., Resident was being wheeled to D/R (Dining room) and noted abd (abdomen) distended with 4 bulging sores to abdomen. She states no when asked if stomach hurts her. She is only concerned about laying back down and hollers that often. Called Physician A (facility's Medical Director, not Resident #2's physician) and left message that one of Physician B's (not Resident #2's physician) residents needed to be checked on. Waiting for answer from Physician A Signed LVN D In an interview on [DATE] at 1:40 p.m., LVN D said Resident #2 had not had a bowel movement in a while and said several things were tried. She said when Resident #2 was admitted she would moan but then started yelling. She said Resident #2 would drink water but refused snacks. She said Resident #2 would let you know she was hurting by facial grimacing and answering yes or no when asked if she was in pain. She said she communicated her changes by communicating in change of shift report. She said she called Physician A (facility's Medical Director but not the primary care physician for Resident #2) on [DATE] but he did not call back. She said nurses are to fax a note to the physician if needing to notify physician of a change in condition of a resident. She said she did not realize Physician A or B was not the physician for Resident #2 because she didn't check the medical chart to see who the physician was. After reviewing her nurses note entries, LVN D said she did not realize at the time what was going on with Resident #2. [DATE] at 9:46 p.m., .speech is clear and is able to voice wants and needs .Bowel Sounds x 4 quadrants with no abdominal distention noted has voiced no needs at this time . Signed LVN E Record Review of Resident #2 nurses notes revealed the following entry; [DATE] at 9:57 a.m., resting in bed with eyes closed, no s/sx (signs or symptoms) of pain/discomfort noted, abdomen remains distended and several buldged (sp) areas to mid abdomen remain . Signed LVN G In an interview on [DATE] at 11:05 a.m., LVN G said on [DATE] CNA showed her Resident #2 had 2 bulging areas above umbilicus and 1 below umbilicus. She said her abdomen was distended but soft and was non-tender when palpated. She said Resident #2 did not appear in pain when touched. She said resident #2 would yell out a lot but never was in pain but would request water to drink. She said did not notify physician of bulging areas or of abdominal distention. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 9:31 p.m., Resident continues to have 4 buldging (sp) areas to abdomen with abdominal distention. Physician C has been notified. Signed LVN E [DATE] at 1:05 a.m., Abd (abdomen) distended when palpating abd res (resident) yells ouch. ABD firm/distended. Checked for impaction. Noted Res to have x 2 very small round hard formed stools. [MEDICATION NAME] 10mg one sup. (Suppository) given rectally. Also noted umbilical buldging (sp). Will continue to monitor. Incontinent of bladder with check performed q (every 2 hrs (hours) and prn (as needed) with peri care given after each episode. T/R (turn/reposition) q 2 hours. Side rails up for safety. Call light in reach. Signed LVN F [DATE] at 1:15 a.m., [MEDICATION NAME] 10mg sup (suppository) one rectally prn For constipation noted to have x2 hard balls in rectum. ABD (abdomen) distended/painful to touch. Signed LVN F [DATE] at 1:17 a.m., Also noted sluggish bowel sound in left lower quad (quadrant). Signed LVN F In an interview on [DATE] at 1:55 p.m., LVN F said Resident #2 was hard of hearing but could answer questions appropriately at times to make her needs known. She said Resident #2 had an area of distention then it progressed to full blown distention. She said Resident #2 was unable to clearly state where she was hurting, but could respond yes or no. She said she was always requesting water. She said she documented her findings in the nurse's notes and would communicate to other shifts via the communication log. She said when CNA's reported any changes in condition of a resident, she would assess the resident and notify the physician via fax. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 4:40 p.m., . BS (bowel sounds) x 4 hypoactive, abdomen distended, nontender on palpation, possible hernia noted around the umbilical region. Resident denies any pain . No stool noted. Signed RN A [DATE] at 11:08 a.m., Resident has been in bed all day with a low grade temp. noted of 99.4 was turned and repositioned. She hollers out for help constantly and hollers out in pain when moved. She continues to have distended abd (abdomen) and 4 knots noted to abdomen. Signed LVN D [DATE] at 1:32 p.m., .Abdomen is soft, observed 4 large soft rounded knots around umbilical region. No discomfort reported by patient on palpation of this area. Bowel sounds are present but hypoactive. Pericare done q (ever) 2 h (hours) and PRN (as needed). Resident continues to have poor po (by mouth) intake with fluids and meals. Signed RN A [DATE] at 9:49 p.m., At 4:20 pm residents stomach continues to be very distended and has had no results from laxative given on the previous day. Administered MOM (Milk of Magnesia) and one [MEDICATION NAME] to try to obtain a bowel movement. At this time 9:48 pm she has had no results. At 8:40 pm resident continuously saying ow. Administered 2 Tylenol for discomfort and repositioned her. At this time she is resting quietly. Signed LVN E In an interview on [DATE] at 4:20 p.m., LVN E said Resident #2 usually hollered help but one day she hollered ow. She said in shift report she was told resident #2 had a suppository and was constipated. She said she assessed her and noted she had bowel sounds and bulging around umbilicus. She said she palpated her abdomen but didn't feel anything abnormal She thought she should give resident something by mouth and rectally to get her going. She said she documented in the nurses notes she notified Physician C but she did not notify him. She said a nurse from a previous shift/day had notified Physician C. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:11 a.m., Res (resident) yelled all shift for help or wanting a drink of water, res has taken 200 cc H2O (water). Voiding QS (quantity sufficient) with peri care given after each episode. No BMS (bowel movements) this shift. Continues to have sluggish bowel sounds with several buldging (sp) areas around umbilical area. Signed LVN F In an interview on [DATE] at 3:43 p.m., LVN F said Resident #2 yelled out a lot on [DATE] and [DATE] but nothing unusual. She said she worked at night with her and when Resident #2 was awake, she was hollering. She said she noticed Resident #2 to have abdominal distention and hypoactive bowel sounds with 3 or so knots noted around umbilicus area. She said she called Physician C but no answer. She said she gave her a [MEDICATION NAME] suppository due to hard round stools but didn't have anything to give her by mouth for constipation. She said she documented on the medication administration record and nurses notes of the [MEDICATION NAME] suppository being administered. She also documented on the 24 hour nursing report for nurses to know to follow-up for effectiveness. She said in report she was notified of Resident #2 having abdominal distention. [DATE] at 3:11 a.m., .Abdomen remains distended. Bowel sounds are present to left upper and lower quadrant. Bilateral lower quads are sluggish. Resident only voided a small amount of urine thus far. Resident holding lower abdomen and was noted with facial grimacing. She has had no results for [MEDICATION NAME] sup thus far. She has been afebrile. She is HOH but will answer staff when we speak loudly by her ear. Signed LVN H [DATE] at 7:21 a.m., 0624 Resident continues to have abdominal distention at this time. Bowels have not moved this shift. Fluids are encouraged and resident will yell out that she does not want fluids.[MEDICATION NAME] sup (suppository) administered rectally. Will relinquish effectiveness to oncoming shift. Signed LVN H In an interview on [DATE] at 3:47 p.m., LVN H said Resident #2 had a hard time with fluid intake and staff feeding her. LVN H said several CNA's had reported to her Resident #2's abdomen was distended. She said when she was having stomach problems, she wouldn't eat or drink and she progressively took in less. She said on an assessment of Resident #2 she noted sluggish bowel sounds and lumps where umbilical hernia that became more pronounced as abdomen became distended and she charted in the nurse's notes her findings. LVN H said she did not notify a physician of changes in Resident #2. She said she told the oncoming shift to follow-up. Record Review of faxed note to Physician C dated [DATE] (This was faxed on Saturday outside physician C's normal operating hours) regarding Resident #2 with message that abd sl (abdomen slightly) firm/distended. Also noted abd buldging (sp) below umbilical, checked resident for impaction, noted x 2 small hard roll stool. Gave res (resident) a [MEDICATION NAME] 10mg supp. rectally without results. Res complained of pain when palpating abdomen. She has nothing more to give on [MEDICATION NAME]. What do you want me to do? I tried calling you this am on both numbers, they went to voice mail. Signed LVN F. Physician C replied on [DATE] with order to try fleet's enema. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:02 p.m., .She continues to have distended abdomen and 4 bulging areas from ABD. (Abdomen). All area's are soft and when pressed down they will sink in. No c/o (complaints of) discomfort to area. She refused to eat breakfast and lunch. Drank nothing. When in bed will request water constantly. New order for a fleet's enema. Signed LVN D In an interview on [DATE] at 10:30 a.m., LVN D said Resident #2 had one knot at umbilical area on admission. On [DATE] she had 4 knots around umbilical area. She said she placed a call into Physician A on [DATE] but did not document it but informed the following shift in report. She said she did not look at the clinical record to know that Physician C was Resident #2's physician and not physician A. She said on [DATE] she attempted Tylenol for pain but resident #2 wouldn't take it. She said she did not administer the Fleets enema to Resident #2 due to she had a small and medium bowel movement on [DATE]. She said if she gives a prn (as needed) medication and it is ineffective, she faxes the physician for an alternate treatment. She said Resident #2 would holler out and when asked what she needed she wanted a drink. She said she was not aware resident #2 did not have a bowel movement for 5 days. Record Review of Resident #2 nurses notes revealed the following entry: [DATE] at 11:05 p.m., Resident was hallering (sp) continuously, repositioned still hallering (sp) abdominal distended checked for impaction bowel soft, placed 18 Fr. Foley cath (catheter) 1400 mi (milliliters) dark colored urine in return called Physician C to notify of resident's urine retention Physician C ordered to leave foley cath in place. Signed LVN C (No documentation of Physician C being informed of Resident #2's continued abdominal issues.) In an interview on [DATE] at 1:30 p.m., LVN C said CNA's reported to her Resident #2's abdomen was distended. In report with previous shift, it was reported Resident was constipated. She said LVN D reported she checked Resident #2 and felt soft BM or felt something soft. LVN C said Resident #2 had been like that for 2 days. LVN C said she inserted a catheter into Resident #2's bladder and resident soaked brief, bedding and she waited then unclamped catheter and obtained 1500ml of urine. She said CNA's reported to her Resident #2 had yelled out for 2 days. She said day shift nurse had administered a fleet's enema to Resident #2 on [DATE]. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 2:31 a.m., .No abdominal distention noted at this time No bowel movement noted thus far. Will continue to monitor. Signed LVN H Observation on [DATE] at 10:10 a.m., Resident #2 was in bed, hollering out milk. Staff turned resident on her right side for nurse to cleanse wound to coccyx and apply dressing. Resident denied pain when asked by nurse. Foley catheter intact with clear yellow urine (approximately 100ml) in bed. Resident was transferred from bed to geri chair by two staff. Observation on [DATE] at 10:15 a.m., Resident #2 was sitting in geri chair while staff changed linens on her bed. Resident continues to moan Oh CNA offered health shake and resident #2 took 3 sips then refused. Observation on [DATE] at 12:01 p.m., Resident #2 remains sitting in the geri chair and moaning Oh Observation on [DATE] at 12:15 p.m., Resident #2 remains sitting in the geri chair and continues to call out Oh Observation on [DATE] at 12:19 p.m., Resident #2 attempting to feed resident. Drank 2 sips of water, ate 3 bites of pork but spit all 3 bites out. Refused to eat corn or beans. Resident is requesting milk. Observation on [DATE] at 12:25 p.m., Resident #2 took 10 sips of milk then said enough, stop. Observation on [DATE] at 07:30 a.m., Resident #2 in bed with eyes closed, moaning. (No additional nurse's notes related to Resident #2's abdominal issues prior to [DATE]) [DATE] at 11:14 a.m., .Resident yelling as if in pain. Tylenol 650mg adm (administered) for s/s (signs/symptoms) pain or discomfort .Will continue to monitor. Signed LVN I (No documentation of follow-up for effectiveness of Tylenol) In an interview on [DATE] at 10:55 a.m., LVN I said Resident #2 would yell out Help me. She said on [DATE] she administered Tylenol to Resident #2. It calmed her. She said in report she heard abdomen was bigger due to [MEDICAL CONDITION] and once foley catheter was placed abdomen went down. She said she had not notified the physician of any changes to Resident #2. (No additional nurse's notes related to Resident #2's abdominal issues) Observation on [DATE] at 12:45 p.m., Resident #2 sitting up in geri chair in room. She was awake, moaning, leaning to the right in her chair. Staff notified and resident transferred to bed by two staff. Observation on [DATE] at 3:00 p.m., Resident #2 in bed, moaning out Oh . Her son in room at bedside. Record Review of Resident #2's nurses notes revealed the following entries: [DATE] documented at 6:58 a.m., 0105 This LVN entered resident's room and noted resident with no respirations at this time. NO chest expansion noted at this time. Resident was pale. Skin is still warm to touch. OU fixed and open at this time. No pulse noted at this time. Signed LVN H [DATE] documented at 7:04 a.m., 0115 Police department called at this time and was notified of resident having no vitals. Stated that JP (Justice of Peace) would be notified and funeral home would be called by PD (Police Department). Signed LVN H [DATE] documented at 7:06 a.m., 0140 JP here at this time and taken to resident's room by this LVN. 0150 Resident pronounced at this time. Signed LVN H In an interview on [DATE] at 8:30 a.m., DON said resident #2 passed away around 1:30 a.m. this morning. She said she went to sleep and was gone. Record Review of Resident #2's BM (bowel movement) and Size Roster from [DATE] through [DATE] revealed Resident #2 did not have a bowel movement between [DATE] to [DATE]. Resident #2 only had one small BM on [DATE], one small BM and one medium BM on [DATE] and one small on [DATE]. Record review of Resident #2's admission physician orders [REDACTED]. Resident #2 had orders for [MEDICATION NAME] 325mg 2 po (=650mg) prn q 4 hours prn pain, Milk of Magnesia ,[DATE] ml po prn for indigestion (not ordered as a laxative), [MEDICATION NAME] ([MEDICATION NAME]) 10mg sup 1 rectally prn for no BM in 3 days, May give SS (soap suds) enema prn constipation and may digitally check and remove BM from rectum per licensed nurse prn. Record Review of Resident #2's Medication Administration Record for [DATE] revealed she received [MEDICATION NAME] 325mg 2 tabs (=650mg) on [DATE] at 1:26 a.m., [DATE] at 8:40 a.m. and [DATE] at 9:56 a.m. Resident #2 received Milk of Magnesia ,[DATE] milliliters for indigestion on [DATE] at 4:20 p.m. Resident #2 also received [MEDICATION NAME] 10mg sup one rectally for no Bowel movement in 3 days on [DATE] at 1:15 a.m., [DATE] at 4:20 p.m. and [DATE] at 6:25 a.m. [DATE] at 6:07 p.m., Medication follow-up ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective Signed LVN E [DATE] at 1:26 a.m., [MEDICATION NAME] 325mg 2 po (by mouth) (=650mg) Q (every) 4 .Has been yelling Help Signed LVN F [DATE] at 3:24 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) Q 4, Medication was not effective Signed LVN F [DATE] at 9:47 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) q (every) 4) Medication was effective; Resting at this time. Signed LVN E [DATE] at 1:26 a.m., Medication follow-up (Milk of Magnesia ,[DATE] ml (milliliters) po prn for indi) Medication was not effective. Signed LVN H [DATE] at 1:27 a.m., Medication Follow-up - ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective. Signed LVN H Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message for lab values signed by LVN J. Physician C replied noted with no date of reply. In an interview on [DATE] at 1:55 p.m., LVN J said on admission Resident #2 spoke a lot. She said she would holler hey. She said the abdominal swelling resolved by placement of foley catheter. She said Resident #2 would holler to let you know if she was hurting. Record Review of Resident #2's laboratory report dated [DATE] revealed a White Blood Cell count of 21.4 (high) with normal referenced at 4XXX,[DATE].0. Laboratory report initialed by Physician C. According to the Mayo Clinic a high white blood cell count can indicate an increased production of white blood cells to fight an infection. http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym- 611 (accessed on [DATE]) Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message new resident arrived this evening signed by LVN A. Physician C signed note on [DATE]. In an interview on [DATE] at 12:40 p.m., Physician C said facility staff notified him of resident #2's admission, of her not voiding so he ordered a foley catheter and need for [MEDICATION NAME] suppository as needed for constipation. He said he was not informed by facility staff regarding Resident #2's abdomen being distended or that [MEDICATION NAME] prn (as needed) medications were ineffective. He said if a medication doesn't work (ineffective) the staff should call him back. He said if he had been notified of Resident #2's abdomen being distended, bulging areas noted to abdomen, altered bowel sounds, etc. he would have sent her to emergency room for further evaluation. He said he wasn't sure if the nurses at the facility were not communicating or what. He said it didn't sound like Resident #2 received appropriate care. He said he was on call the day Resident #2 expired but was not notified of her passing. In an interview on [DATE] at 4:30 p.m., Physician C said he was contacted regarding Resident #2's need for foley catheter but was not contacted regarding any urinary symptoms. He said he came to the facility today to see his residents but was asked to leave and come back later when state was gone so he left the facility. Record Review of Facility 24 hour reports regarding Resident #2 revealed [DATE] - 7am/3pm Physician A was called due to abdomen distended and 4 new bulging areas [DATE] - 3pm/11pm Continues to have 4 bulging areas [DATE] - 11pm/7am left lower quadrant noted with sluggish bowel sounds, others absent at this time. Abdomen firm/distended. [MEDICATION NAME] given suppository/rectum; 3pm/11pm noted hollered out several times only wanted water [DATE] - 11pm/7am yelled all shift, 0126 [MEDICATION NAME] 325mg 2 tabs given, WBC (White Blood Cells) are 21.4 normal 4XXX,[DATE].0; 7am/3pm abdomen distention plus 4 knots noted; 3pm/11pm administered sup plus MOM (Milk of Magnesia)= no results yet 2 Tylenol at 840 [DATE] - 11pm/7am MOM/Suppository given ,[DATE] no results; 7am/3pm N.O. (new order) for Fleets Enema had a small BM; 3pm/11pm Placed 18 Fr. Foley 1400 ml dark urine order to keep foley in place, call family please [DATE] - no entries regarding abdominal issues [DATE] - 7am/3pm did not eat breakfast, 10 x drinks of milk at lunch, been yelling out all morning, foley cath; 3pm/11pm foley cath draining to bedside no other issues [DATE] - 11pm/7am no problems, staff did encourage fluids; 7am/3pm no problems; 3pm/11pm No problems, resident passed away. In an interview on [DATE] at 4:05 p.m., DON said she reviewed nurse's notes for Resident #2. She said Resident #2 had two areas on her abdomen on admission. She said in the moment you don't fit it together but reading her nurses notes, you see the pattern of issues. She said the nurses notified Physician C of all the changes and she had the faxes to prove it. She said the nurses did tell Physician C of the changes in Resident #2. She said on the Admission Nursing Assessment, the nurse should document the two areas on her abdomen on the skin condition section. Admission Nursing Assessment was reviewed with DON and the two areas were not documented on the skin condition section of the Admission Nursing Assessment. DON said looking back over nurses notes for Resident #2, it makes sense for the concern but at the time you don't see it. In an interview on [DATE] at 1:55 p.m., CNA A said Resident #2 could understand what was said to her and she could answer you with yes or no. He said she wasn't much on eating but would drink milk. He said Resident #2 would holler out help but a few days prior to her death, she seemed to holler for help less but still called out. He said she didn't verbalize if in pain but if she was asked if in pain, she could answer yes or No. He said he reported to the nurses that Resident #2 was hollering out and also when she didn't eat but could not remember which nurse he reported this to. In an interview on [DATE] at 3:45 p.m., DON said Resident #2 would let you know she was hurting by facial grimacing and hollering out. She said when Resident #2 was asked what she needed, she would deny needing anything. She said a fax was sent to her physician for Milk of Magnesia, Fleets enema for no bowel movement in ,[DATE] days then after med given she had bowel movements. In an interview on [DATE] at 3:50 p.m., ADON said a CNA reported to her (unknown date) when Resident #2 had a knot on her abdomen. She said she assessed the area and it was soft and located in her right upper quadrant. She said Resident #2 hollered almost continuously but if asked if she was in pain, would deny pain. She said to determine what Resident #2 needed, you had to ask yes or no questions. In an interview on [DATE] at 1:53 p.m., CNA D said Resident #2 would yell help all day. She said Resident #2 had 3 bumps on belly. She had the nurse to look at them and was told the resident was admitted with them. She said the 3 bumps looked like little hernias. She said they were soft, like pudding in a balloon. She said she reported to the nurses that Resident #2 would cry daily and that she thought something was wrong with her. In an interview on [DATE] at 10:35 a.m., CNA E said Resident #2 would holler out as if she was in pain. She said she would give her water but resident would refuse water at times. CNA E said Resident (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for 1 resident (Resident #2) of 16 residents reviewed for change of condition. The facility failed to provide appropriate interventions when Resident #2 who had a history of [REDACTED]. On [DATE] at 1:05 a.m., Resident #2 was found to have no respirations or pulse and pronounced deceased at 1:50 a.m. by the Justice of the Peace. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure to thoroughly assess, monitor, and provide appropriate medical interventions for residents who experienced a change in condition could affect all 61 residents in the facility, and could result in serious medical complications, decline in condition and the need for hospitalization or death. The findings included: Resident #2 Record Review of Resident #2's face sheet, dated [DATE], revealed she was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The face sheet identified Resident #2's physician as Physician C. Record Review of Resident #2's admission MDS (Minimum Data Set) dated [DATE] revealed she had moderate difficulty with hearing. She had clear speech, usually makes self-understood and sometimes has the ability to understand others. A BIMS (Brief Interview of Mental Status) could not be performed due to resident was unable to complete the interview. The MDS indicated Resident #2 had moderately impaired cognitive skills. MDS revealed Resident #2 was noted to always be incontinent of bowel and was totally dependent on one person to physically assist with toileting. The MDS dated [DATE] revealed Resident #2 had not received pain medication in the 5 days prior to the assessment and was unable to answer if pain present. MDS revealed Resident #2 displayed other behavioral symptoms (verbal/vocal symptoms or disruptive sounds) not directed toward others 1 to 3 days of the review period. Record Review of Resident #2's Care plan dated [DATE] revealed she has the potential for pain related to stiff joints, impaired mobility and pressure ulcer with a goal she will have pain level no greater than 2 on pain scale of ,[DATE] daily for the next 90 days. Interventions included monitor for signs/symptoms such as grimacing, guarding, frequent complaints of pain, moaning, crying, etc. Notify charge nurse/Physician as needed of signs/symptoms of pain or increased complications of pain, Administer [MEDICATION NAME] 650mg every 4 hours as needed as ordered per physician and utilize PAINAD assessment tool. Record Review of Resident #2's History and Physical, dated [DATE], by Physician D revealed she had 2 falls while at her home resulting in her being weak and unable to get up even with assistance. Past Surgical history included previous abdomen surgery for [REDACTED].#2's abdomen to be soft, nontender, no rebound, guarding or rigidity noted. According to the Mayo Clinic signs and symptoms of bowel obstruction can include Crampy abdominal pain that comes and goes, Loss of appetite, Constipation, Vomiting, Inability to have a bowel movement or pass gas, Swelling of the abdomen. The Mayo Clinic recommended that Because of the serious complications that can develop from intestinal obstruction (bowel obstruction), seek immediate medical care if you have severe abdominal pain or other symptoms of intestinal obstruction. http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc- 463 (accessed on [DATE]) Record Review of Resident #2's Discharge Summary from Hospital B dated [DATE] revealed she was to be discharged to (the facility) with condition at discharge noted as physically and emotionally stable. Discharge follow-up appointments included to follow-up with Physician C in 2 weeks; please call to schedule an appointment. Record Review of Resident #2's facility clinical record revealed an Exit Care Patient Information Packet from Hospital B dated [DATE]. The Exit Care packet revealed seek medical care if you have abdominal pain and it increases or stays in one area (localizes) .Make sure you understand these instructions, will watch your condition and will get help right away if you are not doing well or get worse. Record Review of Resident #2's Nurses' Admission Nursing Assessment, dated [DATE], and completed by LVN A revealed Resident #2's condition on admission was she was alert and required 2 person assist with transfers, utilized a wheelchair for ambulation, poor hearing bilaterally, clear communication, needs assistance for eating, dependent for shower, grooming, dressing and shampoo. LVN A noted Resident #2 was not continent of bowel and last bowel movement was [DATE]. The nurse's admission record identified Resident #2's pulse as 96 and irregular, her respirations as 16, her temperature as 98.1, and her blood pressure as ,[DATE]. General Skin condition was noted to be warm and dry with pressure ulcer noted to coccyx. Review of Resident #2's Nurses Admission Nursing Assessment did not reveal any documentation regarding abdominal distention or abdominal bulging. Record Review of Resident #2's Nurses' Notes revealed the following entries: [DATE] 5:57 p.m., admitted this 85 yr (year) old female . for services of Physician C .Resident is alert upon admission. Family member present upon admission. Resident is hoh (hard of hearing). Diet mech (mechanical) soft Signed by LVN A In an interview on [DATE] at 4:30 p.m., LVN A said CNA's did not report anything different with Resident #2. She said on admission, Resident #2 refused to eat but would drink. She said sometimes Resident #2 was a feeder. She said Resident #2 would yell help me, help me but couldn't specify what help she needed. She said there was nothing abnormal noted to abdomen. She said in report it came up that Resident #2 had four bulging areas which was toward the end of her life in the last week or so. She said she did not witness Resident #2 crying, holding her abdomen. [DATE] at 9:37 p.m., .Speech is clear and is able to voice her wants and needs. Resident is HOH (hard of hearing) and does not see well .Bowel sounds x 4 quadrants with no abdominal distention noted .Final dose of antibiotic administered has voiced no needs at this time . Signed LVN E (No additional nurse's notes related to bowel issues prior to [DATE].) [DATE] at 9:24 p.m., .Awake, alert in bed .poor appetite needs to be fed during meals abdominal distended where the hernias are present. Resident continues to yell out help when approached resident does not say anything else. No Distress noted at this time . Signed LVN C [DATE] at 12:38 p.m., Resident was being wheeled to D/R (Dining room) and noted abd (abdomen) distended with 4 bulging sores to abdomen. She states no when asked if stomach hurts her. She is only concerned about laying back down and hollers that often. Called Physician A (facility's Medical Director, not Resident #2's physician) and left message that one of Physician B's (not Resident #2's physician) residents needed to be checked on. Waiting for answer from Physician A Signed LVN D In an interview on [DATE] at 1:40 p.m., LVN D said Resident #2 had not had a bowel movement in a while and said several things were tried. She said when Resident #2 was admitted she would moan but then started yelling. She said Resident #2 would drink water but refused snacks. She said Resident #2 would let you know she was hurting by facial grimacing and answering yes or no when asked if she was in pain. She said she communicated her changes by communicating in change of shift report. She said she called Physician A (facility's Medical Director but not the primary care physician for Resident #2) on [DATE] but he did not call back. She said nurses are to fax a note to the physician if needing to notify physician of a change in condition of a resident. She said she did not realize Physician A or B was not the physician for Resident #2 because she didn't check the medical chart to see who the physician was. After reviewing her nurses note entries, LVN D said she did not realize at the time what was going on with Resident #2. [DATE] at 9:46 p.m., .speech is clear and is able to voice wants and needs .Bowel Sounds x 4 quadrants with no abdominal distention noted has voiced no needs at this time . Signed LVN E Record Review of Resident #2 nurses notes revealed the following entry; [DATE] at 9:57 a.m., resting in bed with eyes closed, no s/sx (signs or symptoms) of pain/discomfort noted, abdomen remains distended and several buldged (sp) areas to mid abdomen remain . Signed LVN G In an interview on [DATE] at 11:05 a.m., LVN G said on [DATE] CNA showed her Resident #2 had 2 bulging areas above umbilicus and 1 below umbilicus. She said her abdomen was distended but soft and was non-tender when palpated. She said Resident #2 did not appear in pain when touched. She said resident #2 would yell out a lot but never was in pain but would request water to drink. She said did not notify physician of bulging areas or of abdominal distention. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 9:31 p.m., Resident continues to have 4 buldging (sp) areas to abdomen with abdominal distention. Physician C has been notified. Signed LVN E [DATE] at 1:05 a.m., Abd (abdomen) distended when palpating abd res (resident) yells ouch. ABD firm/distended. Checked for impaction. Noted Res to have x 2 very small round hard formed stools. [MEDICATION NAME] 10mg one sup. (Suppository) given rectally. Also noted umbilical buldging (sp). Will continue to monitor. Incontinent of bladder with check performed q (every 2 hrs (hours) and prn (as needed) with peri care given after each episode. T/R (turn/reposition) q 2 hours. Side rails up for safety. Call light in reach. Signed LVN F [DATE] at 1:15 a.m., [MEDICATION NAME] 10mg sup (suppository) one rectally prn For constipation noted to have x2 hard balls in rectum. ABD (abdomen) distended/painful to touch. Signed LVN F [DATE] at 1:17 a.m., Also noted sluggish bowel sound in left lower quad (quadrant). Signed LVN F In an interview on [DATE] at 1:55 p.m., LVN F said Resident #2 was hard of hearing but could answer questions appropriately at times to make her needs known. She said Resident #2 had an area of distention then it progressed to full blown distention. She said Resident #2 was unable to clearly state where she was hurting, but could respond yes or no. She said she was always requesting water. She said she documented her findings in the nurse's notes and would communicate to other shifts via the communication log. She said when CNA's reported any changes in condition of a resident, she would assess the resident and notify the physician via fax. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 4:40 p.m., . BS (bowel sounds) x 4 hypoactive, abdomen distended, nontender on palpation, possible hernia noted around the umbilical region. Resident denies any pain . No stool noted. Signed RN A [DATE] at 11:08 a.m., Resident has been in bed all day with a low grade temp. noted of 99.4 was turned and repositioned. She hollers out for help constantly and hollers out in pain when moved. She continues to have distended abd (abdomen) and 4 knots noted to abdomen. Signed LVN D [DATE] at 1:32 p.m., .Abdomen is soft, observed 4 large soft rounded knots around umbilical region. No discomfort reported by patient on palpation of this area. Bowel sounds are present but hypoactive. Pericare done q (ever) 2 h (hours) and PRN (as needed). Resident continues to have poor po (by mouth) intake with fluids and meals. Signed RN A [DATE] at 9:49 p.m., At 4:20 pm residents stomach continues to be very distended and has had no results from laxative given on the previous day. Administered MOM (Milk of Magnesia) and one [MEDICATION NAME] to try to obtain a bowel movement. At this time 9:48 pm she has had no results. At 8:40 pm resident continuously saying ow. Administered 2 Tylenol for discomfort and repositioned her. At this time she is resting quietly. Signed LVN E In an interview on [DATE] at 4:20 p.m., LVN E said Resident #2 usually hollered help but one day she hollered ow. She said in shift report she was told resident #2 had a suppository and was constipated. She said she assessed her and noted she had bowel sounds and bulging around umbilicus. She said she palpated her abdomen but didn't feel anything abnormal She thought she should give resident something by mouth and rectally to get her going. She said she documented in the nurses notes she notified Physician C but she did not notify him. She said a nurse from a previous shift/day had notified Physician C. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:11 a.m., Res (resident) yelled all shift for help or wanting a drink of water, res has taken 200 cc H2O (water). Voiding QS (quantity sufficient) with peri care given after each episode. No BMS (bowel movements) this shift. Continues to have sluggish bowel sounds with several buldging (sp) areas around umbilical area. Signed LVN F In an interview on [DATE] at 3:43 p.m., LVN F said Resident #2 yelled out a lot on [DATE] and [DATE] but nothing unusual. She said she worked at night with her and when Resident #2 was awake, she was hollering. She said she noticed Resident #2 to have abdominal distention and hypoactive bowel sounds with 3 or so knots noted around umbilicus area. She said she called Physician C but no answer. She said she gave her a [MEDICATION NAME] suppository due to hard round stools but didn't have anything to give her by mouth for constipation. She said she documented on the medication administration record and nurses notes of the [MEDICATION NAME] suppository being administered. She also documented on the 24 hour nursing report for nurses to know to follow-up for effectiveness. She said in report she was notified of Resident #2 having abdominal distention. [DATE] at 3:11 a.m., .Abdomen remains distended. Bowel sounds are present to left upper and lower quadrant. Bilateral lower quads are sluggish. Resident only voided a small amount of urine thus far. Resident holding lower abdomen and was noted with facial grimacing. She has had no results for [MEDICATION NAME] sup thus far. She has been afebrile. She is HOH but will answer staff when we speak loudly by her ear. Signed LVN H [DATE] at 7:21 a.m., 0624 Resident continues to have abdominal distention at this time. Bowels have not moved this shift. Fluids are encouraged and resident will yell out that she does not want fluids.[MEDICATION NAME] sup (suppository) administered rectally. Will relinquish effectiveness to oncoming shift. Signed LVN H In an interview on [DATE] at 3:47 p.m., LVN H said Resident #2 had a hard time with fluid intake and staff feeding her. LVN H said several CNA's had reported to her Resident #2's abdomen was distended. She said when she was having stomach problems, she wouldn't eat or drink and she progressively took in less. She said on an assessment of Resident #2 she noted sluggish bowel sounds and lumps where umbilical hernia that became more pronounced as abdomen became distended and she charted in the nurse's notes her findings. LVN H said she did not notify a physician of changes in Resident #2. She said she told the oncoming shift to follow-up. Record Review of faxed note to Physician C dated [DATE] (This was faxed on Saturday outside physician C's normal operating hours) regarding Resident #2 with message that abd sl (abdomen slightly) firm/distended. Also noted abd buldging (sp) below umbilical, checked resident for impaction, noted x 2 small hard roll stool. Gave res (resident) a [MEDICATION NAME] 10mg supp. rectally without results. Res complained of pain when palpating abdomen. She has nothing more to give on [MEDICATION NAME]. What do you want me to do? I tried calling you this am on both numbers, they went to voice mail. Signed LVN F. Physician C replied on [DATE] with order to try fleet's enema. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 1:02 p.m., .She continues to have distended abdomen and 4 bulging areas from ABD. (Abdomen). All area's are soft and when pressed down they will sink in. No c/o (complaints of) discomfort to area. She refused to eat breakfast and lunch. Drank nothing. When in bed will request water constantly. New order for a fleet's enema. Signed LVN D In an interview on [DATE] at 10:30 a.m., LVN D said Resident #2 had one knot at umbilical area on admission. On [DATE] she had 4 knots around umbilical area. She said she placed a call into Physician A on [DATE] but did not document it but informed the following shift in report. She said she did not look at the clinical record to know that Physician C was Resident #2's physician and not physician A. She said on [DATE] she attempted Tylenol for pain but resident #2 wouldn't take it. She said she did not administer the Fleets enema to Resident #2 due to she had a small and medium bowel movement on [DATE]. She said if she gives a prn (as needed) medication and it is ineffective, she faxes the physician for an alternate treatment. She said Resident #2 would holler out and when asked what she needed she wanted a drink. She said she was not aware resident #2 did not have a bowel movement for 5 days. Record Review of Resident #2 nurses notes revealed the following entry: [DATE] at 11:05 p.m., Resident was hallering (sp) continuously, repositioned still hallering (sp) abdominal distended checked for impaction bowel soft, placed 18 Fr. Foley cath (catheter) 1400 mi (milliliters) dark colored urine in return called Physician C to notify of resident's urine retention Physician C ordered to leave foley cath in place. Signed LVN C (No documentation of Physician C being informed of Resident #2's continued abdominal issues.) In an interview on [DATE] at 1:30 p.m., LVN C said CNA's reported to her Resident #2's abdomen was distended. In report with previous shift, it was reported Resident was constipated. She said LVN D reported she checked Resident #2 and felt soft BM or felt something soft. LVN C said Resident #2 had been like that for 2 days. LVN C said she inserted a catheter into Resident #2's bladder and resident soaked brief, bedding and she waited then unclamped catheter and obtained 1500ml of urine. She said CNA's reported to her Resident #2 had yelled out for 2 days. She said day shift nurse had administered a fleet's enema to Resident #2 on [DATE]. Record Review of Resident #2 nurses notes revealed the following entries; [DATE] at 2:31 a.m., .No abdominal distention noted at this time No bowel movement noted thus far. Will continue to monitor. Signed LVN H Observation on [DATE] at 10:10 a.m., Resident #2 was in bed, hollering out milk. Staff turned resident on her right side for nurse to cleanse wound to coccyx and apply dressing. Resident denied pain when asked by nurse. Foley catheter intact with clear yellow urine (approximately 100ml) in bed. Resident was transferred from bed to geri chair by two staff. Observation on [DATE] at 10:15 a.m., Resident #2 was sitting in geri chair while staff changed linens on her bed. Resident continues to moan Oh CNA offered health shake and resident #2 took 3 sips then refused. Observation on [DATE] at 12:01 p.m., Resident #2 remains sitting in the geri chair and moaning Oh Observation on [DATE] at 12:15 p.m., Resident #2 remains sitting in the geri chair and continues to call out Oh Observation on [DATE] at 12:19 p.m., Resident #2 attempting to feed resident. Drank 2 sips of water, ate 3 bites of pork but spit all 3 bites out. Refused to eat corn or beans. Resident is requesting milk. Observation on [DATE] at 12:25 p.m., Resident #2 took 10 sips of milk then said enough, stop. Observation on [DATE] at 07:30 a.m., Resident #2 in bed with eyes closed, moaning. (No additional nurse's notes related to Resident #2's abdominal issues prior to [DATE]) [DATE] at 11:14 a.m., .Resident yelling as if in pain. Tylenol 650mg adm (administered) for s/s (signs/symptoms) pain or discomfort .Will continue to monitor. Signed LVN I (No documentation of follow-up for effectiveness of Tylenol) In an interview on [DATE] at 10:55 a.m., LVN I said Resident #2 would yell out Help me. She said on [DATE] she administered Tylenol to Resident #2. It calmed her. She said in report she heard abdomen was bigger due to [MEDICAL CONDITION] and once foley catheter was placed abdomen went down. She said she had not notified the physician of any changes to Resident #2. (No additional nurse's notes related to Resident #2's abdominal issues) Observation on [DATE] at 12:45 p.m., Resident #2 sitting up in geri chair in room. She was awake, moaning, leaning to the right in her chair. Staff notified and resident transferred to bed by two staff. Observation on [DATE] at 3:00 p.m., Resident #2 in bed, moaning out Oh . Her son in room at bedside. Record Review of Resident #2's nurses notes revealed the following entries: [DATE] documented at 6:58 a.m., 0105 This LVN entered resident's room and noted resident with no respirations at this time. NO chest expansion noted at this time. Resident was pale. Skin is still warm to touch. OU fixed and open at this time. No pulse noted at this time. Signed LVN H [DATE] documented at 7:04 a.m., 0115 Police department called at this time and was notified of resident having no vitals. Stated that JP (Justice of Peace) would be notified and funeral home would be called by PD (Police Department). Signed LVN H [DATE] documented at 7:06 a.m., 0140 JP here at this time and taken to resident's room by this LVN. 0150 Resident pronounced at this time. Signed LVN H In an interview on [DATE] at 8:30 a.m., DON said resident #2 passed away around 1:30 a.m. this morning. She said she went to sleep and was gone. Record Review of Resident #2's BM (bowel movement) and Size Roster from [DATE] through [DATE] revealed Resident #2 did not have a bowel movement between [DATE] to [DATE]. Resident #2 only had one small BM on [DATE], one small BM and one medium BM on [DATE] and one small on [DATE]. Record review of Resident #2's admission physician orders [REDACTED]. Resident #2 had orders for [MEDICATION NAME] 325mg 2 po (=650mg) prn q 4 hours prn pain, Milk of Magnesia ,[DATE] ml po prn for indigestion (not ordered as a laxative), [MEDICATION NAME] ([MEDICATION NAME]) 10mg sup 1 rectally prn for no BM in 3 days, May give SS (soap suds) enema prn constipation and may digitally check and remove BM from rectum per licensed nurse prn. Record Review of Resident #2's Medication Administration Record for [DATE] revealed she received [MEDICATION NAME] 325mg 2 tabs (=650mg) on [DATE] at 1:26 a.m., [DATE] at 8:40 a.m. and [DATE] at 9:56 a.m. Resident #2 received Milk of Magnesia ,[DATE] milliliters for indigestion on [DATE] at 4:20 p.m. Resident #2 also received [MEDICATION NAME] 10mg sup one rectally for no Bowel movement in 3 days on [DATE] at 1:15 a.m., [DATE] at 4:20 p.m. and [DATE] at 6:25 a.m. [DATE] at 6:07 p.m., Medication follow-up ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective Signed LVN E [DATE] at 1:26 a.m., [MEDICATION NAME] 325mg 2 po (by mouth) (=650mg) Q (every) 4 .Has been yelling Help Signed LVN F [DATE] at 3:24 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) Q 4, Medication was not effective Signed LVN F [DATE] at 9:47 p.m., Medication Follow-up - ([MEDICATION NAME] 325mg 2 po (=650mg) q (every) 4) Medication was effective; Resting at this time. Signed LVN E [DATE] at 1:26 a.m., Medication follow-up (Milk of Magnesia ,[DATE] ml (milliliters) po prn for indi) Medication was not effective. Signed LVN H [DATE] at 1:27 a.m., Medication Follow-up - ([MEDICATION NAME] 10mg sup 1 rectally prn for N) Medication was not effective. Signed LVN H Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message for lab values signed by LVN J. Physician C replied noted with no date of reply. In an interview on [DATE] at 1:55 p.m., LVN J said on admission Resident #2 spoke a lot. She said she would holler hey. She said the abdominal swelling resolved by placement of foley catheter. She said Resident #2 would holler to let you know if she was hurting. Record Review of Resident #2's laboratory report dated [DATE] revealed a White Blood Cell count of 21.4 (high) with normal referenced at 4XXX,[DATE].0. Laboratory report initialed by Physician C. According to the Mayo Clinic a high white blood cell count can indicate an increased production of white blood cells to fight an infection. http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym- 611 (accessed on [DATE]) Record Review of faxed note to Physician C dated [DATE] regarding Resident #2 with message new resident arrived this evening signed by LVN A. Physician C signed note on [DATE]. In an interview on [DATE] at 12:40 p.m., Physician C said facility staff notified him of resident #2's admission, of her not voiding so he ordered a foley catheter and need for [MEDICATION NAME] suppository as needed for constipation. He said he was not informed by facility staff regarding Resident #2's abdomen being distended or that [MEDICATION NAME] prn (as needed) medications were ineffective. He said if a medication doesn't work (ineffective) the staff should call him back. He said if he had been notified of Resident #2's abdomen being distended, bulging areas noted to abdomen, altered bowel sounds, etc. he would have sent her to emergency room for further evaluation. He said he wasn't sure if the nurses at the facility were not communicating or what. He said it didn't sound like Resident #2 received appropriate care. He said he was on call the day Resident #2 expired but was not notified of her passing. In an interview on [DATE] at 4:30 p.m., Physician C said he was contacted regarding Resident #2's need for foley catheter but was not contacted regarding any urinary symptoms. He said he came to the facility today to see his residents but was asked to leave and come back later when state was gone so he left the facility. Record Review of Facility 24 hour reports regarding Resident #2 revealed [DATE] - 7am/3pm Physician A was called due to abdomen distended and 4 new bulging areas [DATE] - 3pm/11pm Continues to have 4 bulging areas [DATE] - 11pm/7am left lower quadrant noted with sluggish bowel sounds, others absent at this time. Abdomen firm/distended. [MEDICATION NAME] given suppository/rectum; 3pm/11pm noted hollered out several times only wanted water [DATE] - 11pm/7am yelled all shift, 0126 [MEDICATION NAME] 325mg 2 tabs given, WBC (White Blood Cells) are 21.4 normal 4XXX,[DATE].0; 7am/3pm abdomen distention plus 4 knots noted; 3pm/11pm administered sup plus MOM (Milk of Magnesia)= no results yet 2 Tylenol at 840 [DATE] - 11pm/7am MOM/Suppository given ,[DATE] no results; 7am/3pm N.O. (new order) for Fleets Enema had a small BM; 3pm/11pm Placed 18 Fr. Foley 1400 ml dark urine order to keep foley in place, call family please [DATE] - no entries regarding abdominal issues [DATE] - 7am/3pm did not eat breakfast, 10 x drinks of milk at lunch, been yelling out all morning, foley cath; 3pm/11pm foley cath draining to bedside no other issues [DATE] - 11pm/7am no problems, staff did encourage fluids; 7am/3pm no problems; 3pm/11pm No problems, resident passed away. In an interview on [DATE] at 4:05 p.m., DON said she reviewed nurse's notes for Resident #2. She said Resident #2 had two areas on her abdomen on admission. She said in the moment you don't fit it together but reading her nurses notes, you see the pattern of issues. She said the nurses notified Physician C of all the changes and she had the faxes to prove it. She said the nurses did tell Physician C of the changes in Resident #2. She said on the Admission Nursing Assessment, the nurse should document the two areas on her abdomen on the skin condition section. Admission Nursing Assessment was reviewed with DON and the two areas were not documented on the skin condition section of the Admission Nursing Assessment. DON said looking back over nurses notes for Resident #2, it makes sense for the concern but at the time you don't see it. In an interview on [DATE] at 1:55 p.m., CNA A said Resident #2 could understand what was said to her and she could answer you with yes or no. He said she wasn't much on eating but would drink milk. He said Resident #2 would holler out help but a few days prior to her death, she seemed to holler for help less but still called out. He said she didn't verbalize if in pain but if she was asked if in pain, she could answer yes or No. He said he reported to the nurses that Resident #2 was hollering out and also when she didn't eat but could not remember which nurse he reported this to. In an interview on [DATE] at 3:45 p.m., DON said Resident #2 would let you know she was hurting by facial grimacing and hollering out. She said when Resident #2 was asked what she needed, she would deny needing anything. She said a fax was sent to her physician for Milk of Magnesia, Fleets enema for no bowel movement in ,[DATE] days then after med given she had bowel movements. In an interview on [DATE] at 3:50 p.m., ADON said a CNA reported to her (unknown date) when Resident #2 had a knot on her abdomen. She said she assessed the area and it was soft and located in her right upper quadrant. She said Resident #2 hollered almost continuously but if asked if she was in pain, would deny pain. She said to determine what Resident #2 needed, you had to ask yes or no questions. In an interview on [DATE] at 1:53 p.m., CNA D said Resident #2 would yell help all day. She said Resident #2 had 3 bumps on belly. She had the nurse to look at them and was told the resident was admitted with them. She said the 3 bumps looked like little hernias. She said they were soft, like pudding in a balloon. She said she reported to the nurses that Resident #2 would cry daily and that she thought something was wrong with her. In an interview on [DATE] at 10:35 a.m., CNA E said Resident #2 would holler out as if she was in pain. She said she would give her water but resident would refuse water at times. CNA E said Resident #2's abdomen had been distended. She said she notified LVN H and LVN F that resident wasn't urinating, was refusing liquids and appeared in pain. She said she worked the night Resident #2 passed away and nothing out of the ordinary was noted with her. In an interview on [DATE] at 10:45 a.m., CNA F said lumps were present on tummy when admitted . She said Resident #2 would call out help and ouch on admission. She said she would ask Resident #2 if she was in pain and she would say yes and point to abdomen. She said she would drink Ensure, milk and water. She(TRUNCATED)

Based on observation, interview and record review the facility failed to establish infection control measures to help prevent the transmission of infection and disease by bloodborne pathogens for 2 of 2 sampled diabetic residents (#s 3 and 8). The facility failed to ensure that lancing devices were not used on multiple residents to obtain blood for blood glucose tests. One of one LVN, LVN A, performing blood glucose tests used the same pen lancing device on 2 of 2 residents (#s 3 and 8). These failures resulted in the identification of an IJ (Immediate Jeopardy) on 11/08/10 at 2:52 p.m. While the IJ was removed prior to exit on 11/10/10 at 4:30 p.m., the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". These failures involved 12 diabetic residents requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing. These failures placed these 12 residents at risk of bloodborne infections. Non-IJ Failure: The facility failed to ensure staff practiced proper hand hygiene and followed standard precautions when performing wound care. a) Two of two LVNs (LVN A and LVN C) did not follow proper hand hygiene and standard precautions when performing wound care for 1 of 2 residents (Resident #7). b) One of one LVN (LVN A) did not follow proper hand hygiene and standard precautions when performing wound care for 1 of 2 residents (Resident #4). These failures could place any of the 46 residents residing in the facility at risk of infection by cross-contamination. The IJ findings included: Observation on 11/08/10 at 11:35 a.m. revealed that LVN A performed an Accucheck (obtaining a blood sample to determine blood sugar levels) on Resident #8. LVN A punctured Resident #8's fingertip with a lancet that was placed into a fingerstick pen device (device with a lancet that punctures the skin) and obtained a blood sample which she placed onto the test strip in the glucometer. LVN A removed the lancet from the fingerstick pen device and discarded the used sharp into a sharps container (container used to dispose of used sharps) located on the medication cart, then she used an alcohol swab and wiped the glucometer and the tip of the lancing device. Record review of Resident #8's admission record revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's physician's orders [REDACTED]. Observation on 11/08/10 at 11:40 a.m. revealed that LVN A performed an Accucheck on Resident #3. LVN A punctured Resident #3's fingertip with the lancet that had been placed into the fingerstick pen device used for Resident #8. LVN A obtained a blood sample which she placed onto the test strip in the glucometer. LVN A removed the lancet from the fingerstick pen device, replaced the cap and wiped the top of the device with an alcohol swab. She then wiped the glucometer with alcohol swab. Record review of Resident #3's Admission record revealed a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's physician's orders [REDACTED]. In an interview on 11/08/10 at 12:45 p.m. LVN A said that she used the Accu-check softclix lancing device on all residents who require an Accu-check but that she changed the needle each time so that residents are not stuck with the same needle. LVN A stated that the facility had two lancing devices which were used to perform Accu-checks on residents. LVN A said that she cleaned the lancing device between residents with alcohol. During the above noted observations of the lancing device was noted to have, what appeared to be, dried blood at the top of the lancing device. These failures resulted in the identification of an IJ (Immediate Jeopardy) of which the facility Administrator, DON, and ADON were informed on 11/08/10 at 2:52 p.m. During an interview the DON on 11/08/10 at 2:52 p.m. said she was not aware of any recommendations or regulation prohibiting the use of fingerstick pen devices on multiple residents. She stated they had always done it that way. Review of the manufacturer's insert "Accu-check Softclix Lancing Device" provided by the facility revealed, "Note: The Accu-check softclix cap was not designed to be replaced after each use. The Accu-check softclix lancing device is intended for use by a single person and is not suitable for testing different persons with the same device as this may lead to infection." Fingerstick devices touch the skin and come in close proximity to blood with every use. Even if the lancet is changed between each use there is potential for blood to contaminate the device. Bloodborne pathogens such as Hepatitis B, Hepatitis C and HIV could potentially be transmitted from one person to another. Information posted by the Center of Disease Control, updated 08/26/10, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. ? Fingerstick devices should never be used for more than one person. ? Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided." Non-IJ Findings: 1. Observation of wound care performed on Resident #7 by LVN A and LVN C on 11/09/10 at 9:15 a.m. revealed the following: LVN A rolled the treatment cart into Resident #7's room and parked at the resident's bedside. LVN washed her hands and put on gloves. LVN A put on gloves but did not wash her hands. She placed wax paper on top of the cart as a clean barrier and laid 4x4 gauze half on and half off the barrier. LVN C rolled Resident #7 from her back to her left side. The pad the resident was laying on was wet with urine. The resident had a healed pressure area on her coccyx. LVN A sprayed the area with wound cleanser and handed 4x4's to LVN C. LVN C wiped the area with the 4x4s. She then rolled the resident back onto her back on the urine soaked pad. When LVN C was asked if the pad was wet, she responded "Yes." LVN A was going through all of the drawers of the cart, moving items around, looking for Laniseptic cream. The resident was turned onto her side and LVN A applied the cream to the coccyx and buttocks. The resident was again rolled back onto her back on the urine soaked pad. LVN A changed her gloves without washing her hands and removed a dressing soiled with blood from the resident's left ankle. The resident had a pressure ulcer measuring approximately 0.5 c.m. in circumference and depth and dark red in color. As she was removing the dressing she used the soiled dressing to wipe the wound. She then sprayed the site with wound cleanser and wiped it with 4x4 gauze. She took scissors from her pocket and cleaned them with alcohol swabs. She cut a small piece from a 4x4 calcium alginate dressing (a highly absorbent dressing derived from seaweed) and applied it to the wound. She took off her gloves and got a bordered dressing from the cart, opened it and dated it. She then applied the dressing to the resident's left ankle without washing her hands or putting on gloves. She pushed the treatment cart out of the room and proceeded down the hall to continue doing other treatments. 2. Observation of wound care performed on Resident #4 by LVN A on 11/09/10 at 10:10 a.m. revealed the following: LVN A rolled the treatment cart into Resident #4's semi-private room. She parked the cart on the A side of the room. Resident #4 occupied the B side of the room. She put on gloves without washing her hands first. She sprayed the resident's right great, 2nd and 3rd toes with wound cleanser. She rubbed the stasis ulcers on all three toes with the same 4x4 gauze. She then sprayed wound cleanser on the resident's left second toe and wiped it with the same 4x4 gauze that was used on the right toes. She returned to the treatment cart, got a plastic medication cup and TAO from the drawer and put some of the ointment into the cup without washing her hands and putting on gloves. She returned to the resident's bedside and applied TAO to all of the ulcers using the same cotton-tipped applicator. She cleaned the pressure ulcer on the resident's left heel with wound cleanser and wiped it with a 4x4 gauze. She laid the resident's heel back on the bed and returned to the treatment cart. Still, without washing her hands and changing gloves she began going through all of the drawers, moving items around, looking for Laniseptic cream. She then took off her gloves and found the Laniseptic cream on top of the dresser on the A side of the room. She took a bordered dressing from the cart, opened it and dated it. She put on new gloves without first washing her hands and returned to the bedside. She applied the Laniseptic to the pressure ulcer on the left heel. She took off her gloves and applied the bordered dressing. She returned to the cart, put the Laniseptic cream packet into the top drawer and got a Band-Aid out. She returned to the bedside and applied the Band-Aid to the left second toe. She returned to the cart to leave the room and the CNA in the room asked her about the resident's other heel. LVN A returned to the bedside and looked at the right heel. There was a healed pressure area. She put on gloves, cleaned the area with wound cleanser and applied Laniseptic cream. She removed her gloves and took the treatment cart out of the room. She then used hand sanitizer and proceeded down the hall to continue doing other treatments. The facility submitted an action plan to remove the immediacy dated 11/09/10 to the regional office consisting of the following actions: 1) Removing the Accucheck pens (lancing devices) from the treatment trays on 11/08/10. 2) Searching the medication room on 11/08/10 to ensure all Accucheck pens had been removed. 3) Identifying residents at risk of exposure to cross-contamination and performing assessments on those residents to determine if any adverse effects were present. This was performed on 11/08/10 and no adverse effects were identified. 4) Revising the facility's policies and procedures on 11/08/10 to exclude the use of the lancet pen devices and staff review of the revised policy and procedure. This action plan was verified to have been completed on 11/09/10 at 4:30 p.m. as follows: 1) The policy and procedure regarding the use of lancing devices was revised to meet the new guidelines excluding use of the same lancing device on multiple residents. The DON ordered one time use disposable lancing devices. Until the order arrives the facility will use the lancets without a lancing device. 2) LVN A was observed removing all of the lancing devices from the medication room and no lancing devices were in the treatment trays. 3) Inservices were conducted with the facility nurses from 11/08/10 regarding no longer using lancet devices for fingersticks due the possibility of residents being exposed to blood borne pathogens. 4) Interviews were conducted on 11/08/10 with facility nurses to confirm that inservices were conducted and nurses understood the new facility policy and procedure regarding lancing devices. While the IJ was reduced on 11/08/10 at 4:30 p.m., the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern" as the facility must monitor their action plan over time to ensure that the corrections for this issue are effective. There were 12 diabetic residents requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing according to the list provided by the facility DON on 11/08/10 at 3:00 p.m.. Review of the CMS 672 Resident Census and Condition of Residents dated 11/08/10 revealed the facility census was 46.