Every finding on record at Moosehaven

Based on observation, interview, record review and review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered (revised March 2022), the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and included the resident's goals, desired outcomes, and preferences for the use of psychotropic medications, for one (Resident #6) of six residents reviewed for unnecessary medication administration, from a total of 22 residents in the sample. This failure has the potential to result in unmet therapeutic goals, adverse drug events, unnecessary medication use, and reduced quality of life.The findings include: On 6/3/2026 at 8:57 AM, Resident #6 was observed sitting in his reclining chair in the corner of his room with a blanket draped over his lap. The television was off and he was looking out the window. He reported feeling okay. He said he had good days and bad days. He reported being independent with his activities of daily living (ADLs), requiring minimal assistance from staff, and said he received his medications but could not name them all or what they were treating. A review of Resident #6's medical record revealed an admission date of 9/11/2024. His medical diagnoses included type 2 diabetes mellitus, major depressive disorder, insomnia and anxiety disorder. A review of the resident's active physician's orders included: Wellbutrin XL Oral Tablet Extended Release 24 Hour 300 mg (Bupropion HCL), Give 1 tablet by mouth one time a day for depression, 6/4/2026 start date. Citalopram Hydrobromide Oral Tablet 20 mg (Citalopram Hydrobromide), Give 1 tablet by mouth one time a day for depression, ordered 11/27/2025. Trazodone HCL Oral Tablet 50 mg (Trazodone HCl), Give 1 tablet by mouth at bedtime for depression, ordered 6/4/2025.A review of the most recent annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/5/2026, revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 possible points, indicating moderate cognitive impairment. Diagnoses included anxiety and depression (other than bipolar). Antidepressant medication was administered over the look-back period, the Psychotropic Drug Use Care Area was triggered, and the Psychotropic Drug Use Care Planning Decision was coded as yes.A review of the resident's active Comprehensive Care Plan revealed no care plans in place addressing the resident's active diagnoses of depression, anxiety or insomnia, and there was no care plan in place for the use of antidepressant medications or monitoring for adverse side effects related to the daily use of the medications. A review of the most recent behavioral health progress note, provided by the Social Services Director (SSD), and titled, Balanced Wellbeing Psychiatry Subsequent Note with date of service 5/20/2026 from the provider, stated the resident was, Depressed and feeling down. We are monitoring symptoms and behaviors, with medication regimen Citalopram, Wellbutrin along with Trazodone as augmentation strategy for depression. On 6/3/2026 at 11:35 AM, a second observation of Resident #6 was made. He was seated in the same place as he was during the observation made on 6/3/2026 at 8:57 AM. He was in his reclining chair, the television was off, and he was looking out the window. He stated the facility had too many activities going on, and he didn't like that; he enjoyed being alone. On 6/5/2026 at 11:25 AM, an interview was conducted with the SSD, who reported working at the facility in her current role for the last six years. She stated she was responsible for completing the MDS assessment sections for cognitive patterns, mood and behaviors, for each resident. She was also responsible for developing and implementing comprehensive care plans for mood, behavior and cognitive functioning when a resident triggered in those areas. Psychiatry and psychology visits occurred weekly, and if there were changes, she or the MDS Coordinator updated the resident's care plan. She stated, The care plan is implemented as soon as a concern is identified. Depression should go into a care plan as soon as there is an indication. That would include monitoring for signs and symptoms, and the use of medications. She stated she was familiar with Resident #6 and confirmed there was no active care plan developed or implemented for his diagnosis of depression. She said she added a care plan for depression today, 6/5/2026. On 6/5/2026 at 3:06 PM, a joint interview was conducted with the Administrator and the Director of Nursing (DON). They stated the facility currently had no corrective action plans in place. They stated until today, they were unaware that Resident #6 did not have a comprehensive care plan in place for his diagnosis and treatment of depression. The DON stated, I don't know how that got missed. Knowledge of our residents should make us more accurate not less accurate. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered (Policy Version 2.0 -H5MAPL0110, Revised March 2022), revealed: STATEMENT: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. INTERPRETATION: 1) The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2) The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 7) The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8) Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons.

Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #75) of 10 residents receiving respiratory treatment, from a total of 13 residents in the sample. The findings include: On 8/29/2022 at 10:16 a.m., Resident #75 was observed asleep in bed. Her nasal cannula was lying across her chest and an oxygen concentrator was observed at bedside. The concentrator was set to administer oxygen at a rate of 4 liters per minute (LPM). During a follow-up attempt to interview the resident at 1:11 p.m. the same day, she was again observed sleeping. The oxygen concentrator flow rate remained set at 4 LPM. On 8/30/2022 at 10:53 a.m., the resident was observed sitting up in bed with her nasal cannula in place. Her oxygen concentrator was still set to administer oxygen at 4 LPM. (Photographic evidence obtained) During another visit to the resident's room on 8/31/2022 at 11:07 a.m., her nasal cannula was in place. The oxygen concentrator remained set to administer oxygen at 4 LPM. On 8/31/2022 at 1:54 p.m., Resident #75 was observed resting in bed with her nasal cannula in place and her oxygen concentrator set to administer oxygen at 4 LPM. During an interview with Registered Nurse (RN) A on 8/31/2022 at 11:18 a.m., she confirmed the resident's oxygen was ordered at a flow rate of 2 LPM. She stated the certified nursing assistants (CNAs) were responsible for taking the residents' vital signs, and the nurses were responsible for adjusting the oxygen flow rates as needed. During the interview, RN A was asked to observe the oxygen for Resident #75. She went to the resident's room and confirmed that the resident's nasal cannula was in place. She further stated the concentrator was set to administer oxygen at 4 LPM. When she was asked about the flow rate, she stated it was titrated up to keep the resident's oxygen saturation (sats) above 92%. She was asked if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A was unable to provide supporting physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with CNA B on 8/31/2022 at 2:05 p.m., she stated she had been employed at this facility for nine years and Resident #75 was a total assist. She further stated the CNAs were responsible for ensuring that the residents' oxygen concentrators were set at the ordered flow rate. She stated the CNAs could consult the nurses or the residents' care plans for the oxygen orders. She further stated the CNAs were responsible for filling the portable oxygen tanks. During an interview with CNA C on 8/31/2022 at 2:15 p.m., she stated she had been employed at this facility for seven years and the CNAs were responsible for ensuring water was in the oxygen concentrator for Resident #75. They were also responsible for changing the oxygen tubing weekly. She stated the tubing for all residents receiving oxygen was changed every Sunday. When asked what Resident #75's oxygen flow rate should be set at, she did not answer. Instead, she stated, We can titrate it if her sats are less than 90%. We can adjust it between 2 and 4 (LPM) to get it back to the 90% or higher. When asked, she was unable to provide the orders for the oxygen flow rate or the orders for the titration. She stated the CNAs took vital signs daily and documented them on the vital sign sheet for all the residents. Once complete, the form went to the nurse. She stated the nurse then entered the information into the resident's electronic medical record once all the vitals were complete. During an interview with Registered Nurse/Unit Manager D on 8/31/2022 at 2:22 p.m., she stated she was familiar with Resident #75. The resident was currently receiving Hospice services as her health was declining rapidly. She stated she spoke with RN A today regarding Resident #75. When she asked RN A about the oxygen for Resident #75, RN A advised her that the resident's sats were at 88% on 8/30/2022, so she increased the oxygen flow rate. RN D stated she reviewed the resident's records and observed that nursing charted they had increased the oxygen flow rate from 2 LPM to 3 LPM, and stated there was no order for that. She confirmed the current order for the oxygen level was 2 LPM, again stating there was no order to increase or decrease the oxygen flow rate for this resident. RN D stated she contacted the physician on the day of this interview for new orders. A review of Resident #75's medical record revealed a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2L/NC PRN (oxygen at 2 LPM via nasal cannula as needed) to keep O2 sat (blood oxygen saturation) above 92% every shift. The order was signed and dated 8/24/2022. There were no additional orders in Resident #75's record related to her oxygen flow rate or titration.

Based on staff interviews and a review of the facility's policies and procedures, the facility failed to ensure its grievance policy contained all mandated requirements. All 25 residents had the potential to be affected by the omissions in the facility-wide policy. The findings include: A review of the facility's grievance policy (undated) revealed the following purpose: It is the policy of this facility to assist residents, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made. The form listed procedural steps one should take to file a grievance. Step (2) stated, Grievances and/or complaints must be submitted in writing and signed by the resident, or the person filing the grievance or complaint on behalf of the resident. Step four (4) indicated that it was upon receipt of a written grievance and/or complaint that the investigation would commence. The form did not detail guidance to the reader that grievances could be submitted orally, or anonymously. (Photographic evidence obtained) An interview was conducted with the Social Services Director (SSD) on 2/23/2021 at 12:00 p.m. She explained that most grievances came to her or one of the nurses. The policy was reviewed with her and she confirmed this was the same policy that was given to residents when they moved in. She acknowledged the missing information in the policy and confirmed it was undated, so the last time it was updated was unclear. She was given time to investigate whether any updated versions of the policy were being used, but none were presented by the end of the survey. In a follow-up interview with the Administrator on 2/25/2021 at 12:44 p.m., he also acknowledged the importance of updating the policy to include all required elements.

Based on medical record reviews and staff interviews, the facility failed to revise resident care plans following the completion of a signed Do Not Resuscitate (DNR) order for three (Residents #80, #22 and #1) residents sampled for a review of their care plans, from a total sample of 25 residents. The findings include: 1. A review of the medical record for Resident #80, revealed a DNR order dated 10/1/2018. A review of Resident #80's hard chart revealed an admission care plan that stated the resident was a Full Code (the resident desired resuscitation in the event of respiratory/[MEDICAL CONDITION]). The hard copy admission care plan was dated 9/28/2018. A review of Resident #80's current comprehensive care plan, revealed the care plan was not revised to include the current DNR order. 2. A medical record review for Residents #22 and #1 revealed that both residents had signed, active Do Not Resuscitate orders. The signed declarations were located in the hard charts, and the DNRs were also acknowledged in their files located in the electronic medical records. During a review of the two residents' current comprehensive care plans, the advanced directives were not addressed. During an interview with the Nursing Supervisor on 02/23/21 at 10:14 a.m., she confirmed the care plan had not been revised to include the active DNR order for Residents #80, #22 or #1. She stated, DNR orders are care planned by the social worker and they should be listed on the care plan, because that is how we communicate with the interdisciplinary team. During an interview with the Director of Social Services on 2/23/21 at 10:20 a.m., she confirmed that the care plans had not been revised to include the active DNR orders for Residents #80, #22 or #1. She stated, I will revise the care plan to include the DNR orders.

Based on interviews and record reviews, the facility failed to 1) Ensure as needed (PRN) [MEDICAL CONDITION] medications ordered for greater than fourteen days included justification for extended use for one (Resident #9) of five residents reviewed, and 2) Ensure the provision of adverse consequence monitoring for two (Residents #14 and #11) of five residents reviewed for [MEDICAL CONDITION] medications, from a total of 25 residents in the sample. The findings include: 1. A review of the medical record for Resident #9 revealed he was admitted on [DATE]. He had a [DIAGNOSES REDACTED]. On 09/03/2020, a new order was written for 0.5 mg of [MEDICATION NAME] every 6 hours PRN for 90 days. On 01/02/2021, a new order for 1.0 mg of [MEDICATION NAME] every 6 hours PRN was written. The Order Summary Report revealed an end date of 04/02/2021, but no language was added to the order to justify the length of use. (Photographic evidence obtained) A History and Physical dated 06/12/2020, electronically signed by the physician who prescribed the [MEDICATION NAME], revealed no rationale statement for the extended use of the medication. The next physician's assessment, dated 09/03/2020, was also lacking the rationale statement. Resident #9's nurse, Employee C, was interviewed on 02/25/2021 at 11:58 a.m. He confirmed that Resident #9 had been prescribed antianxiety medication since his admission. There was no additional documentation with the rationale for the 90-day supply presented. The Director of Nursing (DON) was asked to present the thinned chart (materials removed from the resident's immediate record and maintained in a medical records file) for review. No documentation with the rationale for extended use was discovered. At 1:55 p.m. on 02/25/2021, the DON confirmed knowledge of the requirement for the PRN order justification. The facility's policy titled Antipsychotic Medication Use, dated December 2016, stated: (14) The need to continue PRN orders for [MEDICAL CONDITION] medication beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. (Photographic evidence obtained) 2. A review of Resident #14's medical record revealed she was ordered [MEDICATION NAME] 125 mg and [MEDICATION NAME] XL (extended release) 150 mg for depression. She was also ordered [MEDICATION NAME] 75 mg for anxiety on 10/16/2020. On 2/23/2021 at 11:11 a.m., her nurse explained that behavior monitoring was completed each shift and documented in the hard chart (physical paper medical record) at the nurses' station. Resident #14's current care plan addressed her depression (initiated on 07/06/2020), which included a goal that she would experience fewer signs and symptoms of depression. An intervention included monitoring and documenting side effects of her medication. (Photographic evidence obtained) Resident #14's hard chart contained a behavior monitoring form for [MEDICATION NAME] ([MEDICATION NAME]). The behavior listed was tremors and the form showed no instances of tremors for the current month. [MEDICATION NAME] ([MEDICATION NAME]) 100 mg and 25 mg each, had a different sheet which listed a behavior of depression. No instances were documented. [MEDICATION NAME] 10 mg had a form which listed the behavior of anxiety. This form listed no behaviors for the current month. These forms all had a section titled side effects with three lines to indicate which side effects staff were to look for. Nothing was specified on any of the forms. The back of the forms listed potential side effects and included 26 potential side effects depending on the drug class. (Photographic evidence obtained) There was no documentation in the electronic record of adverse consequence monitoring for Resident #14. 3. A review of Resident #11's medical record revealed she was admitted on [DATE]. She was diagnosed with [REDACTED]. She also had a PRN order written on 02/18/2021, to be taken every 8 hours as needed. The electronic Medication Administration Record [REDACTED]. The hard chart included behavior monitoring sheets for [MEDICATION NAME] 1 mg, with the behavior anxiety written in. A second form for [MEDICATION NAME] 1 mg was also in this section, also for the behavior anxiety. There was a behavior monitoring sheet for Duloxetine ([MEDICATION NAME]), with the behavior depression written in. None of the behavior sheets had any side effects written in the box to specify which behaviors one was monitoring for. (Photographic evidence obtained) A review of the nursing documentation for the previous three months, located in the electronic record, did not indicate nurses were documenting their efforts to monitor for adverse consequences. Resident #11's depression care plan (initiated 06/17/2020) addressed her anxiety and the first intervention listed was to Administer medications as ordered. Monitor/document for side effects and effectiveness. (Photographic evidence obtained) During an interview on 02/24/2021at 9:15 a.m. with Employee A, Resident #11's nurse, he was asked how he monitored for side effects of Resident #11's medications. Employee A explained that Resident #11 received antianxiety and antidepressant medication. When asked what side effects he was monitoring for with the antidepressant, he stated he didn't know. When asked about PRN medication monitoring, he explained that the nurses documented in the nursing notes when they administered the medications. He further stated the nurses could also use the behavior monitoring sheets. He opened Resident #11's and explained that if she were to have any side effects they'd be able to document those there. A review of the policy titled Behavioral Assessment, Intervention, and Monitoring, dated March 2019, mandated the following in the Management section: (10) When medications are prescribed for behavioral symptoms, documentation will include: (h.) Monitoring for efficacy and adverse consequences. (Photographic evidence obtained) On 02/25/2021 at 10:05 AM, the DON was asked how nurses were monitoring for adverse consequences of medications, and the explain the details of the facility's policy that required documentation. She explained that the nurses were documenting by exception, which was not her expectation. She acknowledged corrective action was needed.

Based on interviews and record reviews, the facility failed to ensure dental appointments were coordinated and scheduled according to physicians' orders for one (Resident #14) of two sampled residents. The findings include: During an interview with Resident #14 on 02/22/2021 at 11:07 a.m., she was asked about her dental needs. She explained she was having issues, and was waiting for the facility to follow up on an order written [REDACTED]. A review of the electronic medical record did not reveal any visits to a dentist, or orders for dental work to be completed. The Director of Nursing (DON) was interviewed on 2/23/2021 at 1:44 p.m. She was asked to provide any information related to dental appointments for Resident #14. The DON called the facility's clinic and was told Resident #14 went to the dentist on 11/11/2020; information would be located in the hard chart (physical paper record) located at the nurses' station. A review of the hard chart conducted directly after the interview showed no notes about Resident #14's dental visit on 11/11/2020. At 2:57 p.m. on 2/23/2021, the DON confirmed she also found no documentation, and agreed to check the thinned materials (materials removed from the resident's immediate record and maintained in a medical records file). She later presented paperwork from Resident #14's dental visits in 2019 and 2020. A review of these records showed that in 2019, she visited the dentist on 3/26/2019 and he ordered work done to smooth out a fractured molar and a filling in a different tooth. This carbon paper had a notation in different handwritten/ink which read,3/27/2019 Committee approval and was signed by an RN (Registered Nurse). A second carbon paper note, dated 4/2/2019, showed the work ordered on [DATE] had been completed. (Photographic evidence obtained) The next dental visit record was dated 11/11/2020, and was on the same yellow carbon paper. This form noted Resident #14 had a lot of decay. At least four teeth should be extracted. And multiple cavities. The bottom of this form indicated the resident was to return on 11/17/2020 at 12:00 p.m. This, as well as the next cleaning date of 11/10/2021, was initialed in different ink. (Photographic evidence obtained) There were no other dental visit records presented from the thinned chart. A second review of the hard chart and electronic medical record found no evidence indicating the resident went back to the dentist on 11/17/2020. This was confirmed by the DON on 2/24/2021 at 4:15 p.m., who stated the clinic may have more records, and she would investigate further. At 11:15 a.m. on 2/25/2021, the DON confirmed there was no follow-up visit on 11/17/2020. She explained the documentation was lacking as to why she didn't go back to the dentisit, but during this time they were reviewing every appointment to see if it was necessary to send people out because of the cases in the community. The DON stated the resident now had an appointment scheduled for 3/2/2021 for a follow-up to the 11/11/2020 orders. She was asked when the appointment for 3/2/ was scheduled for Resident #14, and she confirmed it was not until today, 2/25/2021.

Based on record reviews and staff interviews, the facility failed to provide appropriate supervision for one (Resident #1) of three residents reviewed for falls, resulting in a fall with subsequent head injury, requiring a hospital evaluation and sutures. The findings include: A record review for Resident #1 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. An attempt to interview Resident #1 on 7/25/19 at 1:37 PM, revealed that he was unable to appropriately respond to any questions. A review of the resident's significant change MDS (minimum data set) assessment, dated 5/6/19, revealed a brief interview for mental status (BIMS) score of 7 out of a possible 15 points, indicating severely impaired cognition. A review of the resident's care plan revealed a revision date of 10/12/18. The care plan entitled ADL (activities of daily living) Deficit, revealed, Bathing - extensive one-person assist, may sponge bath at times with supervision and set-up help. A review of the progress notes in Resident #1's clinical record revealed the following: 6/13/19 6:15 AM - Discharge Summary - Written by Employee B, Licensed Practical Nurse (LPN) At around 0530 (5:30 AM) , resident found on floor in the bathroom, laying on his right side, legs straight, large amount of blood noted on floor coming from resident back of head, apparently resident was coming off the shower, resident at time alert and oriented to current situation stated I slipped and fall, complain of pain to injured site. Resident assessed no other injury noted at time, assisted by 3 staff members to the recliner chair, vital signs obtained, medicated for pain, pressure applied to injured site, bleeding had subsided, call placed to Doctor and notified regarding current situation, new order received to send patient to ER for evaluation for head injury, called placed to supervisor nurse for assistance on floor, called place to 911, paramedics arrived to facility around 0600 (6:00 AM), writer explained to resident of transfer to hospital, resident stated that he doesn't want to go to the hospital that he will be okay, paramedics reinstated to resident due to head being bleeding and painful doctor wants for you to be evaluated, resident said okay, resident left facility at around 0620 (6:20 AM) with paramedics transferred by stretcher transported via ambulance, son, made aware, returned call and asked for hospital name, also stated to let him know of any update. 6/13/19 8:46 AM - Nurse's Note - Written by Employee B, Licensed Practical Nurse (LPN) Data: At around 0510 (5:10 AM) writer went to resident room noticed resident taking self a shower without assistance, checking back with resident at around 0515 (5:15 AM), resident sitting in shower chair at time, at about 0520 (5:20 AM) writer informed CNA (certified nursing assistant) on floor to move to S4 (a different hallway) for meds (medication) administration to keep eye on resident, CNA responded okay, Staff assistant came to writer at 0530 (5:30 AM) reported resident observed on the floor in the bathroom, entering room resident found on floor in the bathroom bleeding at back of his head, at time resident alert and oriented to situation laying on his right side, with legs straight, apparently resident was coming off the shower slipped and got on floor. 6/13/19 8:47 AM - Nurse's Note - Written by Employee B, Licensed Practical Nurse (LPN) Data: Action: resident assessed, no other injuries noted, assisted to recliner chair with 3 person assist, vital signs obtained, pain meds administered, Call placed to Doctor notified of current situation, with order received to patient out for evaluation due to head injury, call placed to 911, paramedics arrived to facility around 0600 (6:00 AM), patient left to (hospital) transferred by stretcher with paramedics transported via ambulance service, e-mail sent to unit supervisor, Director of Nursing, Social Services, Administrator, Doctor, son also notified. 6/13/19 12:18 PM - Nurse's Note - Written by Employee C, Licensed Practical Nurse (LPN) Data: resident returned to unit at about 1045hr (10:45 AM), from (hospital). Scalp laceration to back of his skull measured 1.6 cm x 0.4 cm (centimeters) with three staples, wire stitches. Scant amount of sanguineous (blood-tinged, clear drainage) drainage noted. Purplish bruising to site noted. No cover or dressing applied and open to air. Resident continues to fall follow up and neuro check every hour for four hours. Resident voice no complaint of any pain at this time. Respiration equal and unlabored. Afebrile with 97.7 temp. (temperature) Will continue to monitor. Comfort care maintained. Call light within easy reach. Action: Scalp laceration: Cleanse with wound cleanser. Pat dry. Applied TAO (triple antibiotic ointment). Covered with large bandaid. First contact family member son notified for resident returned. On 7/25/19 at 10:42 AM, an interview was conducted with the Hospice Registered Nurse (RN) that was in the facility and was assigned to Resident #1. He stated he recalled hearing about the fall, and that the resident was in the shower by himself. He was asked what the resident was care planned for in reference to his showers. The RN reviewed his electronic medical record and stated the resident was care planned for one-person assist. When asked whether the resident was care planned prior to the fall or after the fall, the RN replied, It was care planned prior to the fall. He has always been a one-person assist. On 7/25/19 at 12:37 PM, an interview was conducted with Employee D, Registered Nurse (RN). She was asked about Resident #1's fall on 6/13/19, and she stated that the nurse and CNA were aware that the resident was in the shower, but they failed to stay with him to ensure his safety. She stated, They should have stayed with him.

Based on clinical record review, staff interview and facility policy and procedure review, the facility failed to ensure the appropriate information was communicated to the receiving health care institution or provider which included the comprehensive care plan goals and discharge summary for one resident (#35) sampled for discharge and two residents (#36 and #144) sampled for hospitalization out of a total of 17 sampled residents. Failure to provide pertinent health care information to the receiving health care provider could negatively impact the ongoing continuity and quality of care received by the resident. The findings include: A review of the electronic and paper clinical records for Residents #35, #36 and #144 revealed no evidence that the facility had provided the comprehensive care plan goals and discharge summaries when the residents were transferred to an acute care setting. A review of the clinical record for Resident #35 revealed the resident was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She was transferred to the Enhanced Living unit on 11/27/2018. Resident #35 was to reside in apartment #224. The Social Services note dated 11/27/2018 read: (Resident #35) verbalizes agreement with discharge plan. She wanted to go to Enhanced Living during the time that her husband would be away on a trip. The discharge plan was to attend outpatient therapy. Nursing notes indicated the resident was alert and oriented in all spheres. She used a motorized scooter for mobility off the unit. Used a rolling walker on the unit. The Minimum Data Set (MDS) assessment dated [DATE] revealed a [DIAGNOSES REDACTED]. The resident received Occupational Therapy (OT) five days a week and Physical Therapy (PT) five days a week. A review of the care plan revealed a focus area: Alteration in musculoskeletal status related to left total knee replacement; Assistance with Activities of Daily Living (ADL) care; Risk for falls, Risk of adverse side effects from [MEDICAL CONDITION] meds; weakness and fatigue; acute pain. A review of the clinical record for Resident #36 revealed the resident was admitted to the facility on [DATE] and then transferred to the hospital on [DATE]. The MDS assessment dated [DATE], revealed the resident was coded as having [DIAGNOSES REDACTED]. The resident was receiving hospice care. A review of the care plan dated 11/19/2018, revealed problem areas including: Difficulty sleeping; Skin infection related to redness and swelling of left lower extremity with [DIAGNOSES REDACTED]. Hospice admitted the resident due to heart failure, [MEDICAL CONDITIONS], left lower extremity abscess drainage sanguineous drainage; hospice services; chronic congestion of the liver; diabetes, risk of hyper/hypo glycaemia; difficulty breathing, anticoagulant therapy; [MEDICAL CONDITION]; pacemaker with defibrillator related to A-Fib; heart failure; cognitive communication deficit; assistance with ADLs; risk of falls; adverse effects of psych meds; risk of pressure ulcer and skin breakdown; acute pain related to gout. A review of the clinical record for Resident #144 revealed the resident was admitted to the facility on [DATE] after a hospitalization . The history and physical (H&P) dated 01/13/2019, revealed Resident #144 was recently admitted from the hospital for [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A review of the progress note dated 01/25/2019 revealed a staff member entered Resident #144's bathroom, and found him sitting with his back against the toilet. He was assessed for pain and injuries with none noted. The resident had full range of motion, and stated he was ready to get up. The resident was found to have a large amount of bright red blood in his brief. His physician was notified of multiple falls with hematochezia (passage of fresh blood through the anus, usually with stools). The physician gave a new order to send the resident to the hospital emergency room (ER). During an interview with the Director of Nursing (DON) on 02/18/2019 at 9:06 AM, she stated Resident #144 went out to the hospital suddenly due to blood in his stool. She looked up his date of transfer and reported it was on 01/25/2019. He was still in the hospital. During an interview with the DON on 02/19/2019 at 4:29 PM, she stated she did not think the facility sent any notice to the resident or their representative of the transfer to the hospital. She stated I have to be honest, we don't do that. She stated that because of the way members paid their dues prior to living on the campus, they had a contract that said the facility would take them back if they were hospitalized . During an interview with Employee C, Director of Social Services, on 02/20/2019 at 10:04 AM, she stated they did not send a discharge notice to the resident or their representative, because with (this facility), the understanding was that the residents had paid dues to become a member of (the organization), and they would not be refused readmission. They are never discharged , only transferred to the hospital if they need more acute care. She provided the Resident Handbook for review. She produced the Agency for Health Care Administration (AHCA) Notice of Transfer Form used by Long Term Care Facilities in the State of Florida, and stated she had not used the form in the eleven years she had worked at the facility. The facility did send the face sheet, the physician's orders, and any assessment that might be useful to the hospital. They did not send the comprehensive care plan goals. She had never heard of that, and did not know she needed to do that. A review of the facility policy and procedure Discharge Summary and Plan read: 2. the discharge summary will include a recapitulation of the resident's stay and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: f. ability to perform activities of daily living; g. sensory and physical impairments; h. nutritional status and requirements; i. special treatments or procedures; j. mental and psychosocial status; l. dental condition; o. cognitive status. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. an evaluation of the resident's discharge needs; b. the post-discharge plan; and c. the discharge summary (Copy obtained).

Based on clinical record review, staff interview and facility policy and procedure review, the facility failed to notify three sampled residents (#35, #36 and #144) out of 17 total sampled residents and the resident's representative(s) of the transfer or discharge, as soon as practicable, and the reasons for the move in writing and in a language and manner they understood. The facility also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The findings include: A review of the clinical record for Resident #35 revealed the resident was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She was transferred to the Enhanced Living unit on 11/27/2018. Resident #35 was to reside in apartment #224. The Social Services note dated 11/27/2018 read: (Resident #35) verbalizes agreement with discharge plan. She wanted to go to Enhanced Living during the time that her husband would be away on a trip. The discharge plan was to attend outpatient therapy. Nursing notes indicated the resident was alert and oriented in all spheres. She used a motorized scooter for mobility off the unit. Used a rolling walker on the unit. The Minimum Data Set (MDS) assessment dated [DATE] revealed a [DIAGNOSES REDACTED]. The resident received Occupational Therapy (OT) five days a week and Physical Therapy (PT) five days a week. A review of the care plan revealed a focus area: Alteration in musculoskeletal status related to left total knee replacement; Assistance with Activities of Daily Living (ADL) care; Risk for falls, Risk of adverse side effects from [MEDICAL CONDITION] meds; weakness and fatigue; acute pain. A review of the clinical record for Resident #36 revealed the resident was admitted to the facility on [DATE] and then transferred to the hospital on [DATE]. The MDS assessment dated [DATE], revealed the resident was coded as having [DIAGNOSES REDACTED]. The resident was receiving hospice care. A review of the care plan dated 11/19/2018, revealed problem areas including: Difficulty sleeping; Skin infection related to redness and swelling of left lower extremity with [DIAGNOSES REDACTED]. Hospice admitted the resident due to heart failure, [MEDICAL CONDITIONS], left lower extremity abscess drainage sanguineous drainage; hospice services; chronic congestion of the liver; diabetes, risk of hyper/hypo glycaemia; difficulty breathing, anticoagulant therapy; [MEDICAL CONDITION]; pacemaker with defibrillator related to A-Fib; heart failure; cognitive communication deficit; assistance with ADLs; risk of falls; adverse effects of psych meds; risk of pressure ulcer and skin breakdown; acute pain related to gout. A review of the clinical record for Resident #144 revealed the resident was admitted to the facility on [DATE] after a hospitalization . The history and physical (H&P) dated 01/13/2019, revealed Resident #144 was recently admitted from the hospital for [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A review of the progress note dated 01/25/2019 revealed a staff member entered Resident #144's bathroom, and found him sitting with his back against the toilet. He was assessed for pain and injuries with none noted. The resident had full range of motion, and stated he was ready to get up. The resident was found to have a large amount of bright red blood in his brief. His physician was notified of multiple falls with hematochezia (passage of fresh blood through the anus, usually with stools). The physician gave a new order to send the resident to the hospital emergency room (ER). During an interview with the Director of Nursing (DON) on 02/18/2019 at 9:06 AM, she stated Resident #144 went out to the hospital suddenly due to blood in his stool. She looked up his date of transfer and reported it was on 01/25/2019. He was still in the hospital. During an interview with the DON on 02/19/2019 at 4:29 PM, she stated she did not think the facility sent any notice to the resident or their representative of the transfer to the hospital. She stated I have to be honest, we don't do that. She stated that because of the way members paid their dues prior to living on the campus, they had a contract that said the facility would take them back if they were hospitalized . During an interview with Employee C, Director of Social Services, on 02/20/2019 at 10:04 AM, she stated they did not send a discharge notice to the resident or their representative, because with (this facility), the understanding was that the residents had paid dues to become a member of (the organization), and they would not be refused readmission. They are never discharged , only transferred to the hospital if they need more acute care. She provided the Resident Handbook for review. She produced the Agency for Health Care Administration (AHCA) Notice of Transfer Form used by Long Term Care Facilities in the State of Florida, and stated she had not used the form in the eleven years she had worked at the facility. The facility did send the face sheet, the physician's orders, and any assessment that might be useful to the hospital. They did not send the comprehensive care plan goals. She had never heard of that, and did not know she needed to do that. A review of the facility policy and procedure Discharge Summary and Plan read: 2. the discharge summary will include a recapitulation of the resident's stay and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: f. ability to perform activities of daily living; g. sensory and physical impairments; h. nutritional status and requirements; i. special treatments or procedures; j. mental and psychosocial status; l. dental condition; o. cognitive status. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. an evaluation of the resident's discharge needs; b. the post-discharge plan; and c. the discharge summary (Copy obtained).

Based on clinical record review, staff interview and facility policy and procedure review, the facility failed to provide written notice of the facility bed hold policy to two sampled residents (#36 and #144) out of a total sample of 17 residents. The findings include: A review of the clinical record for Resident #36 revealed the resident was admitted to the facility on [DATE] and then transferred to the hospital on [DATE]. The MDS assessment dated [DATE], revealed the resident was coded as having [DIAGNOSES REDACTED]. The resident was receiving hospice care. A review of the care plan dated 11/19/2018, revealed problem areas including: Difficulty sleeping; Skin infection related to redness and swelling of left lower extremity with [DIAGNOSES REDACTED]. Hospice admitted the resident due to heart failure, [MEDICAL CONDITIONS], left lower extremity abscess drainage sanguineous drainage; hospice services; chronic congestion of the liver; diabetes, risk of hyper/hypo glycaemia; difficulty breathing, anticoagulant therapy; [MEDICAL CONDITION]; pacemaker with defibrillator related to A-Fib; heart failure; cognitive communication deficit; assistance with ADLs; risk of falls; adverse effects of psych meds; risk of pressure ulcer and skin breakdown; acute pain related to gout. A review of the clinical record for Resident #144 revealed the resident was admitted to the facility on [DATE] after a hospitalization . The history and physical (H&P) dated 01/13/2019, revealed Resident #144 was recently admitted from the hospital for [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. A review of the progress note dated 01/25/2019 revealed a staff member entered Resident #144's bathroom, and found him sitting with his back against the toilet. He was assessed for pain and injuries with none noted. The resident had full range of motion, and stated he was ready to get up. The resident was found to have a large amount of bright red blood in his brief. His physician was notified of multiple falls with hematochezia (passage of fresh blood through the anus, usually with stools). The physician gave a new order to send the resident to the hospital emergency room (ER). During an interview with the Director of Nursing (DON) on 02/18/2019 at 9:06 AM, she stated Resident #144 went out to the hospital suddenly due to blood in his stool. She looked up his date of transfer and reported it was on 01/25/2019. He was still in the hospital. During an interview with the DON on 02/19/2019 at 4:29 PM, she stated she did not think the facility sent any notice to the resident or their representative of the transfer to the hospital. She stated I have to be honest, we don't do that. She stated that because of the way members paid their dues prior to living on the campus, they had a contract that said the facility would take them back if they were hospitalized . During an interview with Employee C, Director of Social Services, on 02/20/2019 at 10:04 AM, she stated they did not send a discharge notice to the resident or their representative, because with (this facility), the understanding was that the residents had paid dues to become a member of (the organization), and they would not be refused readmission. They are never discharged , only transferred to the hospital if they need more acute care. She provided the Resident Handbook for review. She produced the Agency for Health Care Administration (AHCA) Notice of Transfer Form used by Long Term Care Facilities in the State of Florida, and stated she had not used the form in the eleven years she had worked at the facility. The facility did send the face sheet, the physician's orders, and any assessment that might be useful to the hospital. They did not send the comprehensive care plan goals. She had never heard of that, and did not know she needed to do that. A review of the facility Resident Handbook and resident contracts, revealed the facility policy was for the resident to reside in the facility as long as necessary with no charges due to the resident, based on the organization's membership dues being paid in advance. The facility would ensure the resident could return to the facility if needed after transfer to a hospital or other acute care setting. A review of the facility policy and procedure Discharge Summary and Plan read: 2. the discharge summary will include a recapitulation of the resident's stay and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: f. ability to perform activities of daily living; g. sensory and physical impairments; h. nutritional status and requirements; i. special treatments or procedures; j. mental and psychosocial status; l. dental condition; o. cognitive status. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. an evaluation of the resident's discharge needs; b. the post-discharge plan; and c. the discharge summary (Copy obtained).

Based on clinical record review, staff interview and facility policy and procedure review, the facility failed to conduct a Standardized Quarterly Review assessment for one resident (#2) out of 17 sampled residents. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. The findings include: A review of the electronic clinical record for Resident #2 revealed the next quarterly assessment due on 12/18/2018 was 50 days overdue (Photographic evidence obtained). During an interview with Employee E, Registered Nurse (RN)/Minimum Data Set (MDS) Interim Coordinator, on 02/20/2019 at 12:54 PM, she stated she was not aware that Resident #2's quarterly assessment had not been submitted. She reviewed the electronic clinical record and stated the date 12/03/2018 of the last quarterly assessment was about the time the MDS coordinator went out on maternity leave. She stated it appeared it had not been submitted, because it still said In Progress on the screen instead of Accepted. She explained that when the Centers for Medicare and Medicaid Services (CMS) accepted the assessment, it said accepted in their system. She stated she would go find out why it had not been submitted yet. During an interview with Employee E on 02/20/2019 at 1:14 PM, she stated the week the MDS assessment was to have been submitted, the MDS coordinator left, due to the medical need for bed rest, and the submission of the quarterly assessment was overlooked. She stated it just did not get done and slipped through the cracks. A review of the facility's policy and procedure for Resident Assessment Instrument revealed: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. At least quarterly (Copy obtained).

Based on observation, interviews and record reviews, the facility failed to ensure that services provided met professional standards of quality, by failing to administer medication and nutritional supplements as ordered by the physician for one (Resident #27) of seven residents observed during medication administration, and for one resident (#140), who expressed discomfort due to not receiving his medications as ordered, out of a total sample of 17 residents. The facility also failed to adhere to proper cleaning and disinfecting of glucometers per the manufacturer's recommendations and facility policy for one (Resident #24) of four residents who received blood glucose monitoring, involving one (Employee A) of four facility nurses observed. Professional Standard of Care is defined in Chapter 766.102 as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The findings include: 1. On 2/19/2019 at 12:15 PM an observation of medication administration was made with Employee A, Registered Nurse (RN), for Resident #27. Without measuring, the nurse poured Med Pass (nutritional supplement) into an unmarked cup to the top line, and filled another identical cup approximately half full with the same supplement. When she was asked for the volume poured, she stated 120 mL, and proceeded to give Resident #27 the one and one-half cups of Med Pass. Taking an identical unmarked cup and a 30 mL measured cup, using water and properly measuring 30 mL four times, it was revealed that one unmarked cup to the top line equaled 120 mL of fluid. Resident #27 had received more of the nutritional supplement than was prescribed. (Photographic evidence obtained) A review of the facility's policy and procedure for medications entitled Administering Medications by Nursing Services Policy and Procedure Manual for Long-Term care, 2001 MED-PASS, Inc. (Revised (MONTH) 2012) under Policy Interpretation and Implementation and paragraph 3: Medications must be administered in accordance with the orders, including any required time frame. Paragraph 7: The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication (Copy obtained). Review of facility policy and procedures Medications Titled Administering Medications by Nursing Services Policy and Procedure Manual for Long-Term care, 2001 MED-PASS, Inc. (Revised (MONTH) 2012) under Policy Interpretation and Implementation under paragraph labeled 3. Medications must be administered in accordance with the orders, including any required time frame (Copy obtained). Professional Standard of Care is defined in Chapter 766.102 as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers. 2. During an observation and interview on 2/18/2019 at 10:42 AM, small red sores were observed on both of Resident #140's forearms. He the sores on his arms were from scratching due to extreme itching. They are supposed to be putting a cream on it, but I don't think they have it yet. Resident #140 was observed on 2/19/2019 at 11:42 AM at the nurse's station. Both of his forearms had small red sores on them. A review of the electronic clinical record revealed he was admitted on [DATE] from the Enhanced Living Unit on campus. His [DIAGNOSES REDACTED]. (Copy obtained) A review of the initial care plan, dated 2/12/2019, revealed the resident's problem areas included a risk for falls; risk for complications from diabetes; alteration in comfort; potential alteration in skin integrity; bowel and bladder; communication, and activities of daily living (ADL) assist. (Copy obtained) A review of the nursing admission summary, dated 2/12/2019 at 11:28 AM, revealed: Resident was admitted today to S2 room [ROOM NUMBER]. Skin tears to left knee, right knee, left side abdomen, bruise to back of left hand, scratches to left side of abdomen and right forearm. (Copy obtained) A review of the nursing admission assessment, dated 2/12/2019, revealed in the skin integrity section: Color: normal, Temperature: warm, equal and dry, Turgor: normal. Integrity: Skin tears to left knee front (0.6 centimeters) (cm) right knee front (0.2 cm), left iliac crest front (0.7 cm). Left iliac crest other, scratch (2.1 cm). Left hand back, bruising. Other, right forearm posterior scratch (3.0 cm). No comments were noted. (Copy obtained) A review of the weekly skin assessment, dated 2/20/2019, revealed the resident was assessed as not having any skin impairment such as skin tears, bruises, wounds or ulcers. No new skin areas. Faint bruising noted to all extremities related to anticoagulants therapy. No resolved skin impairments this week. (Copy obtained) A review of the physician's orders [REDACTED]. Apply to upper and lower extremity topically every morning and at bedtime for dry skin. Start date 2/5/2019. Lac-Hydrin Lotion 12% (Ammonium [MEDICATION NAME]). Apply to upper and lower extremity topically every 8 hours as needed for itching, dry skin. Start date 2/6/2019. [MEDICATION NAME] HCI ([MEDICATION NAME]) tablet 25 mg (milligrams). Give one tablet by mouth every 8 hours as needed for itching related to pruritus, unspecified. Start date 2/6/2019. (Copy obtained) A review of the Medication Administration Record [REDACTED]. The as needed medications had not been administered during the month. (Copy obtained) During an interview on 2/20/2019 at 9:42 AM with Employee F, Licensed Practical Nurse (LPN), she produced all of the medication for Resident #140 that was stored in the medication cart. The lotion Ammonium [MEDICATION NAME] Lotion 12% was not in the medication cart. She stated it was on the treatment cart. She went to the treatment cart, opened it and did not find the lotion. She stated the lotion was kept in the resident's bathroom, and the certified nursing assistants (CNAs) put it on him when they gave him a shower in the mornings. She went to the resident's bathroom, looked for it and could not find it. She looked throughout his room and could not find the lotion. She stated she signed off on the MAR because she knew the CNAs were supposed to be putting it on him in the morning when they gave him a shower. She did not check to make sure they were doing it. During an interview on 2/20/2019 at 9:59 AM with Employee G, CNA, and Employee F, LPN, Employee G stated the cream was in the resident's bathroom. She went into the resident's bathroom and looked throughout, but did not find the cream. She looked throughout his room, but did not find it. She stated he did tell her that his arms itched, and that he scratched them until they bled, making sores on his arms. She informed the nurse that she did not give the resident a shower every day. He received a shower on Mondays and Thursdays. She produced a bottle of Aloe Vera lotion, and stated We use this for his skin. The nurse informed her that the Aloe Vera lotion was not the lotion they needed to put on his arms and legs for itching. She stated she would get the lotion from the pharmacy on campus. Employee F stated she thought he had it when he moved over from the Enhanced Living Unit. She did not check. During an interview on 2/20/2019 at 10:14 AM with Employee H, Pharmacy Technician, she stated she was out of the Ammonium [MEDICATION NAME] Lotion 12%. She was not sure, but she thought she had been out of it for at least a week. During an interview on 2/21/2019 at 11:08 AM with the Director of Nursing (DON), she was asked to explain how medications were reconciled for new admissions to the health care facility. She stated the staff brought over their medications from their apartment, and they wrote them out on an order slip. Then the nurse called the physician and went over them with him. If the doctor wanted something added or changed they took a telephone order. The admitting nurse reconciled the medications and then listed them in the system. She stated that the admitting nurse should have caught the fact that there was no Ammonium [MEDICATION NAME] lotion for Resident #140, because the Enhanced Living Unit, where he was residing on campus, had a list of his current medications. She stated the nurses should have been applying the medication to Resident #140's extremities, not the CNAs, because it was a prescribed medication. A review of the facility's policy and procedure for Administering Medications revealed: Medications shall be administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 3. Medications must be administered in accordance with the orders, including any required time frame. (Copy obtained) 3. On 2/19/2019 at 11:32 AM, an observation of medication administration was made with Employee A, Registered Nurse (RN), for Resident #24. Following blood glucose testing with Resident #24, Employee A proceeded to cleanse the glucometer with an alcohol wipe. She was immediately interviewed and was asked to describe the facility's protocol for cleaning glucometers. She stated, I should have used a Sani Cloth instead of an alcohol wipe. She pulled the container of Sani Cloth Germacidal wipes from the medication cart drawer. When asked whether she had been trained on proper cleaning of the glucometers, she replied that she had, and acknowledged that she had not performed the procedure correctly. On 2/20/2019 at 1:23 PM during an interview with Employee B, RN, she was asked who was responsible for providing new nurse orientation training, and she replied that she was responsible. When asked whether she covered infection control measures as they related to blood glucose monitoring and cleaning/disinfecting of facility glucometers, she replied that she did. A review of the manufacturer's cleaning recommendations entitled CLEANING AND DISINFECTING THE METER, revealed in the first paragraph: To minimize the risk of transmitting blood-borne pathogens the cleaning and disinfection procedure should be performed as recommended in the instructions below. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Disinfectant Brand Names include: PDI super Sani-Cloth Germicidal disposable wipes. A review of the facility's Policy and Procedure for diabetic care entitled Obtaining a Finger Stick Glucose Level By Nursing Services Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc. (Revised (MONTH) 2011). Subsection labeled Steps in the Procedure 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice (Copy obtained).

Based on observation, interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to administer medication and nutritional supplements as ordered by the physician for one (Resident #27) of seven residents observed during medication administration, and for one resident (#140), who expressed discomfort due to not receiving his medications as ordered, out of a total sample of 17 residents. The findings include: 1. On 2/19/2019 at 12:15 PM an observation of medication administration was made with Employee A, Registered Nurse (RN), for Resident #27. Without measuring, the nurse poured Med Pass (nutritional supplement) into an unmarked cup to the top line, and filled another identical cup approximately half full with the same supplement. When she was asked for the volume poured, she stated 120 mL, and proceeded to give Resident #27 the one and one-half cups of Med Pass. Taking an identical unmarked cup and a 30 mL measured cup, using water and properly measuring 30 mL four times, it was revealed that one unmarked cup to the top line equaled 120 mL of fluid. Resident #27 had received more of the nutritional supplement than was prescribed. (Photographic evidence obtained) A review of the facility's policy and procedure for medications entitled Administering Medications by Nursing Services Policy and Procedure Manual for Long-Term care, 2001 MED-PASS, Inc. (Revised (MONTH) 2012) under Policy Interpretation and Implementation and paragraph 3: Medications must be administered in accordance with the orders, including any required time frame. Paragraph 7: The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication (Copy obtained). Review of facility policy and procedures Medications Titled Administering Medications by Nursing Services Policy and Procedure Manual for Long-Term care, 2001 MED-PASS, Inc. (Revised (MONTH) 2012) under Policy Interpretation and Implementation under paragraph labeled 3. Medications must be administered in accordance with the orders, including any required time frame (Copy obtained). Professional Standard of Care is defined in Chapter 766.102 as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers. 2. During an observation and interview on 2/18/2019 at 10:42 AM, small red sores were observed on both of Resident #140's forearms. He the sores on his arms were from scratching due to extreme itching. They are supposed to be putting a cream on it, but I don't think they have it yet. Resident #140 was observed on 2/19/2019 at 11:42 AM at the nurse's station. Both of his forearms had small red sores on them. A review of the electronic clinical record revealed he was admitted on [DATE] from the Enhanced Living Unit on campus. His [DIAGNOSES REDACTED]. (Copy obtained) A review of the initial care plan, dated 2/12/2019, revealed the resident's problem areas included a risk for falls; risk for complications from diabetes; alteration in comfort; potential alteration in skin integrity; bowel and bladder; communication, and activities of daily living (ADL) assist. (Copy obtained) A review of the nursing admission summary, dated 2/12/2019 at 11:28 AM, revealed: Resident was admitted today to S2 room [ROOM NUMBER]. Skin tears to left knee, right knee, left side abdomen, bruise to back of left hand, scratches to left side of abdomen and right forearm. (Copy obtained) A review of the nursing admission assessment, dated 2/12/2019, revealed in the skin integrity section: Color: normal, Temperature: warm, equal and dry, Turgor: normal. Integrity: Skin tears to left knee front (0.6 centimeters) (cm) right knee front (0.2 cm), left iliac crest front (0.7 cm). Left iliac crest other, scratch (2.1 cm). Left hand back, bruising. Other, right forearm posterior scratch (3.0 cm). No comments were noted. (Copy obtained) A review of the weekly skin assessment, dated 2/20/2019, revealed the resident was assessed as not having any skin impairment such as skin tears, bruises, wounds or ulcers. No new skin areas. Faint bruising noted to all extremities related to anticoagulants therapy. No resolved skin impairments this week. (Copy obtained) A review of the physician's orders [REDACTED]. Apply to upper and lower extremity topically every morning and at bedtime for dry skin. Start date 2/5/2019. Lac-Hydrin Lotion 12% (Ammonium [MEDICATION NAME]). Apply to upper and lower extremity topically every 8 hours as needed for itching, dry skin. Start date 2/6/2019. [MEDICATION NAME] HCI ([MEDICATION NAME]) tablet 25 mg (milligrams). Give one tablet by mouth every 8 hours as needed for itching related to pruritus, unspecified. Start date 2/6/2019. (Copy obtained) A review of the Medication Administration Record [REDACTED]. The as needed medications had not been administered during the month. (Copy obtained) During an interview on 2/20/2019 at 9:42 AM with Employee F, Licensed Practical Nurse (LPN), she produced all of the medication for Resident #140 that was stored in the medication cart. The lotion Ammonium [MEDICATION NAME] Lotion 12% was not in the medication cart. She stated it was on the treatment cart. She went to the treatment cart, opened it and did not find the lotion. She stated the lotion was kept in the resident's bathroom, and the certified nursing assistants (CNAs) put it on him when they gave him a shower in the mornings. She went to the resident's bathroom, looked for it and could not find it. She looked throughout his room and could not find the lotion. She stated she signed off on the MAR because she knew the CNAs were supposed to be putting it on him in the morning when they gave him a shower. She did not check to make sure they were doing it. During an interview on 2/20/2019 at 9:59 AM with Employee G, CNA, and Employee F, LPN, Employee G stated the cream was in the resident's bathroom. She went into the resident's bathroom and looked throughout, but did not find the cream. She looked throughout his room, but did not find it. She stated he did tell her that his arms itched, and that he scratched them until they bled, making sores on his arms. She informed the nurse that she did not give the resident a shower every day. He received a shower on Mondays and Thursdays. She produced a bottle of Aloe Vera lotion, and stated We use this for his skin. The nurse informed her that the Aloe Vera lotion was not the lotion they needed to put on his arms and legs for itching. She stated she would get the lotion from the pharmacy on campus. Employee F stated she thought he had it when he moved over from the Enhanced Living Unit. She did not check. During an interview on 2/20/2019 at 10:14 AM with Employee H, Pharmacy Technician, she stated she was out of the Ammonium [MEDICATION NAME] Lotion 12%. She was not sure, but she thought she had been out of it for at least a week. During an interview on 2/21/2019 at 11:08 AM with the Director of Nursing (DON), she was asked to explain how medications were reconciled for new admissions to the health care facility. She stated the staff brought over their medications from their apartment, and they wrote them out on an order slip. Then the nurse called the physician and went over them with him. If the doctor wanted something added or changed they took a telephone order. The admitting nurse reconciled the medications and then listed them in the system. She stated that the admitting nurse should have caught the fact that there was no Ammonium [MEDICATION NAME] lotion for Resident #140, because the Enhanced Living Unit, where he was residing on campus, had a list of his current medications. She stated the nurses should have been applying the medication to Resident #140's extremities, not the CNAs, because it was a prescribed medication. A review of the facility's policy and procedure for Administering Medications revealed: Medications shall be administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 3. Medications must be administered in accordance with the orders, including any required time frame. (Copy obtained) .

Based on observations, interviews and record reviews, the facility failed to maintain an infection control program designed to prevent the development and transmission of communicable diseases and infections, by failing to adhere to proper cleaning and disinfecting of glucometers per the manufacturer's recommendations and facility policy for one (Resident #24) of four residents who received blood glucose monitoring, and involving one (Employee A) of four facility nurses observed. The findings Include: On 2/19/2019 at 11:32 AM, an observation of medication administration was made with Employee A, Registered Nurse (RN), for Resident #24. Following blood glucose testing with Resident #24, Employee A proceeded to cleanse the glucometer with an alcohol wipe. She was immediately interviewed and was asked to describe the facility's protocol for cleaning glucometers. She stated, I should have used a Sani Cloth instead of an alcohol wipe. She pulled the container of Sani Cloth Germacidal wipes from the medication cart drawer. When asked whether she had been trained on proper cleaning of the glucometers, she replied that she had, and acknowledged that she had not performed the procedure correctly. On 2/20/2019 at 1:23 PM during an interview with Employee B, RN, she was asked who was responsible for providing new nurse orientation training, and she replied that she was responsible. When asked whether she covered infection control measures as they related to blood glucose monitoring and cleaning/disinfecting of facility glucometers, she replied that she did. A review of the manufacturer's cleaning recommendations entitled CLEANING AND DISINFECTING THE METER, revealed in the first paragraph: To minimize the risk of transmitting blood-borne pathogens the cleaning and disinfection procedure should be performed as recommended in the instructions below. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Disinfectant Brand Names include: PDI super Sani-Cloth Germicidal disposable wipes. A review of the facility's Policy and Procedure for diabetic care entitled Obtaining a Finger Stick Glucose Level By Nursing Services Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc. (Revised (MONTH) 2011). Subsection labeled Steps in the Procedure 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice (Copy obtained).

Based on observations and staff interviews, the facility failed to ensure 2 of 2 blue colored dumpsters with plastic lids in the loading area were maintained and sanitary during two of two days observed (8/31/15 and 9/2/2015) related to: 1) dumpsters were not securely covered with lids; and 2) Loading area was not free from uncontained trash/refuse. The findings include: During the kitchen tour on 8/31/15 at 10:30 am and on 9/2/15 at 11:30 am, the following was observed: 1. Two of two blue colored dumpsters with black plastic lids were noted overfilled with trash/refuse bags overflowing from both dumpsters, which could not be closed. Further observations revealed trash around and along dumpsters and enclosure. (Photographic evidence obtained). 2. The area adjacent to the loading/off-loading ramp was filled with piled up trash lying in puddles of water. Further observations revealed resident care equipment, which included used gloves, along with random papers, cigarette butts, water bottles, cans, and other unrecognizable items, were piled up at least 2- 4 inches off the ground in this area. (Photographic evidence obtained). An interview was conducted on 8/31/15 at 10:45 am with the Registered Dietitian. She confirmed that the dumpsters were overfilled with trash, and that trash was visibly exposed around and along dumpsters and enclosure. She also confirmed the extensive amount of trash build up around the loading/off-loading area. She said that she was not previously aware of the condition of the area, and she did not recall the collection days for waste management. She stated she would follow up with the department director to find out which department was responsible for maintaining that designated area. In an interview conducted on 9/2/15 at 11:40 am with the Director of Dining and the Kitchen Chef he confirmed the trash build-up in the loading/off-loading area. The Chef identified gloves and a milk crate among the refuse. The Director of Dining said he was informed by the Registered Dietitian regarding the trash in this area. He said he was in the process of trying to locate the department responsible for maintaining the area.

Based on observations, record review, and staff interviews, the facility failed to ensure the kitchen and its equipment were maintained and sanitary during three of three days observed (8/31/2015, 9/2/15, and 9/3/15) related to the following: 1) Grease tray on stove/ range was maintained clean and emptied timely; 2) Ovens were maintained in a clean manner; 3) Walk in refrigerator with internal thermometer; 4) Ice machine scoop holder was maintained clean and sanitary; 5) Employees were wearing the proper attire and protective garments; 6) Tiles were maintained clean with non- porous surfaces; 7) Food temperature logs were maintained completely; and 8) Trash cans with closed lids and not in close proximately of food and food preparation stations. The findings include: During the kitchen tour on 8/31/2015 at 10:10 a.m., on 9/2/2015 at 11:15 a.m. and 3:40 p.m., and on 9/3/15 at 9:55 a.m., the following was observed: 1. One of one stove grease tray was observed with buildup of hardened grease and debris located under the stove top. 2. Two of two ovens were observed with a buildup of caked on grease along the base and racks. 3. One of two refrigerators was observed without an internal thermometer. 4. One ice machine scoop holder was observed with a built-up layer of bio-growth along the base lining of the container. 5. Two tiles between and adjacent to the fryers were observed broken and missing. The space was filled with puddled grease. 6. Food temperature logs were incompletely documented and missing. Review of the Taste Temperature Reports, dated for 8/22/15 and 8/28/15, revealed that some temperatures were taken for consistency altered menu items, but not all dates had temperatures for mechanical soft or pureed menu items. It was unclear how many meals were missing temperatures since the records were from more than one serving location, and not all of them were dated. An interview was conducted on 9/2/15 at 4:30pm with the Registered Dietitian, and she confirmed the logs were missing data. 7. Three trash cans were observed uncovered with food waste and the garbage exposed. It was observed one trash can was located at one of the food preparation stations, another can was located close to the cook preparation station, and the third trash can was located at one of the hand washing stations. All trash cans were open and with no visible lids in close proximity, with exposed garbage and food waste. In accordance with the Food Code section 5-501.113, trash receptacles shall be kept covered when not in continuous use. 8. On 9/2/15 at 11:15 am, Employees A, B, C, and D were observed in the kitchen during food preparation. They were not wearing hair nets or beard nets. In addition, the Registered Dietitian was observed in the kitchen on 9/2/15 at 3:40 pm. She was not wearing a hairnet. An interview was conducted on 9/1/2015 at 3:50 p.m. with the Executive Chef, who confirmed the kitchen staff should wear hair restraints. He stated that hair and beard restraints must be worn when all staff enter the kitchen. In addition, he provided the facility policy which revealed the purpose, Hair must be controlled to prevent it from being both direct and an indirect vehicle of off contamination. Dislodged hair must be kept from falling into food or onto food-contact surfaces, and associates must be discouraged from touching their hair.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan which described resident specific and appropriate services which were to be furnished for [MEDICAL TREATMENT] for 1 of 1 residents on [MEDICAL TREATMENT] (Resident #41). The findings include: Record review conducted for Resident #41 revealed an admission date of [DATE], with a [DIAGNOSES REDACTED]. The record showed that the resident was on a 1500 cc fluid restriction. An interview was conducted with Resident #41 in her room at 2:25 PM on 9/1/15. The resident stated, I have [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays. My chair time is 10:15 AM. I have a [MEDICAL TREATMENT] book I take back and forth with me. Staff weigh me in [MEDICAL TREATMENT] when I arrive and leave. The staff here give me my medications and take my vital signs. They send a snack with me; fruit, such as berries, protein, and water is sent with me. My port is on the right side of my chest. Staff here check my port, but staff at the [MEDICAL TREATMENT] center change the dressing. When I return back from [MEDICAL TREATMENT], the staff take my vital signs. I leave at 9:30 AM to go to [MEDICAL TREATMENT], and on Tuesdays and Thursdays, the campus driver takes me. On Saturdays, an ambulance service takes me to [MEDICAL TREATMENT]. I am at [MEDICAL TREATMENT] for about 3 and a half hours. I have been on [MEDICAL TREATMENT] three or four months. Record review of the Care Plan for Resident #41 revealed the following focus: Needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION], goes three times a week. The interventions included: Encourage to go to [MEDICAL TREATMENT] appointments 3 times a week; monitor intake and output; fluid restriction 1500 ml daily, broken up between nursing and dietary; monitor/ document site for signs and symptoms of infection; report to physician any signs and symptoms of [MEDICAL CONDITION]; and obtain vital signs and weight per protocol. Surveyor did not observe any interventions concerning where the resident goes for [MEDICAL TREATMENT] or contact number, location of the resident's access port, communication with dyalisis center, how resident is transported, chair time at [MEDICAL TREATMENT], nurse responsibilities before the resident leaves the facility for [MEDICAL TREATMENT] and when she returns; and whether bag lunch and fluids are sent with resident. An interview was conducted with the MDS Coordinator, RN, on 9/3/15 at 10:09 AM. The RN confirmed the care plan did not address where the resident received [MEDICAL TREATMENT] and contact information, location of access port, scheduled days or chair time for dyalisis, transportation needs, communication with [MEDICAL TREATMENT], or the [MEDICAL TREATMENT] book which needed to accompany the resident. The resident's care plan was updated on 9/2/15 to include a bag lunch.

Based on observations, staff interviews, and record review, the facility failed to ensure 1 of 3 storage areas for medications was free of expired medications (S3 medication cart). The findings included: An observation of the medication cart for the S3 unit at 10:30 am on 9/3/15 revealed a vial of Novolog insulin 32 days beyond it's open date. The Novolog vial was opened on 8/2/15. In an interview with Employee G, Licensed Practical Nurse, on 9/3/15 at 10:35 am she confirmed that the vial of Novolog insulin was opened on 8/2/15. She stated that the facility policy was that opened vials expired after 28-30 days of use. Record review of the instructions included in the front of the Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing (DON) at 12:25 PM on 9/315. The DON confirmed the Novolog insulin was expired, and should not have been used after 28 days from being opened. She stated, The pharmacist was in on Monday and checked the cart, but missed it.

Based on record review and staff interview, the facility failed to ensure the medical record was accurately documented for 1 resident (Resident #24) out of 2 residents reveiewed for urinary incontinence, out of 18 sampled residents. The findings include: A record review was conducted for Resident #24, which revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) Quarterly assessment, dated 8/10/15, revealed that Resident #24 had impaired vision, was sometimes understood and sometimes understands. The resident's cognitive skills for daily decision making were severely impaired, and she was coded as needing extensive assistance with toileting. The resident was coded as frequently incontinent of bladder, and always continent of bowel. A review of Resident #24's Care Plan, updated 8/20/15, revealed as a focus: Incontinent at times of bladder and continent of bowel related to dementia, impaired mobilility, and the need for assistance with toileting. Interventions included: check for bowel bladder incontinence; provide toileting and /or pericare as needed; establish voiding routine before/ after meals, upon arising, bedtime, and upon request. Resident needs reminding and cueing. Toilet her according to schedule listed above, and provide briefs/ pads/ pullups daily for dignity. Electronic record review for Resident #24 revealed documentation for urinary continence or toileting was provided once per shift. The documentation observed included the following: 8/25/15: Resident was documented as being toileted at 1:10 AM, 8:23 AM, 1:02 PM, and 10:02 PM. 8/26/15: Resident was toileted at 00:53 AM, 9:24 AM, 1:44 PM, and 10:15 PM. 8/27/15: Resident was toileted at 1:10 AM, 9:09 AM, and 11:46 PM. 8/28/15: Resident was toileted at 00:51 AM, 6:00 AM, 1:49 PM, and 11:36 PM. 8/29/15: Resident was toileted at 00:57 AM, 8:29 AM, 1:30 PM, and 11:34 PM. 8/30/15: Resident was toileted at 3:00 AM, 1:56 PM, and 10:32 PM. 8/31/15: Resident was toileted at 3:31 AM, 1:42 PM, and 9:23 PM 9/1/15: Resident was toileted at 00:50 AM, 8:39 AM, and 10:23 PM. An interview was conducted with Employee F, Certified Nursing Assistant (CNA), at 3:45 PM on 9/2/15. Employee F stated, I toilet Resident #24 when I get here, after dinner, and before bed. She goes to bed at 7:30-8:00 PM. I do not document every single time I take her to the toilet. I document once or twice a shift. An interview was conducted with Employee E, CNA, at 12:40 PM on 9/3/15. He stated, I am supposed to document every time the resident was toileted or changed. I do forget sometimes. An interview was conducted at 8:30 AM on 9/3/15 with the Director of Nursing. She said her expectation was for CNAs to document incontinence and toileting everytime the care was provided.

Based on observation, medical record review and staff interview the facility failed to immediately report and investigate fully a bruise for 1 resident (Resident #17), out of 1 resident reviewed for injury of unknown origin, out of 25 stage 2 sampled residents. The findings include: An observation of Resident #17 on 8/05/2014 at 3:12 pm revealed the resident was seated in her wheelchair in the dayroom. The resident had a deep purple bruise approximately the size of a half dollar on her right forearm. Review of Resident #17's Bruise Investigation form dated 8/7/14 at 3:00pm revealed "Size:" 4x3 (measurement increment not specified) right forearm. "Color:" dark purple/black. In the section titled "Resident factors," check marks were placed for: Does not ambulate on own, Bruises easily, and Recent lab procedure 7/25/14. The section titled "Education" was annotated as follows: "Staff educated to report bruise promptly even if they don't know when or how it occurred." The section titled "Actions" revealed check marks for: Care plan updated, Physician notified, and DON (Director of Nursing)/Risk manager notified. The form was annotated at the bottom as follows: "Discussing with Abuse Coordinator and Administrator regarding this. 8/8/14 called to abuse hotline." Review of Resident #17 ' s Minimum Data Set ((MDS) dated [DATE] revealed in section C that the resident could not complete the Brief Interview for Mental Status (BIMS). She was assessed as having short-term and long-term memory problems, and her cognitive skills for daily decision making were severely impaired. The resident was coded for difficulty focusing attention, disorganized thinking and psychomotor [MEDICAL CONDITION]. Section I revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident #17 ' s Care Plan dated 5/21/14 revealed focus areas of diabetes, dehydration due to use of diuretic medication, [MEDICAL CONDITION], risk of renal (kidney) failure, Hospice services, constipation, communication difficulty, mood/psychosocial, ADL (Activities of Daily Living) deficit, risk of injury from falls, adverse side effects from psychiatric medications, and pain due to arthritis. A focus initiated on 6/21/13 for risk of pressure ulcer or skin breakdown related to decreased mobility, incontinence and history of skin rashes listed the intervention: " Check skin during daily care for any open or reddened areas, any new bruises or rashes and report such to nurse. " This task was assigned to the Certified Nursing Assistant (CNA). Review of Resident #17 ' s Nursing assessment dated [DATE] revealed in the Skin Turgor section that the resident was assessed as having good skin turgor. The box next to "Bruises Easily" was not checked. Review of Resident #17 ' s hospice nursing assessment dated [DATE] revealed in the section for skin: "Friable/fragile, pallor. No wound or skin impairment present." Review of the facility policy and procedure for abuse, neglect, exploitation and misappropriation of property revealed in the section titled "Identification" that "Staff will be alert to signs of bruising, skin tears, physical and emotional decline, crying, complaints of pain, weight loss, dehydration, etc." The "Investigation" section stated: "All injuries of unknown origin (bruises, skin tear, etc.) will be investigated to attempt to determine the cause. The "Reporting" section stated: "Reporting the incident to employee's supervisor is sufficient provided the supervisor takes the appropriate steps as detailed in this policy to initiate action based on the report. The facility will ensure that all alleged violations involving known or suspected abuse, neglect, and or misappropriation of property will be reported immediately to the employee's supervisor, facility specific abuse representative, Director of nursing and Administrator." Interview with Employee #G, RN, and Employee #H, LPN, on 8/07/14 at 3:05 pm, revealed that neither of them was aware that Resident #17 had a bruise on her arm. Employee #G went with this surveyor to the resident's room to see the bruise. The resident was lying in bed awake. The resident was not verbal, and could not say what happened to her arm. Interview with Employee #F, CNA, on 8/07/14 at 4:20 pm revealed she saw the bruise on Resident #17's arm, but she thought it looked like an old bruise so she didn't report it to her supervisor. Interview on 8/08/2014 at 9:00 am with the DON revealed that after the surveyor informed the facility of Resident #17's bruise, the facility initiated an investigation into the origin of the bruise. She stated that the resident had a blood draw on 7/25/2014, and the phlebotomist draws the resident ' s blood below the elbow joint in the same area of the current bruise. She stated however that she did not think that the blood draw was the cause of the bruise, because she thought the bruise looked " too recent. " She stated the bruise was " too dark. " The DON confirmed that the staff failed to report the bruise to her per the facilty policy. She stated she interviewed staff and they do not know the origin of the bruise. She stated she could not determine the origin of the injury, so she called it in to the Abuse Hotline. Interview on 8/08/2014 at 1:00 pm with the Hospice RN revealed she did not see the bruise on the resident's arm, and the Hospice CNAs did not report it to her. .