Every finding on record at Oak Village Healthcare

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents requiring Hoyer lift transfers on 2ut of 2 hallways, reviewed or environment. The facility failed to remove a broken electric Hoyer lift (a mechanical assistive device that uses a sling and sturdy frame to safely transfer immobile residents to and from bed) from continued use rotation on facility residents requiring Hoyer lift transfers. The facility failed to repair a broken electric Hoyer lift that was used for Sunset and Rodeo facility hallways. These failures could place residents at risk of injury, unsafe transfers, and environment.During an observation and interview on 6/10/26 at 3:02 P.M., in the common area of the Sunset hallway, of 1 of 2 electric Hoyer lifts, with CNA A revealed the aide identified the lift as one of the Hoyer lifts she used to transfer facility residents. The Hoyer lift's rectangular control box located near the base of the lift was beige in color and separated in the middle exposing jagged inner plastic edges. CNA A said there were 2 electric Hoyer lifts, but she was pretty sure she had used the broken Hoyer lift that day because there was one on each hall and they used them interchangeably depending on which lift was free for use at the time it was needed. CNA A said no residents were injured during her transfers when she used the lift. CNA A said staff was not sure to whom they should have reported the issue to but said she could have told the Maintenance Director or written it in the maintenance repair log, located at the nursing station. During an observation and interview with Corporate and DON on 6/10/26 at 3:08 P.M., The DON and Corporate both said none of the staff had notified them that the electric Hoyer lift needed to be repaired, and they both said it needed to be fixed so it would not cause any injury to a resident. Corporate removed the electric Hoyer lift from the common area and put it into the Administrator's office. She said that was to prevent staff from continuing to use the device until it was fixed so no resident could be injured. Corporate said she was notifying the facility Maintenance Director and the company that serviced the Hoyer lift. In an interview with the DON on 6/10/26 at 3:10 P.M., she said the staff were trained to report broken or malfunctioning equipment to administrative management and write repair issues in the maintenance repair logs as there was a log located at each of the two facility nursing stations. The DON said she did not know why staff had not done so and did not know why staff had not notified her. The DON said a resident could be injured by the open jagged edges of the box and could not understand why staff continued to use the device in that condition because there was a manual Hoyer lift and one other electric Hoyer lift on the other unit. During an observation and interview on 6/10/26 at 3:12 P.M., in the Administrator's office with CNA B revealed the aide said staff used the electric Hoyer lift. CNA B said that particular electric Hoyer lift had been broken for a while but could not say exactly how long. CNA B said the electric Hoyer lift not only had the cracked and open beige box at the bottom, near the base of the Hoyer lift, but the emergency mechanical lowering descent mechanism was also broken. CNA B demonstrated that the red collar freely slid up and down the column, instead of being engaged to lower the boom (the part that supports the weight of the resident) at a safe controlled rate when the battery was not in use. CNA B said staff had not specifically told anyone in management about it because staff thought everyone already knew it was broken. CNA B said staff probably should have reported the issues with the lift to management and written it in the maintenance repair log at the nurses' station, because that was what they had been trained to do. During a follow up observation and interview on 6/10/26 at 3:18 P.M., with Corporate in the Administrator's office, of the electric Hoyer lift, revealed she said no staff reported to the Administrator or DON that the lift was broken and that the emergency mechanical lowering descent mechanism was also broken. Corporate said the Maintenance Director had been notified and the facility had already ordered a rental electric Hoyer lift and said she would provide the invoice for the rental and the service repair request the facility had submitted. Corporate said if the emergency mechanical lowering descent mechanism was broken, a resident could get stuck in the air if the battery/electrical went out and there would be no way to lower the resident to safety. Corporate said the broken and malfunctioning parts on the electric Hoyer lift should have been reported and they were working on getting it fixed ASAP. Corporate said they removed the device from rotation and employee access, so it would not continue to be used while in disrepair and so no residents could be injured by it. Observation on 6/10/26 at 3:23 P.M., of a second electric Hoyer lift in room [ROOM NUMBER] revealed it was in good working condition. During an interview with the facility Maintenance Director on 6/10/26 at 3:48 P.M., he said no one notified him about the broken electric Hoyer lift and he was only notified today, by Corporate, the DON and Administrator. The Maintenance Director said the staff should have notified him of the broken electric Hoyer lift using the maintenance logs because there was one located on each of the two facility nursing stations. The Maintenance Director said the electric Hoyer lift needed to be fixed so it would work properly and if the emergency mechanical lowering descent mechanism was broken, a resident could get stuck in the air if the battery/electrical went out and there would be no way to lower the resident to safety. He said the jagged edges of the box at the bottom could cut a resident. The Maintenance Director said the device should be fixed and staff should have reported the issue. Record review of the facility maintenance logs from each nursing station for July 2025 through June 2026 revealed no entries for repairs to an electric Hoyer lift. Record review of a handwritten list of residents who required Hoyer lift transfers revealed a total of 18 residents. Record review of the facility's policy titled Lifting Machine, Using a Mechanical, dated Revised July 2017, revealed in part: 6. Test the lift control. Ensure the emergency release feature works. 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.

Based on observation, interview and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for 1 ( Resident # 1) of 4 residents reviewed for quality of care. The facility failed to provide necessary arrangements to repair broken eyeglasses for Resident # 1.This failure could lead to injury and/or decreased quality of life. Findings included:Record review of Resident # 1's face sheet dated, 6/9/2026 revealed a [AGE] year old male, admitted to the facility on [DATE]. Relevant diagnosis included Parkinson's Disease without Dyskinesia, without mention of fluctuations ( a stage of the condition where the patient has smooth, relatively stable symptom control) and Dementia with other behavioral disturbance (agitation, aggression, anxiety, depression, delusions, wandering, and sundowning). Record review of Resident # 1's MDS assessment submitted on 3/19/2026, reflected BIMS score of 14, indicating cognitively intact. Resident # 1 was assessed as having vision impairment and the resident required corrective lenses. Record review of Resident # 1's Care Plan Report, revised on 5/7/2026, revealed Resident # 1 had impaired visual function. Interventions were to ensure appropriate visual aids ( glasses) were available to support Resident # 1's participation in activities; monitor/document/report to MD the following signs and symptoms of acute eye problems: change in ability to perform ADL's, decline in mobility.In an interview on 6/10/2026 at 10:00 am Family Member # 1 stated that Resident # 1's glasses had been broken for months. She stated that she reported the concern to the Administrator two or three months ago. She stated that the Administrator told her that the Ophthalmologist was coming to the facility on July 2, 2026. She stated that it was unacceptable as Resident # 1's glasses were taped and broken. Family Member # 1 stated that the facility should be held accountable as Resident # 1's needs were not met. She stated that Resident #1 was vision impaired and needed to wear eyeglasses. She stated that Resident #1's eyeglasses were broken he cannot wear the glasses, therefore, this had an effect on his vision as he cannot see. She stated that staff offered to pay for glasses for Resident # 1. She stated that she felt it was the facility's responsibility to replace or repair Resident # 1's glasses. She stated that she was told that Resident # 1's eyeglasses could be sent out for repair, but it would take a while before they would be returned to the facility. Record review of the facility's concern and grievance report, dated 6/5/2026, revealed in part [Family Member # 1] came into the DON's office stating [Resident # 1's] glasses were broken. [Family Member #1] asked when [Resident # 1's] next optometry visit. The final was resolution was Resident # 1 had a scheduled Optometry visit on July 2, 2026. In an interview with Social Worker A on 6/10/2026 at 11:10 am, she stated that she was aware that Resident # 1's eyeglasses were broken. She stated that it was brought to her attention this month. She stated that Resident # 1 was scheduled to see the Ophthalmologist on July 2, 2026. She stated that Resident #1's eyeglasses were not sent out for repair as it would be a while before the eyeglasses would be fixed and returned.In an interview with RN A on 6/10/2026 at 11:38 am, he stated that he was aware that Resident # 1's eyeglasses were broken. He stated that he did not know how Resident # 1's eyeglasses were broken. He stated that he fixed Resident #1's eyeglasses by taping them. He stated that he did not inform anyone that Resident # 1's eyeglasses needed to be repaired or replaced. During an observation and interview on 6/10/2026 at 1:35 pm with Resident #1's consent revealed Resident # '1 glasses were observed on the top of the dresser across from his bed and they were taped with white colored tape where the lens met the hinges on the right side and bilaterally (two sides) covered in tape at the temple tip. The eyeglasses appeared crooked. Resident # 1 stated the the eyeglasses were broken a months ago when he fell out of the wheelchair in the hallway and landed on his face.In an interview with Family Member #2 on 6/10/2026 at 4:40 pm she stated that Resident #1's eyeglasses had been broken for about 3 months. She stated that she did not know how Resident # 1's eyeglasses were broken. She stated that staff taped the glasses up. She stated that Resident # 1 did not wear his eyeglasses due to the eyeglasses being broken. She stated the eyeglasses were normally on the counter. Record review of the facility's resident rights policy dated February 2021, revealed the following in part: 1. Federal and stated laws guarantee certain basic right of this facility. These rights include the resident's right to: a) a dignified existence.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 residents (Resident #1) reviewed for adequate supervision, accidents, and hazards. CNA A and CNA B failed to provide adequate supervision to Resident #1 during a Hoyer lift transfer and Resident #1 sustained a skin tear to his right shin. This failure could place residents at risk for injury and harm. Findings included: Record review of Resident #1's admission Record revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, Parkinson's (a progressive neurological disorder that primarily affects movement), dementia (a decline in mental abilities, like memory, reasoning, and communication that is severe enough to interfere with daily life), dysphagia (difficulty or discomfort in swallowing food, liquids or even saliva), neoplasm of prostate (any abnormal growth or tumor in the prostate gland), and chronic pain syndrome (a condition where persistent pain lasts beyond the standard healing time [typically 3-6 months] and is accompanied by emotional and behavioral symptoms such as depression, anxiety and severe disruptions to daily life). Record review of Resident #1's Quarterly MDS (Minimum Data Set) dated 03/19/2026 revealed he had a BIMS score of 14 out of 15 indicating his cognition was intact. Section GG regarding Resident #1's Activities of Daily Living assistance revealed he was dependent on at least 2 staff members for transfers. During an observation and interview with Resident #1 on 06/10/2026 at 1:35 PM of incontinent and wound care. Observation of his right shoulder abscess, wound care was performed by the Wound Care Nurse and assisted by CNA A, without concerns. Observed incontinent care performed by CNA A and assisted by the Wound Care Nurse with no concerns. When staff rolled Resident #1 back onto his back, observed 3 regular sized tan band-aids across his right shin. The Wound Care Nurse said she did not know what the 3 band-aids were for because no one told her there was any wound or injury. CNA A then said she knew about the band-aids on Resident #1's right shin because she accidentally bumped his leg on Sunday , 06/07/2026 during an electric Hoyer lift transfer with CNA C. CNA A said they were transferring Resident #1 from his bedside reclining chair, back into his bed and during the transfer she thought she heard a bump or noise, but Resident #1 never complained or made a sound. CNA A said that once she and CNA C got Resident #1 back in bed, they noticed his right shin bleeding and a skin tear. CNA A said they told LVN A immediately. The Wound Care Nurse removed the 3 band-aids to expose a linear vertical skin tear approximately 4 cm in length. There was no active bleeding. Interview with LVN A on 06/10/2026 at 1:47 PM, LVN A said CNA A and CNA B did tell him about Resident #1's skin tear on Sunday 06/07/2026 and he did not complete an SBAR or incident report and he did not tell the DON or Wound Care Nurse. LVN A said he was supposed to complete an SBAR and Incident Report in Resident #1's EMR. LVN A said he must have gotten busy and forgot to complete documentation and report the incident. LVN A said they did call the MD on call for Resident #1 after assessing the injury and he did put a treatment in place but did not document an order for treatment. LVN A said it was his failure to report as trained and complete documentation per facility policy and procedure and repeated that he must have gotten busy after that and forgotten to do it. Interview with the DON on 2:20pm , the DON said no one told her about Resident #1's skin tear and it would be considered risk management and an SBAR change in condition and incident and accident report as well as a progress note should have been documented by LVN A. The DON said all staff had been trained on how and when to complete incident and accident reports, SBAR's and progress notes. The DON said she went to assess Resident #1, and the skin tear had a treatment in place and the MD and RP had been notified. The DON said an incident and accident report would be completed and the Administrator would also be notified.Interview with CNA C on 06/10/2026 at 2:23pm who said she and CNA A were transferring Resident #1 using the electric Hoyer lift on Sunday, 06/07/2026 and were transferring Resident #1 from his bedside reclining chair, back into his bed. CNA C said once she and CNA A got Resident #1 back in bed, they noticed his right shin bleeding and a skin tear. CNA C said they told LVN A, who was the charge nurse for Resident #1 on 06/07/2026, immediately. Record review of Resident #1's EMR for assessments on 06/10/2026 at 3:22pm revealed no incident or accident report. Record review of Resident #1's nursing progress notes from 06/07/2026 through 06/10/2026 revealed staff documented by exception, and Resident #1 had no progress notes on 06/07/2026 and no progress notes regarding a Hoyer lift incident/accident. There were no nursing progress notes regarding skin tears. Record review of facility's incident and accident log with a date range of 12/01/2025 through 06/09/2026 revealed no skin tear for Resident #1. Record review of facility's Hoyer -Total Mechanical Lift in-service competency acknowledgement dated 04/03/2026 revealed CNAs A and B received training for the use of a two-person electric and manual Hoyer lift. Continued record review revealed LVN A completed their training on 04/02/2026. Record review of facility policy and procedure dated 2001 and titled, Accidents and Incidents-Investigating and Reporting revealed in part: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.Policy Interpretation and Implementation1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.2. The following data, as applicable, shall be included on the Report of Incident/Accident form:a. The date and time the accident or incident took place.b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.).c. The circumstances surrounding the accident or incident.d. Where the accident or incident took place.e. The name(s) of witnesses and their accounts of the accident or incident.f. The injured person's account of the accident or incident.g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions.h. The date/time the injured person's family was notified and by whom.i. The condition of the injured person, including his/her vital signs.j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.).k. Any corrective action taken.l. Follow-up information.m. Other pertinent data as necessary or required; andn. The signature and title of the person completing the report.3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device.5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident.6. The director of nursing services shall ensure that the administrator receives a copy of the Report of Incident/Accident form for each occurrence.7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Based on interview and record review, the facility failed to accurately assess each resident's status for 3 (Resident #11, #35, and Resident #38) of 20 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident # 11's annual MDS assessment, dated 02/09/25, did not reflect her hearing deficit, and her oral cavity. 2. The facility failed to ensure Resident #35's Quarterly MDS assessment dated [DATE] and Significant Change in Status MDS dated [DATE] accurately reflected the resident's antiplatelet medication use and incorrectly coded the resident for anticoagulant medication use. 3. The facility failed to ensure Resident # 38's annual MDS assessment dated [DATE]-reflected her hearing deficit. These failures could place residents at risk for inaccurate assessments, inaccurate plans of care, inadequate care, diminished quality of life and decline in health. Findings include: Resident #11 Record review of Resident #11's face sheet dated 04/29/25 revealed 87- year -old female admitted to the facility on [DATE]. her diagnoses included Essential hypertension (primary), complete traumatic amputation at level between right hip and knee, metabolic encephalopathy (change in how the brain works due to an underlying condition) muscle weakness, type 2 diabetes mellitus with diabetic nephropathy (refers to kidney damage due to diabetes) major depressive disorder, chronic obstructive pulmonary disease, and heart failure. Record review of Resident #11's annual MDS assessment dated [DATE] indicated she was coded 3 on her BIMS score; indicating her cognition was severely impacted. For hearing she was coded as Adequate - no difficulty in normal conversation, social interaction, and listening to TV. For oral/ dental status, she was coded as Z- no problem with her oral cavity. Record review of Resident # 11's care plan dated 02/14/24 with a revision date of 06/21/24 indicated Resident #11 was care planned for: -Having a hearing deficit. Date Initiated: 02/14/2024 Revision on: 06/21/2024. Goal: maintain the highest level of communication for this resident through the next review date Initiated: 02/14/2024 Revision on: 06/21/2024 Target Date: 07/21/2025 Intervention: Do not cut off or interject when [Resident #11] was speaking. o If resident has a device to assist them with hearing, encourage them to use it. o Maintain eye contact while speaking to resident. Monitor hearing ability and report any changes to the physician. -Having oral/dental health problems caries Date Initiated: 02/14/2024, Revision on: 06/21/2024. Goal: Resident #11 will comply with mouth care at least daily through review date. Initiated: 06/21/2024 Revision on: 06/21/2024 Target Date: 07/21/2025 Intervention-: Administer medications as ordered. Monitor/document for side effects and effectiveness. o Coordinate arrangements for dental care, transportation as needed/as ordered. o Monitor/document/report to MD PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, lesions. o OT screen for adaptive equipment PRN Date Initiated: 06/21/2024. o Provide mouth care as per ADL personal hygiene Observation on 04/28/25 at 10:00AM, revealed Resident #11 was sitting on her wheelchair alert and oriented. In an attempted interview, she said speak louder I cannot hear. Her roommate said Resident #11 was hard of hearing and they need to speak loud and very close to her ear. Resident #35 Record review of Resident #35's Admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), dysphagia (difficulty or discomfort in swallowing), and chronic atrial fibrillation (an abnormal heartbeat where the two upper chambers of the heartbeat irregularly and quickly). Record review of Resident #35's Significant Change in Status MDS assessment dated [DATE] revealed in her BIMS score was 11 out of 15 indicating she had moderate cognitive impairment, and she was coded in Section N Medications as taking Anticoagulant medication. The column for Antiplatelet medication was blank. Section N was signed as completed by MDS Coordinator A on 4/25/25 and verified as completed by DON on 4/25/25. Record review of Resident #35's Q MDS dated [DATE] on 4/29/25 at 4:10pm revealed in Section N Medication Resident #35 was coded as follows: I. Antiplatelet . Is Taking .Section X. Correction revealed: Reasons for Modification .A .Transcription Error .B. Data Entry Error .Z. Other error requiring modification. Section Z Assessment Administration Signature of Persons Completing the Assessment of Entry/Death Reporting, was signed by MDS Coordinator A with Date Section Completed, 4/29/25. Record review of Resident #35's physician order summary report dated Active Orders As Of 04/01/2025 revealed Resident #35 had no order for any anticoagulant (medication that prevents or slows down the formation of blood clots). Resident #35 had the following order: Clopidogrel Oral Tablet 75 mg .Give 75 mg by mouth one time a day .Verbal Order .Order Status Active .01/30/2025 .Order Date .01/30/2025 . There was no end date. Resident #38 Record review of Resident #38's face sheet dated 04/29/25 revealed an 81- year -old female admitted to the facility on ,d+[DATE]. Her diagnoses included Essential hypertension (primary) diverticulitis of both small and large intestine without perforation or abscess (an inflammation or infection of the pouches formed in the colon), kidney failure, muscle weakness (generalized), chronic obstructive pulmonary disease with heart disease of native, liver disease. dementia, anxiety disorder, psychotic disturbance, and cognitive communication deficit. Record review of Resident #38's annual MDS assessment dated [DATE] revealed her BIMS score was 15 out of 15 indicated her cognition was intact. For hearing, she was coded as Adequate - no difficulty in normal conversation, social interaction, and listening to TV. Record review of Resident #38's care plan dated 12/26/23 with a revision date of 01/25/24 revealed Resident #38 had communication problem r/t . Goal- will maintain current level of communication function by (how, with what assistance. making sounds, using appropriate gestures, responding to yes/no questions, appropriately, using communication board, writing messages) through the review date Initiated: 12/26/2023 Revision on: 01/25/2024 Target Date: 07/28/2025. Intervention: Ensure availability and functioning of adaptive communication equipment message board, hearing aids, telephone amplifier, computer, pocket talker etc. Date Initiated: 12/26/2023, Revision on: 01/25/2024. CNA o Refer to Audiology for hearing consult as ordered. Observation and interview on 04/28/25 at 11:00AM, Resident #38 was in her room on her recliner. She was alert and oriented . In an attempted interview, she said, Speak louder. I cannot hear. Resident #38 said she had hearing aids and pointed to her hearing aids on her nightstand . She said she did not use them. During an interview with CNA J on 04/28/25 at 10:30AM, she said [Residents #11 and #38] are hard of hearing and you need to speak louder and close to Resident #11's her ear. She said Resident #38 did not have hearing aid. In an interview with LVN E on 04/28/05 at 1:00PM, she said both Residents #11 and # 38 were hard of hearing. She said Resident # 38 have hearing aid on her nightstand, but she chose not to use her them. She said Resident #11 does not have hearing aid. Record review and interview with the MDS Coordinator A on 4/29/25 at 2:42pm revealed Resident #35 was taking Plavix (Brand Name)/Clopidogrel. When asked if Plavix was an anticoagulant or an antiplatelet medication they replied, Oh. It's an anti-platelet. When asked what was coded on Resident #35's Q MDS dated [DATE] the MDS Coordinator said they coded for anticoagulant medication and again on the significant change MDS dated [DATE]. The MDS Coordinator A said it was an error on her part in coding the MDS' and they were incorrect. The MDS Coordinator A said they would correct the MDS assessments. The MDS Coordinator A said they worked as the MDS Coordinator A at the facility since 2023 and the MDS Consultant was the oversight person over the MDS Department. MDS Coordinator A said they had been trained by the MDS Consultant and the Regional MDS and used the RAI manual as the policy and procedure for MDS completion and accuracy. Interview with the DON on 4/29/25 at 4:33pm, revealed they signed the facility MDS' for completion and did their best to ensure accuracy. When asked if they knew if Resident #35 was taking an anticoagulant, the DON looked at her mobile device which had access to Resident #35's EMR and replied, He's taking Plavix. RDO and RNC were present, and both stated quietly, that Plavix was antiplatelet. The DON said, yes that was correct, that Plavix was an antiplatelet and not an anticoagulant. The DON was not 100 percent sure who trained MDS Coordinator A, but said both the MDS Consultant and the Regional MDS were oversight over the faility's MDS department. Telephone interview with the MDS Consultant on 4/30/25 at 3:47 pm revealed they did not train MDS Coordinator A, but was over the MDS department. The MDS Consultant said MDS Coordinator A would have been trained by the Regional MDS. The MDS Consultant said the MDS Coordinator A had continuing education that included webinars, meetings, and on-line trainings. When asked if the MDS Coordinator A had been trained on how to code an anticoagulant versus an antiplatelet medication, the MDS Consultant said Clopidogrel/Plavix was not an anticoagulant medication and she had discussed this and reinforced the information with MDS Coordinator A when the MDS Coordinator A called the MDS Consultant on 4/29/25. Attempted a telephone interview with Regional MDS on 4/30/35 at 4:04 pm. There was no answer and was unable to interview prior to facility exit. Record review of CMS's RAI Version 3.0 Manual dated October 2024, read in part . the assessment accurately reflects the resident's status. 39977

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The Dietary Manager failed to wear hair net in the kitchen. 2. The facility failed to keep the cooking area clean and free of grease build up on the stove. 3. The facility failed to ensure the tabletop can opener blade and base were free of grime and debris. 4. The facility failed to ensure kitchen cooking equipment was cleaned. 5. The facility failed to label, and date left over food items in walk in refrigerator\freezer. 6. The facility failed to ensure that expired food products were not stored in the welkin- cooler and in the dry goods storage area. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation and interview on [DATE] at 8:45AM revealed the following: -The DM was observed in the kitchen on [DATE] at 8:45AM without a hairnet on. She looked at herself and said she forgot to wear her hair net. There was grease and debris on the stove and around the cooking area. One conventional oven had a tray with dark brown substances on the tray inside the conventional oven. The DM looked at the tray and said it needed to be cleaned. She said the tray was in the oven to collect the grease. -The tabletop can opener had grime, debris, and a dark looking substances between the cutting blades. The DM took it off and said it need to be cleaned . -The walk cooler\freezer had half 64 oz apple thickener with a manufacturer use-by of [DATE]. Left over chicken parmesan in a plastic container had no labeled and was dated [DATE]. This was identified by the DM. She said all left over food products in the [NAME] cooler \freezer should be labeled with food product for identification, the date opened and a use by date. She said left over food was discarded after 3 days if not use. -The dry goods storage had three 46 oz bottle of sweetened tea dated use-by [DATE], three 46 oz bottles of thickened water dated use-by [DATE]. The DM took them out and said she would discard them. During an interview at 9:00 AM on [DATE], the DM said serving expired food may cause food borne illness. She said she was new to the position, and was still learning and cleaning up. She said she was about 3 weeks in as the Dietary Manager. The DM said it was the responsibility of all staff to keep the kitchen clean. In an interview with the Administrator on [DATE] at 3:00PM, she said the DM was new and had been trying to clean up. She said the DM was still in training and the staff who was supposed to be training her was out sick. She said all food items out of original the container should be labeled and dated. She said all identified expired food products were trashed. Record review of facility's police dated 2001 revised [DATE] revealed - 1. Clean storage areas: Food Services, or other designated staff, will maintain clean food storage areas at all times. 2. Storage of Prepared Food: Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid .

Based on observations, interviews and record reviews, the facility failed to develop and implement comprehensive care plans with measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs identified in the comprehensive assessment for 2 of 20 residents reviewed for care plan accuracy. --The facility failed to develop care plans for cognition, ADL assistance, Dialysis, anticoagulane and insulin for Resident # 12. --the facility failed to develop a care plan for ADL assistance for Resident # 100. These failures placed residents at risk of receiving inadequate care due to incomplete care plans. Findings include: Record review of Resident # 12's face sheet revealed admitted [DATE] with diagnoses including end stage renal disease (loss of kidney function), Diabetes (body's inability to produce or use insulin), schizoaffective disorder (a combination of mood disorders), hypertension (high blood pressure), heart failure (inability of the heart to pump efficiently), peripheral vascular disease (reduced blood flow to limbs). Record review of Resident # 12's quarterly MDS dated [DATE] revealed BIMS of 09, indicating moderately impaired cognitive skills, assistance for ADL's including supervision for eating and total assistance for toileting, bathing, dressing and hygiene, Dialysis (while a resident), anticoagulant (taking while a resident), insulin (taking while a resident). Record review of Resident # 12's undated care plan revealed no care plan with appropriate interventions developed for conditions including cognition (moderately impaired cognitive skills), ADL assistance (supervision/total) , Dialysis while a resident, insulin and anticoagulant use while a resident. Observation of Resident # 12 on 4/28/25 revealed she was in bed, alert, clean and groomed. Interview at that time revealed she said she has Dialysis tomorrow and it was going well. She said she needed help to dress and get up out of bed and was waiting for someone to come help her soon, and the nurse gave her insulin shots. Record review of Resident # 100's face sheet revealed admitted [DATE] with diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing food or liquids), hypertension (high blood pressure), coronary atherosclerosis (damage in the heart's major blood vessels), depression (low mood), fibromyalgia (widespread pain throughout the body), aphasia (inability to speak). Record review of Resident # 100's Significant Change MDS dated revealed no speech, rarely or never understood by others, understands others, inattention, moderately impaired cognition, feeding tube, substantial assistance required for bathing, dressing, hygiene, and total assistance for toileting. Record review of Resident # 100's undated care plan revealed no care plan developed with appropriate interventions for ADL assistance (substantial/total). Observation of resident # 100 on 4/28/25 at 9:40am revealed she was in bed, alert, dressed, with feeding tube infusing formula. Resident # 100 motioned to her throat to indicate she could not speak, but pointed to communication items on her bedside table with pictures and words printed on paper she could use to let staff know her needs. Interview with MDS nurse on 4/30/25 at 2:40 pm revealed she said she was working on the care plans currently. She said she completes the care plans with input from nurses and morning meetings, and after the care plans were complete, she will ask the nurses to check their areas for accuracy. She said the risk of having incomplete care plans would be staff would not know what to do for the residents because the care plan directed care. Interview with the DON on 4/30/25 revealed she was aware some of the care plans were not complete, and they will be having some care plan training in the facility. She said the risk of having incomplete care plans would affect the residents because they wouldn't receive the care they needed. Record review of facility undated Care Plan policy revealed, in part, every resident will have a specialized care plan for all ADL needs .every resident will have all needs/specialized services care planned such as PASRR, Hospice, and reviewed routinely .care plans will be revised as needed weekly and/or between routine reviews.

Based on observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 2 (Resident #26 and #35) of 15 residents reviewed for comprehensive assessments. This failure could place the residents at risk of not having all medical needs assessed and met. Findings included: Resident #26 Review of Resident #26's electronic face sheet undated Admission Record revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Essential hypertension (high blood pressure), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone.) , vitamin B12 deficiency anemia, diverticulosis of large intestine (An inflammation or infection of the pouches formed in the colon), Renal failure, diabetes mellitus, muscle weakness (generalized), difficulty in walking, major depressive disorder, dementia, and anxiety, and cognitive communication deficit. Review of Resident #26's Significant change MDS assessment dated [DATE] revealed a BIMS score of 5, indicating her cognition was severely impaired. Her Functional Status indicated she required extensive assistance with her ADLs. Record review of section L of the MDS reflected she was checked none of above indicating no problem on an all section of oral dental health. Record review of Resident #26's care plan dated 02/13/20 revealed Resident #26 had oral/dental health problems r/t Poor oral hygiene. Date Initiated: 02/13/2020. No revision date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/20/2020. Coordinate arrangements for dental care, transportation as needed/as ordered. Date Initiated: 02/20/2020. Monitor/document/report to MD PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Date Initiated: 02/20/2020. Provide mouth care as per ADL personal hygiene. Date Initiated: 02/20/2020. Record review of the social worker's notes dated 12/15/23 at 10:46 AM read in part family requested dental services for resident. Contracted local dental services. Resident is a private pay; information provided and will follow up. Observation and attempted interview on 03/05/23 at 12:40 PM, revealed Resident #26 was sitting on her wheelchair in her room. An attempt was made to have an interview with her but failed as she could only answer yes and no questions. Observation revealed she had two teeth on each side of her lower oral cavity. Observation revealed she ate 30% of served meal (puree regular diet) During an interview with facility's social worker on 03/05/24 at 4:00PM revealed Resident #26's family had requested for dental service in the past because Resident #26 had lost her dentures. She said she provided the information to the responsible party since Resident #26 was a private pay resident and the responsible party declined services at that time. The Social Worker said the resident's responsible party requested again and she would include resident on the next visit. Resident #35 Record review of Resident #35's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included displaced intertrochanteric fracture of right femur, dementia, mood disturbance, anxiety, muscle wasting and atrophy, malnutrition, anemia and muscle weakness, age-related osteoporosis, lack of coordination, cognitive communication deficit (lack of communication). Record review of Review of Resident #35 's admission MDS dated [DATE] revealed a BIMS score of 9, indicated she was moderately impaired on cognition. Her Functional Status indicated she required extensive assistance with her ADLs. Record review of section L of the MDS revealed section A-G were left blank. Section Z was checked none of the above indicated no concerns on all section of oral dental health. Observation and interview on 03/04/24 at 10:00AM revealed she was in bed. Her responsible party was with her. During an interview, resident responded that she was doing fine with her hand over her mouth. Resident #35 looked at her responsible party and did not speak. Her responsible party said he came in to assist Resident #35 with her meals sometimes. He said Resident #35 have hard time eating sometimes depending on what was served . He said Resident #35 lost her dentures at the hospital and the retainers that she had does not fits very well. He brought out the retainer from Resident's nightstand and gave them to her. He said he had not been asked about dentures or natural teeth. During an interview with the facility social worker on 03/05/23 at 4:00pm, she said Resident #35 was a new resident and she was not aware that she needs dental services. During an interview with the MDS Coordinator on 03/06/24 at 2:45 PM, she said she thought Resident #35 had her natural teeth and did not assess her for dental. She said acknowledged that Resident #26's had lost her dentures prior to being admitted to the facility and family had requested for oral denture services. She said she would follow up and update the MDS to reflect her oral denture status. Facility's policy on accuracy of MDS assessment on 03/06/24 at 4:00PM the facility's Administrator and the MDS Coordinator said the facility followed the RAI manual and no policy .

Based on observation, interview, and record review, the facility failed assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for one (Resident #14) of 15 residents reviewed accuracy of assessment in that: The facility failed to accurately assess Resident #14 her fall and for use of catheter on her significant change MDS assessment dated [DATE]. This failure could place residents at risk of unnecessary medical expenses due to inaccurate records, and not receiving needed services to improve their health and psychosocial wellbeing. Findings included: Resident #14 Record review of Resident #14's electronic face sheet on 03/04/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]/24 her diagnoses included Essential (primary) hypertension (high blood pressure), hypothyroidism (decreased production of thyroid hormones), dementia, repeated falls, back pain, bipolar disorder, psychotic disorder with delusions and hallucinations, and generalized anxiety disorder. Record review of Resident #14's significant change MDS dated [DATE] revealed her BIMS score was 3 indicated her cognition was severely impaired. Section H - (100) bowel and bladder were coded as having an indwelling catheter. Section H-300 urinary continence was coded as always incontinence. Record review of physician orders dated 01/25/24-03/06/24 revealed no others for urinary catheter. Record review of Facility's accident and incident log indicated Resident #14 had a fall on 12/11/23. Record review of facility accident and incident log from 09/04/23 through 03/04/24 revealed Resident # 14 had an unwitnessed fall on 12/11/23. Record review of Resident #14's accident and incident's fall assessment dated [DATE] read in part Nurse called by another resident to station, Resident #14 was by nurses' station between wheelchair and sofa chair resident #14 on her buttocks legs in front No injuries noted . Observation on 03/04/24 at 9:15 am, revealed Resident #14 was in her room sitting on her bed. Observation revealed no catheter. She was alert and oriented. Attempt was made to have an interview but could only answer yes and no questions . was with her. During an interview on 03/05/23 at 9:00AM, LVN B said Resident #14 did not have a catheter and (he/she) had not seen her with one. During an interview with CNA E on 03/05/23 at 11:00AM, she said she had not seen Resident #14 with catheter. During an interview with MDS Coordinator on 03/ 5/24 at 2:00 PM, she said Resident #14 did not have catheter. She looked at the MDS and said nothing. She looked at section J and said the fall was an overlook. She said Resident #14 should have been assessed for her fall on the MDS. She said not assessing resident accurately may prevent residents from getting needed services. Record review of facility's provided policy on accuracy of resident assessment dated 2001 revised November 1019 Redid not address accuracy of resident assessment.

Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of two medication carts (Nurse Medication Cart Hall 300) reviewed for medication storage. 1. The facility failed to ensure the Nurse Medication Cart Hall 300 was locked when unattended. 2. The facility failed to ensure LVN A lock Insulin in the medication cart prior to leaving the medication cart unattended. The insulin was left sitting on top of the medication cart. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety and drug diversion. Findings include: Observation on 01/11/2023 at 7:13 AM revealed LVN A parked the nurse medication cart for 300 hall in the hall at room [ROOM NUMBER]. LVN A gathered medications and walked into room [ROOM NUMBER], walked behind a wall to the resident's bedside to administer medications. The medication cart was unlocked and a vial of insulin was sitting on top of the medication cart. Observation on 01/11/2023 at 7:18AM revealed LVN A returned to nurse medication cart 300 hall. The cart was unlocked, and a vial of insulin was left on top. There was one housekeeper in the hall two rooms away there were no residents or visitors in hall. Inventory of nurse medication cart 300 hall accompanied by LVN A at this time: Drawer #1: Insulin vials and insulin injection pens, needles, syringes, heparin (anticoagulant) vials; Drawer #2: Resident individual medications, Liquid medications, locked narcotic box with medications for 8 residents. Drawer #3: Medication supplies; Drawer #4: Nutritional supplements. In an interview on 01/11/2023 at 7:22AM, LVN A stated she was responsible for making sure the medication cart was locked. LVN A stated she believed it happened because she was not thinking correctly. LVN A stated to make sure it did not occur again she would stop and make sure the cart was locked and no medications were left out on top before leaving. The risk was a resident could take some medications from the cart they should not have. In an interview on 01/11/2023 at 8:54 AM, the DON stated LVN A told her she forgot to lock the cart. The DON stated the nurse working the cart was the one responsible for making sure the cart was locked The risk was anyone could get into the cart. The DON stated she does random checks on medication carts during medication pass checking the medication carts were locked The DON stated the plan to prevent this in the future was to educate. In an interview on 01/11/2023 at 9:09 AM, the Administrator stated she expected the medication cart to be locked and all medications secured when it was left unattended. Record review of the facility's policy, Security of Medication Cart, revised April 2007, read in part Policy Statement: The medication cart shall be secured during medication passes. 1.The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .4. Medication carts must be securely locked at all times when out of the nurse's view

Based on observation, interview, and record review, the facility failed to conduct a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS, for 2 of 14 residents (Residents #,5 and #34) reviewed for comprehensive assessment. 1. The facility failed to ensure Resident # 5 was assessed for his dental needs. 2. The facility failed to ensure Resident # 34's significant change MDS assessment notincluded his race\ethnicity and assessed the resident for falls. These deficient practices could place residents at risk of not having their needs met. Findings included: 1. Record review of Resident #5's face sheet, dated 10/20/21, revealed a [AGE] year-old, admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's annual MDS, with ARD date of 08/12/21 and completed 08/26/21, revealed his BIMs score was coded as 8 out of 15, which indicated he was moderately impaired cognitively. Record review of the MDS revealed the following- - Section L of the MDS regarding - oral dental status was checked as none of the above, which indicated, he had all his natural teeth. Record review of Resident #5's care plan, dated 10/18/19 with a revision date of 11/24/21, revealed he was care planned for dental as followed- [Resident # 5] has oral dental problem related to broken teeth or dental carries. Intervention was - Resident #5 will be free of infection, pain, bleeding in oral cavity by\through review date. Date initiated 10/18/19 target date 11/24/21. Observation and interview on 10/19/21 at 10:00 AM, revealed Resident #5 was in bed watching television. He was alert and oriented. He said he would like to see a dentist for his teeth but have had not been able to see one . He said he told a lady some time ago , but he does not remember how long ago. He said he had some loose teeth and had pain from time to time making which made it hard to eat. During an interview with the Social Worker on 10/21/21 at 1:00 PM, she said Resident #5 had not seen any dentist since admission. She said she had discussed his dental issue with him in the past and he wanted his dental to fit in certain ways if he was to have some and the discussion did not go further. She said she would put him on the list again. She said all outside services stopped coming due to the pandemic. She said the facility had a new dental team that which would be start in November . 2. Record review of Resident #34's face sheet, dated 10/21/21, revealed a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 34's significant change MDS, with ARD date of 08/06/21 and completed 08/20/21, revealed his BIMs score was coded as 12 out of 15, which indicated indicating he was mildly intact cognitively. Record review of the significant change MDS, dated [DATE], revealed - Section A on race and ethnicity was left blank . Record review of Resident # 34's Quarterly MDS, with ARD date of 09/28/21 and completed 10/11/21, revealed his BIMs score was coded as 11 out of 15, which indicated he was mildly intact cognitively. Record review of Resident #34's quarterly MDS revealed - Section A on race and ethnicity was left blank. Section J- fall history was left blank . Record review of Facility's accident and incident history report, dated 01/01/21 to 10/19/21, revealed Resident #34 had an unwitnessed fall on 09/11/21 . Record review of nurses notes, dated 9/11/2021 at 12:45 PM, read in part- resident heard yelling out for help, upon arrival at room,, writer observed res on the floor next to the bed, res stated the bed was too high as he was transferring himself from his recliner chair to the bed, no visible injuries noted at this time, no c/o pain noted, ROM x4 extremities noted without c/o pain or discomfort, res denies hitting his head on any object, res assisted back to bed via several staff members, neuro checks immediately initiated, MD . notified, responsible party/spouse notified, res encouraged to call for help before transferring himself without assistance. During an interview with the MDS coordinator on 10/21/21 at 2:00 PM, she said she was 2 weeks old at the facility . She said she was not around when the MDS's were completed. She said Resident's assessments and the completion of the MDS is was an interdisciplinary team effort. She said it was her responsibility to ensure that all MDS assessments accurately reflected the resident's condition. She said Resident #34's race and ethnicity and fall should have been on the quarterly assessment and his race\ethnicity should always be on every assessment. She said she would make amendments to the MDS's that were pointed out to her . In an interview with the Cooperate MDS coordinator on 10/22/21 at 10:00AM, she said Resident's assessments and care planning was an interdisciplinary team effort. She said the MDS coordinator gathered information from every discipline to complete the MDS and the care plan. She said the MDS coordinator was new and amendments would be made to all inaccurate assessment and updates care plans as pointed out. At this time the Facility's policy on MDS assessment was requested. She said the facility follows the RIA manual by CMS .

Based on interview and record review the facility failed to develop a comprehensive person-centered, care plan for each resident that included measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for1of 14 residents (Resident #34) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and time frames to address Resident #34's communication and fall . This failure could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. Finding include: 1 Record review of Resident #34's face sheet, dated 10/21/21, revealed a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 34's significant change MDS, with ARD date of 08/06/21 and completed 08/20/21, revealed his BIMs score was coded as 12 out of 15, which indicated he was mildly intact cognitively. Section B of the MDS on hearing, speech and vision revealed the following -Speech clarity: he was assessed as usually understand -difficulty communicating some words or finishing thoughts . -Ability to understand others, he was coded as 1 usually understood. Misses some part\intent of message but comprehensive most conversation. Section V CAAs revealed Resident #34 was triggered for communication . Record review of Resident #34's Care Plan, dated 01/27/21, revealed no evidence of care plan documented for communication . Interview with the MDS Coordinator on 10/21/21 at 9:40 AM, revealed she was not the MDS Coordinator who completed this assessment and care plan for Resident # 34. She said she was two weeks old at the facility . During an interview with the DON on 10/22/10 at 10:00 AM she said care plans were generated by the interdisciplinary team and completed by the MDS staff . Record review of the facility's, undated, policy, titled Policy and procedure Comprehensive Care Planning undated and un # pages did not address read in part Purpose : Ensure every resident has a comprehensive , complete, accurate and all-inclusive specific care plan written timely to meet all requirements of the RAI and regulatory process to include input from all IDT members.

Based on interview and record review the facility failed to ensure all irregularities identified by the licensed pharmacist were reviewed and action has been taken by the attending physician to minimize or prevent adverse consequences to the extent possible for 2 (Residents #39 and #25) of 15 Residents reviewed for drug regimen review. 1. The facility failed to follow-up on or communicate Pharmacist Consultant recommendations on 9/07/21, for the dose reduction of Resident #25's antipsychotic [MEDICATION(S)] 800 mg and obtaining a rationale from the Physician. 2. The facility failed to follow-up on or communicate Pharmacist Consultant recommendations on 9/07/21, for dose reduction of Resident #25 Losartan 50 mg (to lower B/P) due to his B/P trending low. 3. The facility's Pharmacist Consultant recommended Resident #39's use of [MEDICATION(S)] 0.25 mg (antipsychotic medication) did not have the approved psychiatric diagnosis for continued use. These failures could place residents at risk for medication errors, unnecessary medications and incorrect medication administration. Findings include: 1. Record review of Resident #25's clinical record revealed an [AGE] year old male admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, [CONDITION(S)], depression, difficulty in walking and [CONDITION(S)] disorder. He required supervision for most ADLs. Record review of Resident #25's Consolidated Physician Order, dated October 2021, revealed to give [MEDICATION(S)] 400 mg 2 tabs=800 mg QHS for [CONDITION(S)], start date 9/11/19. Record review of Resident #25's quarterly MDS, dated [DATE], revealed he had a BIMS score of 15 or with intact cognition. Resident #25 did not have any hallucinations or delusions and no [CONDITION(S)]. He had not exhibited rejection of care behavior. He received antipsychotic along with antidepressants medications 7 days/week. Record review of Resident #25's care plan, dated 9/04/19, revealed he was taking antipsychotic [MEDICATION(S)] for [CONDITION(S)] and antidepressant medications. Review behaviors or interventions and alternate therapies attempted and their effectiveness per facility policy. Consult with pharmacist, MD to consider dosage reduction when appropriate at least quarterly. Record review of Resident #25's Pharmacy consultant MRR, dated 9/07/21, revealed the resident has the following Psychoactive meds that are due for review per CMS regulations. Per regulation, dose reduction trials must be requested by Pharm to help establish the lowest effective dose or to discontinue Unnecessary meds . Please review and consider any changes .Next evaluation due date 9/20/21 for [MEDICATION(S)] (antipsychotic) 400 mg give 2 tabs QHS dx [CONDITION(S)], since 9/2019 .If dose reduction is contraindicated or resident has failed previous dose reduction attempt, please document clinical rationale below. Record review of the Physician /Prescriber Response, dated 9/10/21, to the Pharmacy consultant MRR for Resident#25 on 9/07/21, revealed to Follow with Psychiatry. Record review of Resident #25's Consent for Psychoactive Medication Therapy, dated 7/14/16, revealed antipsychotic [MEDICATION(S)] was indicated for prolonged treatment, for dx [CONDITION(S)]. During an interview on 10/20/21 at 11:30 AM, CNA C stated she had not seen the Resident confused or exhibiting any aggression, either verbal or physical. She added the resident was no harm to himself or others. During an interview on 10/20/21 at 11:40 AM, LVN B stated the Resident was cooperative, and had no behaviors or exhibited any confusion or delusion noted. During an interview on 10/20/21 at 1:30 PM, the SW stated the facility was switching to a new company, since the old Psych group stopped coming to see residents since June 2021. The SW stated that Psychiatry follow-up in process for Resident #25 and he would be seen next week by a new Psych group. During interview on 10/20/21 at 2:00 PM, the DON stated Resident #25's Psych follow-up was not carried out per MD order and as recommended by Pharmacy Consultant. The DON stated Resident was last seen by Psychiatry in June 2021, since replacement for old Psych group did not come to see the residents. The DON stated will have a new Psych group to initiate Psychiatry services and would see him next week. 2. Record review of Pharmacy consultant MRR, dated 9/07/21, revealed Resident #25's B/P has been trending low requiring the nurse to hold meds .Please consider a decrease in medication continue to monitor. Record review of Resident#25's Physician /NP Response, dated 9/11/21, to the Pharmacy consultant MRR, revealed to decrease the Losartan dose from 50 mg tab QD to 25 mg tab QD. During an interview on 10/21/21 at 2:30 PM, the DON stated she missed to decrease the Losartan dose from 50 mg tab to 25 mg tab QD as ordered, and per Pharmacy Consultant MRR for Resident #25. The DON stated she was assigned to review both MRR and the monthly consolidated physician order. The DON stated she would notify the MD and decrease Resident's Losartan dose today 10/21/21, as per MD order. During an interview on 10/22/21 at 10:00 AM, the ADON stated if the DON was not around she was designated to follow-up on the MRR and monthly consolidated physician orders. The ADON stated moving forward she would double check with the DON, to ensure no MD order or recommendations/ MRR were missed. Record review of Resident #25's Physician order dated 10/21/21, revealed to give Losartan Potassium 25 mg 1 tab PO QD, hold for SB/P<100 or HR<60. 3. Record review of Resident #39's clinical record revealed a [AGE] year old female who was admitted to the facility on [DATE], with diagnoses which included dementia without behavioral disturbance, depression, [CONDITION(S)], [CONDITION(S)], dysphagia and difficulty in walking. She required 1 staff extensive assist for most ADLs. Record review of Resident 39's Pharmacy consultant MRR, dated 9/07/21, revealed current antipsychotic, [MEDICATION(S)] was discontinued 06/2021 and restarted 9/01/21 due to behaviors. The Current diagnosis does not support antipsychotic use per CMS guidelines. Please document the most appropriate diagnosis and provide a rationale below if therapy is to be continued. Record review of Resident #39's consent for Psychoactive Medication Therapy, dated 9/01/21, indicated the condition being treated, for dementia with psychotic features. The proposed course of the medication was for prolonged treatment. Record review of Resident #39's re-entry MDS, dated [DATE], revealed resident had severely impaired cognitive status. No hallucination or delusion. No [CONDITION(S)]. She had active diagnoses of non-Alzheimer's dementia, depression other than [CONDITION(S)], psychotic disorder other than [CONDITION(S)]. She received antipsychotic along with antidepressants medications 7 days/week. Record review of Resident #39's care plan, dated 9/06/21, revealed she took antipsychotic [MEDICATION(S)] for dementia, and had impaired cognitive function or impaired thought processes related to dementia. Provide necessary cues, stop and return if agitated. Face the resident when speaking, she usually understands consistent, simple, directive sentences. During an interview on 10/20/21 at 11:30 AM, CNA C stated the Resident only responded yes or no and word damn it, which she did not mean it, but stuck with her due to stroke. She stated the Resident was no harm to self or others and redirectable. During an interview on 10/20/21 at 12:00 PM, the DON stated the last time Resident #39 was seen by Psychiatry was in June 2021, since the old Psych consult group stopped coming to see residents since June 2021. The DON stated currently Resident's Psych follow-up was in process and the new company to initiate Psych services would see her next week. The DON stated the diagnosis of [CONDITION(S)] was added to Resident's antipsychotic medication [MEDICATION(S)]. During an interview on 10/21/21 at 2:00 PM, the DON stated the facility had to follow the policy on the MRR process. She stated she would ensure the [CONDITION(S)] medications had appropriate diagnoses and adequate indication for use. The DON stated she was responsible to follow-up on the MRR and she received MRR through e-mail. During interview on 10/22/21 at 10:00 AM, the ADON stated if the DON was not around she was designated to review the MRR and monthly consolidated physician order. The ADON stated moving forward she would double check with the DON and ensure no MD order and pharmacist MRR was missed. During an interview on 10/21/21 at 1:00 PM, the Pharmacist consultant stated she was not aware the residents were not evaluated by Psychiatry and she was not informed. She stated her assumption was the residents were seen by Psych consult and the MD order was followed. During an interview on 10/22/21 at 11:00 AM, the Administrator stated the [CONDITION(S)] med consents were sent out and the new Psych consult group was coming next week to see the residents. Record review of Resident #39's Consolidated Physician Order, dated October 2021, revealed to give [MEDICATION(S)] 0.25 mg 1tab PO two times a day for unspecified [CONDITION(S)] not due to substance or known physiological condition, start date 9/22/21. Record review of Medication Administration Record (MAR), dated October 2021, revealed Resident #39 received [MEDICATION(S)] 0.25 mg 1tab PO two times a day for unspecified [CONDITION(S)] not due to substance or known physiological condition, start date 9/22/21 Record review of the facility provided, undated, policy titled, Drug Regimen Reviews read in part, .These irregularities identified in the MRR will be acted upon within 7 days of receipt of the signed report. Any immediate action identified from the pharmacist during the review will be reported to the DON / designee immediately. Record review of the facility provided policy titled, Psychoactive Drug Use, dated 01/2001, documented in part residents would only receive Psychoactive drug therapy when it is necessary to treat a specific condition for which the use of Antipsychotic drugs are indicated .Which have been quantitatively and objectively documented; and which are persistent; and which are not by preventable reasons .

Based on observation, interview and record review, the facility failed to provide or obtain routine dental services from an outside resource to meet the needs of each resident in obtaining routine dental care for 1 of 13 Residents (Resident #5) who were reviewed for dental services. The facility failed to ensure that Resident #5 was referred for routine dental care as needed. This deficient practice could place residents in need of dental care at risk of deterioration of their oral health. Findings included: Record review of Resident #5's face sheet, dated 10/20/21, revealed a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's annual MDS, with ARD date of 08/12/21and completed 08/26/21, revealed his BIMs score was coded as 8 out of 15, which indicated he was moderately impaired cognitively. Record review of Resident #5's care plan, dated 10/18/19 with a revision date of 11/24/21, revealed he was care planned for dental as followed- [Resident # 5] has oral dental problem related to broken teeth or dental carries. Goal - [Resident #5] will be free of infection, pain, or bleeding in the oral cavity through revision date. Date initiated -10/18/19. Target date 11/24/21. Intervention - coordinate arrangements for dental care, transportation as needed\ordered. Monitor \document \report to MD PRN . Observation and interview on 10/19/21 at 10:00 AM, revealed Resident #5 was in his room. He was alert and oriented. h. He said he He said he would like to see a dentist for his teeth but have had not been able to see one. He said he told a lady some time ago , but he did not remember how long ago. He said he had some loose teeth and had pain from time to time . During an interview with the Social Worker on 10/20/21 at 1:00 PM, she said Resident #5 had not seen any dentist since his admission. She said she had discussed his dental issue with him in the past and he wanted his dental to fit in certain ways if he was to have some and the discussion did not go further. She said the pandemic outbreak did put things on hold. She said she would include Resident #5 on the list . At this time, facility's policy was requested but was not provided prior to exit on 10/22/21

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary environment in 3 rooms on the 200 hall in that: There were personal items not labeled or bagged. This failure affected 6 residents on 200 hall and placed them at risk of living in an unsafe, unsanitary, and uncomfortable environment and a diminished quality of life. Findings included: Observation on 10/22/19 at 8:36 AM in room [ROOM NUMBER] found one hair brush and 1 toothbrush not labeled with a name or placed in a bag. This bathroom was shared by 2 residents. Observation on 10/22/19 at 8:40 AM in room [ROOM NUMBER] found 2 combs and 1 toothbrush not labeled with a name or placed in a bag. This bathroom was shared by 2 residents. Observation on 10/22/19 at 8:49 AM in room [ROOM NUMBER] found 1 toothbrush not labeled with a name or placed in a bag. This bathroom is shared by 2 residents. Interview on 10/23/19 at 08:30 AM RNA said items like toothbrushes and brushes should be labeled and bagged. She said they should be labeled with their name. She said personal items in rooms 203, 205 and 209 were not bagged or labeled. Interview on 10/23/19 at 8:35 AM DON said personal items were to be labeled and bagged if they shared a room. Items in rooms 203, 205 and 209 should have been labeled and in bags. Interview on 10/23/19 at 10:22 AM, DON said they did not have a specific labeling policy on personal toiletries, but they should be labeled and bagged.

Based on observation, interview and record review, the facility failed to ensure the daily nursing staffing was posted as required in that - The facility did not post the total number and the actual hours worked by licensed and unlicensed nursing staff. The facility failed to post daily nurse staffing information on 10/23/19. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Findings include: Observation on 10/22/19 at 8: 30am revealed the posted staffing read in part: Licensed staff - RN/DON- 8am-5pm - 1 LVN/ADON-8am-5pm- 1 RN- 6am-6pm- 1 LVN- 6am-6pm- 1 LVN 6pm-6am- 2 CNA-6A-2P-1 CNA-6am-6pm- 5 CNA- 6pm-6am- 4 CNA- 6pm-10am- 0 Med Aide- 6am-9pm- 1 During an interview on 10/22/19 at 2:30pm, RN A said there were two shifts-6A-6P but some nursing staff worked from 6am to 2pm on certain days. During an interview on 10/22/19 at 3:00pm, the Administrator said the staffing has always been posted that way. Observation on 10/23/19 at 1:45pm revealed the posted staffing was dated 10/22/19. Same as above. No current posting for 10/23/19 was found. During an interview on 10/23/19 1:51 PM, the ADON she said the form that the facility used was an old form. She said she would modify the form to accurately reflect the required specifications.

Based on observation, interview, and record review, the facility failed to store, and serve food under sanitary conditions in that -. The facility failed to keep 2 refrigerators near the nurse's stations clean. There was leftover food items in the refrigerator at the nurse's station that were unlabeled. These failures placed all residents risk of foodborne illness. Findings included: Refrigerator #1 Observation and interview on 10/22/19 from 2:30pm -3:00pm, revealed Refrigerator #1 (Sunshine station) had assorted food items including sandwiches and unknown food items in grocery bags that were undated and unlabel. The bottom of the refrigerator was dirty. There were two cartons of cream thickener dated 09/29/19. During an interview at this time RN B said the date on the box was when it was opened. she said it should be discarded after 7 days of opening. She said the refrigerator was supposed to be for residents only because staff had a different refrigerator. Refrigerator #2 Observation and interview on 10/22/19 at 3:31pm revealed Refrigerator #2 had multiple food items that were unlabeled and undated. Observation at this time revealed the Corporate Nurse started emptying the refrigerator. Record review of facility's provided policy revised (MONTH) 2006 title Food Brought By family/Visitors read in part' .Perishable food must be discarded after an appropriate time (specify to food and temperature).

Based on observation, interview, and record review, the facility failed to ensure suitable and nourishing snacks were offered to residents who want to eat at non-traditional times or outside of scheduled meal service times and served at times in accordance with resident's needs, preferences, and requests for 6 confidential residents and 2 of 14 residents reviewed for snacks in that; -The facility failed to provide or offer snacks to all residents in which snacks were not prohibited due to dietary restrictions. This failure affected 8 residents and placed them at risk of unplanned weight loss, altered nutritional status, and a diminished quality of life. Findings include: Resident's Council During a group interview on [DATE] at 11:00AM, 6 of 6 residents said there were no snacks available throughout the day and they would like to have snacks in between meals. Resident #27 Record review of Resident #27's face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #27's physician orders [REDACTED]. Observation and interview on [DATE] at 8:33 AM revealed Resident #27 was sitting in her room in a wheelchair eating breakfast and her family member was at her bedside visiting. She said they do not offer her snacks. She said because she was diabetic and took insulin, it was important to have snacks. She stated she had not had any hypoglycemic events, but if her blood sugar was low she became sweaty and shaky. Further interview on [DATE] at 10:08 AM with Resident #27, she stated she never got snacks and was never offered any since she has been at the facility Interview on [DATE] at 10:24 AM, RNA said passing snacks was something the facility just started today. She said, To be honest at some point we had a nutrition room, then they just stopped passing the snacks in the room. She said they used to offer snacks to the residents stating the kitchen would prepare the snacks and put them in the nutrition room. When asked if the residents had access to the nutrition room she stated yes, they could go in the room and choose their snack, or the families could go into the room to choose a snack. She said sometimes the families would bring snacks and store them into the nutrition room. When asked how a resident who had cognitive impairment would know to go to the nutrition room to get a snack, or how would a resident who had difficulty ambulating get to the nutrition room get a snack, the RNA did not respond. Resident #9 Record review of Resident #9's face sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's physician orders [REDACTED]. Interview on [DATE] at 12:32 PM with Resident #9, he stated his family member brought him snacks because the facility did not offer snacks. He said if he did ask for a snack, he could not eat it because it was not appropriate for his renal diet. He further stated he kept his snacks in his room, so he had access to it. Interview with the Dietary Manager on [DATE] 02:40 PM, she said the snacks were prepared daily in the evening and sent to the nourishment room for the staff to distribute to those that need them. During an interview and observation with RN B on [DATE] at 3:15pm, when asked about snacks, she said What snacks? That is a good question. When asked about the nourishment room, she entered the nourishment room and opened the refrigerator. The refrigerator contained multiple expired, undated food items. She said the snacks were for the residents who need them. She said, they have to come to the nurse's station to ask for them if needed. When asked about the diabetics residents she said snacks were provided before bed time but could not give account of when and by whom. Record review of facility Frequency of Meals policy dated ,[DATE] read in part, Each resident shall receive at least three (3) meals and at least one snack daily .3. Between-meal snacks will be available for residents who need or desire additional food between meals. 4. Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment. Timing of the snack will consider relevant factors (e.g., individuals with [MEDICAL CONDITION] reflux disease may be advised not to eat too close to bedtime.). 7. The facility will choose the snacks that are served at bedtime. However, the Clinical Dietician and Food Services Manager will solicit input from the residents and/or the resident council.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate is not 5% or greater. The facility had a medication error rate of 35% based on twelve errors out of 34 opportunities; which involved 1 of 7 residents (Resident #90) and 1 of 2 staff (LVN A) reviewed for medication errors in that; -LVN A mixed Resident #90's [DEVICE] medications into one clear plastic cup and administered them all at once without the appropriate H2O flush between each medication as ordered. This failure affected 1 resident and placed her at risk of not receiving the intended therapeutic effects of the medications and a potential decline in health. Findings include: Resident #90 Record review of Resident #90's face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #90's care plan dated 9/22/17 revealed she had a [DEVICE] for medication administration. Interventions included check [DEVICE] for placement and cleanse and flush as ordered. Record review of Resident #90's physician orders [REDACTED]. [DEVICE] one time a day; Vitamin B-12 Tablet Give 1000 mcg via [DEVICE] one time a day; [MEDICATION NAME] Tablet 0.25 MG Give 1 tablet via PE[DEVICE] every 12 hours; Calcium-D Tablet 600-400 MG Unit (Calcium [MEDICATION NAME]-Vitamin D) Give 1 tablet via [DEVICE] two times a day; [MEDICATION NAME] Tablet 10 MG Give 1 tablet via [DEVICE] two times a day; [MEDICATION NAME] Solution 20MG/5ML Give 15 ml via [DEVICE] every 12 hours; [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG Give 1 tablet via [DEVICE] every 8 hours; [MEDICATION NAME] Tablet 25 MG ([MEDICATION NAME] Chloride) Give 1 tablet via [DEVICE] every 6 hours; [MEDICATION NAME] Capsule 300 MG Give 1 capsule via [DEVICE] every 8 hours. Record review of Resident #90's physician orders [REDACTED]. There were no orders to mix all medications together and administer all at once. During med pass observation and subsequent interview on 10/23/10 at 7:10 AM with LVN A, she put all twelve of Resident #90's [DEVICE] medications (listed above) into one clear plastic cup with approximately 250ml of water and administered the medications all at one time. She was observed pouring small amounts of water with the medication into the residents [DEVICE] and flushing with small amounts of water in between. The water flushes were not measured, she was observed pouring small amounts of water from a clear plastic container to flush the [DEVICE]. She stated the resident was very particular about how her medications were administered, further stating the resident requested to have her medications administered all at once. Interview on 10/23/19 at 9:25 AM, LVN A, was informed Resident #90's orders stated to flush the resident's [DEVICE] with 10cc of H2O between each med and to flush the [DEVICE] with 60 cc of H2O before and after meds every shift. LVN A was asked if there should have been an order to mix and administer the medications altogether. She stated, There probably should have been an order, I will get one now. She further stated, The resident doesn't like the medications being administered like that. When asked how long she has been administering the medications altogether, she stated, Since I've been here, she's been getting her medications that way. When asked how long she had been at the facility, she said since the end of (MONTH) this year. When asked if other nursing staff have been administering the medications the same way, LVN A stated she thought some of the other nurses have been administering the medications the same way. Interview on 10/23/19 at 9:34 AM with the DON and Corporate nurse, when asked what the facility's policy was on administering [DEVICE] medications all at one time, the Corporate nurse stated at one time there was a provider letter stating the medications should be administered separately, but then another recent provider letter stated the medications could be administered together if there were no interactions. When asked if the physicians' orders should be followed if the orders specifically state to administer each medication separately and flush with 10cc of water between each medication, the DON stated yes, the order should be followed. Record review of the facility [DEVICE] policy procedure no date read in part, .Pour each medication into 60cc syringe. Allow medication to flow from syringe into tube. Rinse syringe with 20~30cc more water to assure complete dose of medication will be administered . Record review of the facility's policy on Administering Medications dated 01/01 read in part, .8. The individual administering the medication must ensure that the right medication, the right dosage, the right time and the right method of administration are verified before the medication is administered (e.g., review of drug label, physician orders, etc.) .

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 14 residents (Resident #34) reviewed for ADLs, in that; Resident #34 was not provided fingernail care. This failure affected 1 resident and placed her at risk of diminished quality of life, loss of dignity, self-worth and infections. Findings include: Resident # 1 Record review of Resident # 34's face sheet revealed an [AGE] year-old female with an admission date of [DATE] and re-admit of 6/26/19. [DIAGNOSES REDACTED]. Record review of Resident #34's Significant Change MDS dated [DATE] revealed BIMS score of 6 indicating cognition was severely impaired. Further review revealed personal hygiene required extensive assistance by 1 person. Record review of Resident #34's care plan with target date of 1/14/19 revealed resident had alteration in musculoskeletal status related to contracture of left ring and pinkie fingers. One of the interventions was keep fingernails short to prevent digging into skin. Care plan also revealed resident has potential for impairment to skin integrity and one of the interventions was keep fingernails short. Observation and interview on 10/22/19 at 08:55 AM found Resident #34 in bed with her left hand contracted with a wash cloth in her hands. She had long fingernails on both hands and 1 nail on the right hand was jagged. Resident #34 said her nails were long and her hand (with the washcloth) was dirty because it was closed due to the contracture. Interview on 10/22/19 at 9:05 AM CNA C said the nurse did Resident #34's nails because she was diabetic. She said yes, her nails were long, and the nurse knew about them. She said the nurses attempted to cut them yesterday. Interview on 10/22/19 at 09:14 AM, LVN J said the nurses took care of cutting and trimming Resident #34's nails. She said they had not been cut because the resident said it hurt for them to be cut. She said the nails were long. Interview on 10/22/19 at 09:19 AM ADON said Resident #34's nails were long. She said the left-hand hurts when the nurse tried to cut them. She said they should have done the right hand. Interview on 10/23/19 at 8:35 AM DON said she saw the nails yesterday and they had not been cut for a while. CNA's and nurses said she cried when they try to cut her nails. She said they should have told the nurse and the nurse should notify the DON or ADON if they were unable to cut them. She said they need to be cut. She said they could contact the doctor and let him now about the situation. Record review of facility policy titled Routine Nail Care revised in (MONTH) 2006 read in part, .each resident will receive routine nail care And .the nursing care staff will conduct ongoing assessment to assure each resident receives adequate nail care

Based on interview and record review, the facility failed to ensure each resident's assessment accurately reflected the status of each resident for 1 of 14 residents (CR #1) reviewed for assessments in that: -CR #1's discharge MDS had the discharge status inaccurately coded. This failure affected 1 former resident and placed him at risk of having inaccurate assessments. Findings include: Record review of CR #1's face sheet revealed, a [AGE] year-old-male admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Comprehensive MDS dated [DATE] revealed, documentation indicating the resident was discharged from the facility to an acute hospital on [DATE]. Record review of CR #1's Final Transfer/Discharge From Facility dated 08/06/19 revealed, on 08/05/19, the resident was transferred to another NH per request of the family. Interview on 10/24/19 at 9:32 AM with the DON, she stated CR #1 was discharged from the facility because the family wanted the resident to be closer, further stating the RP requested the resident be transferred to another NH that was closer. Interview on 10/24/19 at 10:29 AM with the MDS nurse, when asked where CR #1 was discharged to, she stated the resident was discharged to another nursing home. She said an ambulance came to pick him up from the facility. She stated she was under the impression he was going home, or back into the community, but realized he went to another NH. When she was shown the documentation on the resident's discharge MDS indicating he was transferred to an acute hospital and asked if the discharge MDS had an option to select transfer to a NH facility, she stated yes. When asked if the NH transfer would have been the appropriate choice on the MDS she stated, yes.

Based on observation, interview, and record review, the facility failed to implement an effective infection control program to prevent the development and transmission of infection for 4 of 7 residents (Residents #5, #19, #8, #18) reviewed for infection control in that: The facility did not have a system to track and trend infections at the facility designed to identify and control the infections before they can spread to other persons in the facility. Resident #5 who was on contact isolation was taken into the hallway and to shower room by staff. Items were transported between the nourishment room and Resident #5's room. Resident #5's lunch bag with condiments in it was taken from the refrigerator in the nourishment room placed on Resident #5's abdomen, items removed and then the lunch bag was put back into the refrigerator in the residents' nourishment room without being santitized. Facility staff did not provide proper indwelling catheter care for Resident #8. Facility staff did not provide proper incontinent care per facility policy for Resident #19. Soiled linens on the floor of Resident #18's room containing feces, urine and soiled wipes. CNA J was standing in hallway with gloves on outside of a resident's room. CNA G used a wrist blood pressure cuff on all residents in the 200 hall, including residents on isolation without properly cleaning and against facility policy. Dietary Services used same trays/utensils/carts for contact isolation residents and other residents without sanitizing. Facility staff delivered meal trays to residents on the 200 hall which included residents on isolation and residents not on isolation without donning isolation equipment. An Immediate Jeopardy (IJ) was identified in the areas of abuse and neglect on 06/01/17 and another IJ was called in the area of Infection Control on 06/05/17 at 4:45pm. While the IJ was lowered on 06/09/17, the facility remained out of compliance at a scope of wide spread and a severity of potential for more than minimal harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected four residents and placed 51 residents who reside at the facility at risk of infection, decreased quality of life and decline in health status. Findings included: Record review of the facility's Infection Control Logs revealed the following: February 2017- There were 11 urinary tract infections, nine upper respiratory infections, four rashes and one skin infection. March 2017- There were 17 urinary tract infections, six respiratory infections, three rashes and six skin/wound infections. April 2017- There were five urinary tract infections, four respiratory infections, one rash and three skin infections and one ear infection. May 2017- There were eight urinary tract infections, six respiratory infections, one rash and eight skin/wound infections. Interview on 06/06/17 at 11:54am with the ADON revealed she took over the infection control around February 2017. She said she would color on the maps (floor plans) and then the DON told her not to worry about doing it anymore. She said she used to try and fill out the log daily but was too busy now and does it when she can but it is usually filled out the log at the end of the month. When asked how she knew when a pattern of infections were beginning and she said she would not be able to do so.When asked how did she know where the infections were because the log did not have a place to put room numbers she said she just knew where the residents were located. When asked if she used the log to help with the prevention of the spread of infection she said no. She said she would just tell the DON when a resident had an infection. She said there was no education provided to the staff if there were an increase in infections. When asked about all the residents with ESBL having catheters she said that was from the DON, she wanted everyone to have a catheter so they could come out of their room or have a roommate that did not have an infection. She said there were no standing orders regarding placing catheters that the doctor would have to be called on a case by case basis. She also said a catheter did not completely contain the infection but the residents were free to go anywhere in the facility as long as they had a catheter. She then said she had never been trained in infection control and did not know how to fill out the floor plan to accurately capture the infections. Resident #5 Record review of Resident #5's face sheet revealed an admitted [DATE] and a readmitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. MDS further revealed that Resident #5 required extensive assistance with two person physical assist for bed mobility, dressing and personal hygiene. Resident #5 was total dependence with two person assist for bathing. Record review of care plans for Resident #5 revealed the following care plans, which read in part . Frequent Urinary Tract Infections (UTI's) and is at risk for increased temperature, dehydration, and pain/discomfort as evidenced by Extended Spectrum Beta Lactamase (ESBL) of urine, Foley Catheter dated 05/30/2017. Approach- give medications per order, encourage p.o. (by mouth) fluid intake, monitor for increased temperature, dehydration, pain, discomfort. Staff to provide catheter care every shift and as needed. Resident requires isolation as evidenced by ESBL dated 05/30/2017. Approach-follow facility isolation policy, inform staff and visitors of residents isolation requirements, provide protective equipment at entrance to room, post isolation precautions on the door to the room, hand washing to prevent spread of infection. Resident has Foley Catheter and is at risk for increased urinary tract infections dated 05/30/2017. Approach- change Foley Catheter, bag per order, monitor urine for odor, color, sediments and amount of urine. Keep tubing/bag below the bladder, do not kink tubing. Observation and interview with Resident #5 on 06/01/2017 at 2:55pm revealed contact isolation signage on the door and cart outside of door containing gowns, gloves and mask. Resident #5 laying in bed with head of bed elevated, indwelling catheter in place and draining dark yellow urine. In an interview with Resident #5 at same time, Resident #5 said that she needed clarification about contact isolation. Resident #5 said that she was put on contact isolation 2 days ago and she the nurses forced me to have a foley. Resident #5 said that she was incontinent of bowel and bladder and did not think she needed an indwelling catheter for ESBL of the urine. Resident #5 said that staff has told her that since she has an indwelling catheter that the ESBL is contained and she can leave the room to eat in the dining room and staff has insisted she get up and has taken her to the dining room for her meals while on isolation. Resident #5 also said that she is a retired nurse and knows that it is wrong for her to have a roommate and leave the room for meals while on isolation. In an interview with Licensed Vocational Nurse (LVN) K on 06/01/2017 at 3:10 pm she said that Resident #5 had an indwelling catheter to keep the ESBL in her urine contained. LVN K said that the night shift nurse had put the catheter in and that Resident #5 did not like having the catheter for a urinary tract infection with ESBL. When LVN K was asked by surveyor who made the decision to put in the catheter for Resident #5, LVN K said the Director of Nurses (DON) made the decision to put indwelling catheters in all residents with ESBL of the urine and if residents wanted to stay in their rooms they needed an indwelling catheter. LVN K also said that it did not make sense to have residents on isolation when they have roommates in their rooms. Observation on 06/03/17 at 12:06 PM revealed CNA F removed a lunch bag from the residents nutrition room labeled with Resident #5's name and placed the lunch bag on top of Resident #5's abdomen who was in bed and helped her get sour cream for her food. CNA F then placed the bag on top of Resident #5's table and left the room. Observation on 06/05/17 at 5:06 PM of the nutrition room revealed Resident #5's lunch bag in the refrigerator with other food and juices for the facility residents. In an interview on 06/03/17 at 12:07 PM CNA F stated she removed the Resident #5's lunch from the nutrition room and took it to Resident #5. In an interview on 06/05/17 at 5:07 PM the Acting DON stated that the lunch bag should not be in the refrigerator and that she was concerned. In an interview on 06/05/17 at 5:08 PM the ADON stated that the lunch bag should not be in the refrigerator. In an interview on 06/06/17 at 2:00 PM CNA F stated it was a normal practice to take Resident #5 her lunch bag and put it back into the refrigerator in the nutrition room. CNA F said that they have never used disposable cups, plates or utensils for residents on contact isolation. Observation and Interview on 06/05/2017 at 6:05 pm revealed contact isolation signage on the door and cart outside of Resident #5's room containing gloves, gowns and mask. In an interview with Resident #5 at same time she said that the staff made me get out of bed today and go out into the hall and also had Resident #5 taken to the showers via shower bed. When Resident #5 was asked how staff made her get out of bed and go to the shower room, she said when she told the floor nurse No that the floor nurse told the Assistant Director of Nursing (ADON), Director of Nursing (DON) and 2 Certified Nurse Aides and they all came to the room and told her to get up, so she felt that she had to because there were 5 staff telling her she had to get up. Observation on 06/05/2017 at 6:20 pm revealed the ADON walking into Resident #5's room. ADON explained to Resident #5 that the facility had to throw out her (Resident #5's) lunch kit as it was contaminated but the facility would buy her another. Resident #5 started shaking her head and said No. ADON informed Resident #5 that she was not sure if it could be cleaned and it had to be thrown out due to ESBL. Resident #5 informed ADON that she was confused because staff wants to throw her things out due to ESBL, but makes her leave the room when she is on contact isolation for showers and to eat. Resident #5 asked ADON why she was made to leave room to go to the shower room earlier in the day. ADON replied that she was only doing what she was told to do. Resident #19 Record review of Resident #19's face sheet revealed an admission date of [DATE] and a readmitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #19's MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. MDS further revealed that Resident #19 required extensive assistance with two person physical assist for bed mobility, dressing and personal hygiene. Resident #19 was total dependence with two person physical assist for toilet use. MDS further revealed that Resident #19 was always incontinent of bladder and frequently incontinent of bowel. Observation of incontinent care provided by CNA T and CNA U on 06/02/2017 at 12:00 pm revealed CNA U putting foam cleanser on a disposable wipe and she wiped right inner thigh, left inner thigh, lower abdomen and labia majora with the same wipe. CNA U then used another disposable wipe to remove cleanser from right inner thigh, left inner thigh, lower abdomen and labia majora. CNA U then removed another wipe from the container to cleanse the labia minora. Gloves were changed and Resident #19 was rolled onto her side. CNA U pulled a disposable wipe from the container and wiped the left buttock, right buttock and then the rectal area with the same wipe. CNA U pulled another wipe from container and wiped the left buttock, right buttock and then rectal area again. In an interview on 06/02/2017 at 12:10 pm with CNA U, she said that she always puts soap on a wipe and uses it to wipe all areas and then uses another wipe to clean all the areas again as Resident #19 likes to be clean as she has psoriasis. CNA U said that she does wipe midline from front to back once and changes gloves before providing care to backside. CNA U said that she realizes everyone does things differently but that is how she provides incontinent care. In an interview with CNA Ton 06/02/2017 at 12:12 pm she said that when providing incontinent care that you should always wipe front to back and discard wipe after each use. CNA T said wipes should never be reused and hands should be washed and gloves should be worn. Resident #8 Record review of Resident #8's face sheet revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Minimum Data Set not provided by facility before exit. Record review of care plan for Resident #8 dated 04/25/2017 revealed a care plan for Catheter which read in part .Resident has Foley Catheter and is at risk for increased urinary tract infections. Approach- change foley cath, tubing and bag per order. Monitor urine for odor, color, sediments and amount of urine. Encourage by mouth fluids. Keep tubing/bag below the bladder. Record review of urinalysis culture dated 06/05/2017 revealed Resident #8 was diagnosed with [REDACTED]. Observation on 06/02/2017 at 10:30 am revealed a contact isolation sign on Resident #8's door along with 2 biohazard containers in Resident #8's room between his bed and the wall. Both containers were not covered. Resident #8 had an indwelling catheter that was draining yellow urine. Observation further revealed that Resident #8 had a roommate who was not on isolation. Interview with LVN E on 06/02/2017 at 10:36 am she said that Resident #8 had ESBL and was on contact isolation and because he had an indwelling catheter the infection was contained. LVN E said Resident #8 has a roommate because the ESBL is contained in the catheter bag. When LVN E was asked by surveyor why the biohazard linen box and biohazard trash box was in Resident #8's room between his bed and the wall, she said that since his roommate is ambulatory and uses the restroom that the boxes could not be left in the restroom. LVN E did not say why the biohazard boxes were not covered. When LVN E was asked about indwelling catheters and infection control, she said that the DON makes the decision about the indwelling catheters and usually everyone with ESBL gets an indwelling catheter per facility policy. Observation of incontinent care for Resident #8 provided by CNA P and CNA Q on 06/02/2017 at 2:19 pm revealed that CNA P and CNA Q donned their isolation gowns and donned gloves outside of Resident #8's room. No hand hashing was performed prior to donning gloves. CNA P used gloved hand to use crank on bed to elevate bed to waist level to provide care. CNA P and CNA Q removed Resident #8's pants and CNA Q took pants and lowered them into the biohazard trash box and CNA P corrected her and said Resident #8's pants did not go in either box as family does Resident #8's laundry. CNA Q then took Resident #8's pants and opened the wardrobe and laid the pants on the bottom shelf. Observation of incontinent further revealed that Resident #8 had scant amount of blood on brief with redness, excoriation and lesion to penis. CNA P held Resident #8's penis and wiped indwelling catheter from mid catheter to tip of penis 3 times using a different wipe each time. In an interview with CNA P on 06/02/2017 at 2:29 pm she said that she was not aware that when provided catheter care that you should wipe away from the penis/vagina and that no one ever showed her the proper technique. CNA P said that hands were not washed prior to care as they had been told to apply gloves outside of the room prior to providing care. In an interview with CNA Q on 06/02/2017 at 2:30 pm she said that she was aware that you wipe an indwelling catheter away from the resident. CNA Q also said that gloves are always donned outside of the room prior to providing care per policy. Observation of Resident #8's room on 06/02/2017 5:58 pm revealed a biohazard trash box and biohazard linen box without lids between Resident #8's bed and wall. Observation also revealed Resident #8 had a roommate who was not in isolation and contact isolation signage on the door. Resident #18 Record review of Resident #18's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #18's MDS dated [DATE] revealed she had a BIMS of 15 which indicated no cognitive impairment. Record review of Resident #18's Care Plan dated 04/17/17 revealed Resident #18 had an ADL self-care performance deficit related to [DIAGNOSES REDACTED] and stroke. Resident #18 had mixed bladder incontinence related to impaired mobility and physical limitations. Staff are to clean peri-area with each incontinence episode. In an interview on 06/05/17 at 6:20 PM Resident #18 stated her family member picked up the soiled linens from behind the bed that one of the aides had left there. Observation and interview on 06/05/17 at 6:26 PM revealed rolled up soiled linens on the floor in Resident #18's room that contained urine, feces and soiled disposable wipes. In an interview at same time with CNA J she said that she had just started her shift and someone from the last shift left the soiled linens on the ground but she would clean it up. CNA J said This is a shame. In an interview on 06/06/17 at 1:10 PM CNA L said she was not sure if she left the soiled linens behind the bed or if it was from someone on the night shift. She last checked on Resident #18 before lunch and does remember asking the nurse to give her something for her constipation. Observation on 06/02/2017 at 10:11 am revealed Housekeeping V leaving resident room [ROOM NUMBER] which was an isolation room carrying a full yellow biohazard linen bag. Housekeeping V carried the full biohazard linen bag down the hall and exited a door at the end of the hall that led outside. In an interview with Housekeeping V on 06/02/2017 at 10:13 am, she said that she always carries the linen bags including biohazard linen bags down the hall to the exit door because the laundry room is in a separate building outside. Housekeeping V said she was taught to do it that way. Observation and interview on 06/02/2017 at 7:49 pm revealed CNA J to be standing in the 300 hall wearing gloves. Interview at same time with CNA J, she said that she had just exited resident room [ROOM NUMBER]. CNA J would not say if the gloves were clean or dirty. Interview with LVN O on 06/02/ at 7:50 pm, she said that staff should not wear gloves in the hallway as no one could tell if they were dirty or clean. Observation on 06/03/17 at 12:01 PM revealed dietary service used same carts,utensils, trays and plates for all facility residents, including residents in isolation rooms. Staff would remove trays from carts and deliver to residents on contact isolation with out donning protective equipment as well as delivering trays to residents who were not on contact isolation. In an interview on 06/03/2017 at 12:08 pm with Dietary Manager she said that all dishes/trays are are sent out on the cart together, collected in same cart and sent back to kitchen to be washed together whether the resident is on isolation or not because she was told the residents had indwelling catheters and the infection was contained. Observation and interview on 06/06/2017 at 7:25 am revealed Housekeeping Supervisor exiting a residents room carrying a biohazard trash bin lid with no gloves on. Observation further revealed biohazard trash bin in hallway without lid. In an interview on 06/06/2017 at same time with Housekeeping supervisor, she said that she was not wearing gloves because the gloves were outside of the room on the isolation cart and she was getting ready to put some gloves on. When asked why the biohazard trash bin was left in the hall without a lid, Housekeeping Supervisor said that she had just removed the biohazard bin from the room. Observation on 06/06/2017 at 8:01 am revealed CNA G exit a resident room who was on isolation carrying a blood pressure cuff. CNA G then entered another residents room (non-isolation) room with same blood pressure cuff. Interview with CNA G on 06/06/2017 at 10:16 am she said that she uses the same blood pressure cuff for all residents on her hall. CNA G said the facility did not provide blood pressure cuffs that were specifically for residents on isolation. CNA G said that she does wipe the blood pressure cuff with alcohol swabs between resident use and that the facility does not have a specific policy on how to clean a blood pressure cuff. Observation of laundry room on 06/06/2017 at 2:41 pm revealed 2 washing machines. One machine was connected to the wall and had tubing that ran from the wall to the machine and would measure the amount of detergent, bleach and chemicals needed to cleanse linens. The other washing machine was a regular machine where staff had to measure detergent and bleach and set water temperatures. Interview at same time on 06/06/2017 with Housekeeping W revealed that she used both washing machines to wash isolation linens in. When asked by surveyor to open the regular washing machine, Housekeeper W said the lid was locked because the washer was running. Surveyor lifted the lid, which did not contain a lock and the washer was set to rinse and was agitating. Washer contained towels, sheets and chucks pads. No visible water level seen above linens. Housekeeping W was asked how the detergent and bleach were measured for the regular washer and Housekeeping W said she puts a cup of bleach and whatever detergent she thinks was necessary based on the type of load she washes. When Housekeeping W was asked by surveyor to show her the measuring cup for the bleach, Housekeeping W was not able to. Record review of the facility in-service binder revealed that the last infection control training was on 04/27/17 an in-service was conducted regarding safe handling of blood/bodily fluids and 35 staff attended the training. In an interview on 06/08/17 at 3:18 PM the ADON said she was responsible for tracking and trending the infection control binder but she was never trained on how to do this. Record review of the facility's Healthcare-Associated Infections, Identifying revised December 2007 read in part .2. The goals of determining healthcare-associated infections are: a. To identify and correct breaches in infection control practices that may have contributed to the spread of a healthcare associated infection; b. To prevent the further spread of infection .through the initiation of appropriate isolation precautions .c. To identify and treat .organisms that have a high risk of transmission, severity oif disease, and/or are difficult to treat .5. The facility has established procedures and forms to perform and document surveillance . Record review of the facility's policy on Isolation revised October 2010 read in part .Contact Isolation .b. Resident Placement (1) Place the individual in a private room .f. Resident-Care Equipment (1) When possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope, sphygmonometer (blood pressure machine) . to a single resident . to avoid sharing between residents. Record review of Policy and Procedure for Laundry and Bedding, Soiled dated 2001 and revised July 2009 provided by facility read in part 1. Soiled laundry and bedding contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2.Place contaminated laundry in a bag or container at the location. 3.Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling of and disposal of contaminated items. 4.Anyone who handles soiled laundry must wear protective gloves and other protective equipment (gowns if soiling of clothing is likely). 5.Environmental services staff will bag contaminated laundry that is to be picked up and processed by commercial means, prior to pick up. Record review of Policy and Procedure for Hand Hygiene provided by facility dated 2001 and revised August 2014 read in part .1.All personnel shall be trained and regularly in-serviced in hand washing. 2.All personnel shall follow the handwashing procedures to help prevent the spread of infections. 3. Hand hygiene products and supplies shall be readily available accessible for staff. Record review of Policy and Procedure of Resident-Care Items and Equipment provided by facility dated 2001 and revised July 2014 read in part Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standards. The Administrator was notified on 06/01/17 at 2:15PM of the IJ situation due to the above failures and PoR was requested. The PoR was received and after multiple revisions it was accepted on 06/08/17 at 3:32PM. The PoR included in part: Issues that have been addressed on Infection Control: Mini-Fridges have been located in the Resident/Patient rooms that are on Isolation so they may have access to cold items in their room. Completed 6/6/2017. Boxes that were used for Isolation waste and linen have been replaced with cans with lids. Completed 6/6/2017. Dietary is now using disposables for Residents/Patients on Isolation. Completed 6 June 2017. We will utilize a live Infection Control Map that the ADON will update daily based on any changes that might have happened the previous day. This will be started 6 June 2017. Infection Control In-Service for staff subjects to include: Hand Washing, Isolation, Blood & Body Fluids, Cleaning & Disinfection, Soiled Laundry & Bedding, Trash Removal, Standard Precautions, Dietary Isolation, Catheter Care Peri Care. In-services will start 6 June 2017. All employees will be in-serviced by 7 June 2017. PRN or any staff that were not available to be in-serviced will be in-serviced before they start their next shift. In-services will be completed by: The Acting DON, The ADON, and LVN E. The facility was monitored from 06/07/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Record review of the in-services conducted revealed they were over infection control procedures to include handwashing, blood and body fluids, cleaning and disinfecting, procedure for handling soiled laundry and trash removal, isolation procedures, standard precautions, dietary isolation techniques, catheter and incontinent care procedures. Interview with different staff including nursing staff from both shifts on 06/0717, 06/08/17, 06/09/17 revealed they had been in-serviced on infection control procedures to include handwashing, blood and body fluids, cleaning and disinfecting, procedure for handling soiled laundry and trash removal, isolation procedures, standard precautions, dietary isolation techniques, catheter and incontinent care procedures. Observations on 06/09/17 revealed there was a mini fridge in Resident #5's room, the boxes used for isolation waste and linen had been replaced by cans with lids, dietary utilized disposable dishes and plastic ware for residents in isolation. Record review revealed a floor plan that had been updated daily with the infections for June that was to be used as the track and trending in addition to the Infection Control Log. An in-service had been conducted with approximately 95% of the staff trained on the infefction control subjects listed above. The Administrator was informed on 06/09/17 at 10:03am that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to train the staff. The facility's CMS 672 listed a census of 55 residents.

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 3 of 18 residents, Closed Record (CR) #1, Resident #2 and Resident #7 reviewed for abuse and neglect in that: The Administrator failed to start an investigation and suspend the DON when she was found to have a gun in her possession in the facility and had allegations of physical, mental and verbal abuse of residents made against her. It was alleged that she used her bag with the gun in it to intimidate residents, families and staff, she pulled a resident's hair and called a resident's family member a demeaning name. The facility failed to ensure Certified Nursing Assistant (CNA) B, LVN N and the ADON provided immediate care for Resident #7 following an injury where CNA B slammed the door on Resident #7's hand. An Immediate Jeopardy (IJ) was identified in the area of abuse and neglect on 06/01/17. While the IJ was lowered on 06/09/17, the facility remained out of compliance at a scope of wide spread and a severity of potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed all residents, staff and visitors at risk of injury and harm. Intake# 8, 0, 4, 7 Findings included: Record review of the facility policy Abuse Investigations dated 02/2014 revealed .8. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation . Record review of the facility policy Reporting Abuse to Facility Management dated 02/2014 revealed .Policy Interpretation and Implementation 2. a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish e Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .f. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse 6.Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information Record review of Complaint Investigation Worksheet Intake # 7 dated 05/31/17 revealed the DON would put a pink bag with a gun in it in residents' faces to intimidate and threaten them and would tell them if they did not get away from her they would find out what's in the bag. The DON called CR#1's (family member) a stupid cunt when she asked for his medication list. Upon entering the facility, local law enofcement was notified and arrived at the facility on 06/01/17 at 10:10am to investigate the allegation of the DON having a weapon in her purse. Observation on 06/01/17 at 10:12 AM in the DON's office revealed local law enforcement found a loaded gun in a pink purse under the desk. The DON was detained by local law enforcement. In an interview on 06/01/17 at 10:15 AM the DON stated the owner of the facility knew she carried a gun in her purse and in her car. She stated she had never threatened any residents or staff members. The staff were just aware of the gun through conversations where she may have brought it up. She stated she had the gun for protection due to a shooting at another facility in a different town. During the interview with DON the Administrator was present in the office and was told of the allegations of verbal/mental/physical abuse of CR#1 and Resident #2 made against the DON. In an interview on 06/01/17 at 10:42 AM the Administrator stated he was not aware that the DON was carrying a gun at the facility. He was not sure why she had a gun. He was going to write a policy about no guns at the facility and he had spoken with her about the gun issue. He was not aware of any abuse by the DON against residents but some staff had mentioned some things about her but he had not looked into the issues. The Administrator did not elaborate on what the issues were when asked; he said was probably just disgruntled staff. In a telephone interview with the Administrator on 06/01/17 at 11:40AM he stated the DON had secured the gun in her car. He said he was not aware that she had the gun in the facility and he was not aware of any allegations of physical or verbal abuse made against the DON. When told of the allegations and asked what he planned to do to keep the residents safe he said he was going to talk with the DON. He then said he was writing a new procedure regarding having weapons in the facility and would start in-servicing the staff at 6:00PM this evening and not wait until the regular payday in-service time. He said he had not started in-servicing any staff because he wanted to finish the new procedure first. When asked what the facility's policy and procedure was for abuse, neglect he said he did not know but when he was through writing the new procedure on the weapon he was going to read the abuse/neglect policy and procedure page by page to see what he was to do. When asked who the Abuse Prohibition Coordinator was he said it was him.When he was asked what the first step he should take regarding the allegations of abuse against the DON he said he was going to talk to her later but first he wanted to finish the new procedure. When asked if she was still in the facility he said yes. When asked if she had access to residents and all areas of the facility he said she was only allowed to go from the administration office to the Nurse's station and not work with residents. When asked if residents were ever present at the Nurse's station he said yes but the DON was only getting information that the State Surveyor needed and that she had a staff member with her at all times. He was then asked what he would do if the same allegations were made against a different staff member and he said he would talk to them. When asked if he would suspend the person and do and investigation he said he would talk to them as part of checking into what happened. When asked if we was going to suspend the DON and investigate the physical and verbal abuse allegations against her he said that he would talk to her but would keep her at the facility in case the State Surveyor had questions for her or needed anything. He was then told he should not keep the DON at the facility for the Surveyor. The DON could be contacted by phone if there were any questions and anyone at the facility could get information that was requested, it did not have to be the DON. He then said okay he was going to talk to her and then send her home. Observation and interview on 06/01/2017 at 1:17 pm revealed DON unattended in hallway outside of conference room. When asked what she was doing in hallway, DON said she was on her way to the conference room to speak to surveyor. In an interview on 06/01/17 at 11:40 AM CNA A stated she heard that the DON had a gun but did not know for sure. In an interview on 06/01/17 at 11:43 AM CNA B stated the DON would make residents get up out of bed even if they did not want to. She made Resident #3 get out of bed before 9:00 AM which she does not like to get out of bed before 9:00 AM. The DON wanted control of everything. If a resident did not want to follow her rules they were discharged from the facility or threatened with discharge. CNA B stated she knew the DON had a gun she would tell people she had a gun. She told everyone she kept one in her purse and one in her car. In an interview on 06/01/17 at 12:02 PM CNA C stated she was aware that the DON had a gun at the facility she said the DON would tell staff at the facility. She would tell staff she had a gun in her purse and car. In an interview on 06/01/17 at 1:07 PM the Administrator stated he spoke with the owner and the DON was given verbal permission to have the gun in the facility but not sure if she had written permission. In an interview on 06/01/17 at 1:14 PM the DON stated she did not have written permission to have a gun in the facility. She said the police officiers told her if she wanted to bring the gun back in the facility she would need written permission by the owner. Local law enforcement then let her go and had her put her gun in her car. In an interview on 06/02/17 at 11:18 AM Resident #3 stated the facility staff would force her to get up out of bed early and go to rehab. In an interview on 06/02/17 at 11:20 AM Family Member stated the facility staff would make Resident #3 get out of bed early. The Family Member had to speak with Administration about forcing Resident #3 out of bed to make them stop. The DON never got back with me about the incident or even if they looked into the incident. The DON would not like to deal with problems and would always tell us she did not have time to talk. In an interview on 06/02/17 at 2:32 PM the Administrator stated he was not sure of the abuse protocols when asked what the facility's procedure was when an allegation of abuse or neglect was brought to his attention. He stated he needed to get the facility policy because he was not sure of the procedure. He did not suspend the DON because he wanted her at the facility to answer questions in case the surveyor needed to talk with her. He had a staff monitor the DON while at the facility. In an interview on 06/03/17 at 10:30 AM CNA D stated that the DON told her that if anything happened she had a gun in her purse that could be used on staff and the residents. She would also tell residents don't make her go get her purse. She would tell staff that she kept a gun in her purse under her desk. Staff knew the gun was there and they were terrified of the DON. In an interview on 06/06/17 at 2:01 PM CNA M stated the DON would yell at residents sometimes, she told one resident if she did not want to be at the facility she could be discharged and gave her a list of home health agencies. The DON was mad because the resident was telling her about an incident that occurred at the facility. That resident was no longer here. CNA M said the DON was very unprofessional at times. CR#1 Record review of CR#1's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 05/24/17. Record review of CR#1's MDS dated [DATE] revealed he had a BIMS score of 15 which indicated he had no cognitive impairment. In an interview on 06/06/17 at 12:10 PM CNA D stated the DON told CR#1 and his family member that she had something in her purse because she was getting frustrated with the family asking about CR#1's medications. CNA D stated she asked the DON what she had in her purse and the DON stated you will soon find out. CNA D did not want to get any other nurse aides involved and did not want to give the name of witnesses. She was not sure what date the incidents occurred it was either in April or May. Surveyor attempted to contact CR#1's and/or family member on 06/09/17 at 11:00 AM and a message was left. Resident#2 Record review of Resident #2's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed she had a BIMS of 3 which means she had severe cognitive impairment. Observation and interview on 06/01/17 at 2:47 PM Resident #2 was lying in bed dressed, groomed, no sign of injury. Resident #2 stated she had no issues with abuse at the facility and nobody had threatened or abused her. Record review of Complaint Investigation Worksheet Intake# 7 dated 05/31/17 revealed an allegation of abuse, Resident #2's hair was pulled by the DON. The DON would put a pink bag with a gun in it in residents' faces to intimidate and threaten them and tells them if they don't get away from her they will find out what's in the bag. Resident #7 Record review of face sheet for Resident #7 revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. Resident #7 required extensive assistance with two person physical assist for bed mobility, locomotion on and off unit, dressing and personal hygiene. Resident #7 was total dependence with two person physical assist for transfer, toilet use and bathing. Care plans requested from facility Assistant Director of Nursing for Resident #7. Records not received prior to exiting the facility. Observation on 06/02/2017 at 12:51 pm revealed Resident #7 propelling down the 200 hall way in her wheelchair. Resident #7 was observed using handrails, doors and entry ways/door frames to propel down hall way. Resident #7 was observed in wheelchair next to the wall with her hand near the door frame. Resident #7 screamed loudly in pain and nurses at the nursing station and the certified nurse aids in the hall way continued their work and did not respond. Resident #7 screamed loudly again and said You closed the door on my hand. Resident #7 continued screaming and said she wanted to cry when CNA B pulled the door open and came out of the room and said I didn't do it and Resident #7 said yes you did. CNA B continued to argue with Resident #7 and said I didn't close the door on you. The ADON and LVN N approached and quickly looked at Resident #7's fingers and right hand and the ADON told Resident #7 she was fine. Resident #7 continued to tell the ADON, LVN N and CNA B that she was hurting and she wanted to cry. LVN N looked at her right hand and told Resident #7 that she was fine. The Surveyor intervened on and asked Resident #7 to hold up her right hand so it could be assessed. Resident #7 complied and showed surveyor her hand. Resident #7's right middle and right ring finger had chipped nail polish across middle of nail. No other nails were chipped. Observation of right hand and right middle and ringer fingers further revealed indentions on both fingertips (palm side) that went completely across her fingers. Fingers and palm of hand were red and Resident #7 kept grabbing her right hand and fingers. ADON and LVN N continued to tell Resident #7 that she was fine. Surveyor went and notified Administrator of the issue. In an interview with ADON on 06/02/2017 at 12:56 pm, she said that it was not normal to argue with a resident about an injury. ADON said that Resident #7 had behaviors and hollers all the time. ADON said that maybe staff thought it was a behavior at first and not an injury. ADON said the hollering this time was different and the nurse should have been notified so she could assess Resident #7. Observation and interview on 06/02/2017 at 1:02 pm revealed Administrator at Resident #7's side holding her hand which was wrapped in a wet wash cloth. Administrator asked surveyor if the nurse had called physician and was told by surveyor that he would have to ask the nurse. Administrator said that he was handling the situation and consoling Resident #7. Interview with Resident #7 at same time revealed that she still had a lot of pain to her right hand. Administrator said he would make sure physician and family was notified. In an interview with CNA B on 06/02/2017 at 1:05pm, she said that when she went into the room to provide care for another resident that Resident #7 was sitting outside of doorway to the room and both of her hands were in her lap. CNA B said she went into the room to provide care to a resident but she did not close the door. CNA B said that while she was in the room she heard a scream and she exited the room and Resident #7 said that she (CNA B) closed the door on her hand. CNA B said she told Resident #7 No I didn't after Resident #7 accused her of closing the door on Resident #7's hand. CNA B said she looked at Resident #7's hand and then went back into the room when LVN H arrived. CNA B said she just wanted it to be clear that she did not close the door on Resident #7's hand. Interview with Administrator on 06/02/2017 at 2:54pm, he said that the nurse (LVN N) had notified the physician about Resident #7's hand but maybe did not provide all the information or suggest anything to the physician. The Administrator said that he called the physician after LVN N and an order was received for an x-ray of Resident #7's right hand and orders were received for physical therapy to evaluate and treat. The Administrator said he would in-service the nurses and CNA B was removed from the floor following the incident. Record review of incident investigation dated 06/02/2017 at 5:10 pm revealed the following: Resident #7 yelling in the hallway. Complaints of pain to right hand. Assessed area and noted reddened areas to right finger and middle finger anterior tips. Resident very close to wall near open door frame. Resident stated that the door closed on her fingers. Ice was applied to fingers. Pain was rated at a 10 out of 10. No witnesses found. Physician and family notified. The Administrator was notified on 06/01/17 at 2:15PM of the IJ situation due to the above failures and PoR was requested. The PoR was received and after multiple revisions it was accepted on 06/06/17 at 3:00PM. The PoR included in part: Abuse Reporting: .The DON was terminated on 06/05/17. The DON will not be allowed in this facility for any reason. Self-report for all allegations of verbal and physical abuse made against the DON was called into the DADS (Department of Aging and Disability) Hot Line .06/03/17 at 10:15am. The facility's abuse coordinator letter had been placed in all resident rooms by 06/01/17. Any new residents .admitted to the facility will be given the facility abuse coordinator letter. This was added to the admit package on 06/01/17. All residents in the facility have been interviewed to check for any type of abuse and to inform them of the facility abuse coordinator. This was completed by 06/01/17. .All staff in the building will be in-serviced on reporting abuse and who the abuse coordinator is. Staff will be informed that any and all reports need to be reported immediately no matter .All reports must be taken seriously and reported . This was started 06/01/17 and will be completed 06/05/17. All staff will be in-serviced. PRN (as needed) staff that were not available to be in-serviced (by completion date) will be in-serviced before they start their next shift. The facility was monitored from 06/06/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Interview with different staff including nursing staff from both shifts on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed they had been in-serviced on reporting allegations of abuse, who the Abuse Prohibition Coordinator was, and the Abuse Neglect policy and Procedure. Interview with 15 residents on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed the Administrator had been into visit with them. He discussed what abuse and neglect meant, he told them he was the Abuse Prohibition Coordinator and placed a letter in with their TV guides. He told the residents that they should report any allegations of abuse or neglect to him but if they did not feel comfortable talking to him they could call the DADS hotline number. Record review of the Abuse Prohibition Coordinator letter dated 06/01/17 revealed it contained information regrading types of abuse and neglect, the Administrator was the Abuse Prohibition Coordinator, the Administrator's contact information, and the DADS Hotline number. Observations of the resident rooms selected for review revealed there was a copy of the Abuse Prohibition Coordinator letter present. Record review of in-services conducted icluded the abuse and neglect policy and procedure, who the abuse prohibition coordinator was, types of abuse and what to do if witnessed abuse and when to report. The Administrator was informed on 06/09/17 at 10:03am that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that was not immediate jeopardy due to the facility needing more time to train the staff. The facility's CMS 672 revealed a census of 55 residents.

Based on observation, interview and record review, the facility failed to be administered the facility in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 of 18 residents (Resident #5, #8, #11, #18, #19) who were reviewed for administration. The Administrator failed to ensure the facility's policies and procedures were implemented for the prohibition of abuse and neglect. The Administrator failed to [MEDICATION NAME] the DON complied with Texas Government Code (TGC), Title 4, Chapter 411, §411.204, as amended by House Bill 910 (84th Texas Legislature, Regular Session, 2015). The Administrator failed to supervise the DON to ensure she carried out her responsibilities in the areas of nursing staff training/monitoring, to provide accurate and complete documentation, and implement preventive measures to avoid abuse/neglect, infection control, and quality of care issues. The Administrator failed to supervise the Maintenance Director to ensure he carried out his responsibilities of monitoring the Wander Guard system on the exit doors. The DON failed to provide staff training/monitoring, to provide accurate and complete documentation, and implement preventive measures to avoid elopements, infections, abuse/neglect, and substandard quality of care. An Immediate Jeopardy (IJ) was identified in the area of abuse and neglect on 06/01/17. While the IJ was lowered on 06/09/17, the facility remained out of compliance at a scope of wide spread and a severity of potential for more than minimal harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed all 55 residents, staff and visitors at the facility at risk of infections, accidents, injuries and death. Findings include: Record review of Complaint Investigation Worksheet Intake # 7 dated 05/31/17 revealed the DON would put a pink bag with a gun in it in residents' faces to intimidate and threaten them and would tell them if they did not get away from her they would find out what's in the bag. The DON called CR#1's (family member) a stupid cunt when she asked for his medication list. Upon entering the facility, local law enforcement was notified and arrived at the facility on 06/01/17 at 10:10am to investigate the allegation of the DON having a weapon in her purse. Observation on 06/01/17 at 10:12 AM in the DON's office revealed local law enforcement found a loaded gun in a pink purse under the DON's desk. The DON was detained by local law enforcement. In an interview on 06/01/17 at 10:15 AM the DON stated the owner of the facility knew she carried a gun in her purse and in her car. She stated she has never threatened any residents or staff members. The staff were just aware of the gun through conversations where she may have brought it up. She stated she had the gun for protection due to a shooting at another facility. During interview with DON the Administrator was present in the office and was told of the allegations of verbal/mental/physical abuse made against the DON. In an interview on 06/01/17 at 10:42 AM the Administrator stated he was not aware that the DON was carrying a gun at the facility. In a telephone interview with the Administrator on 06/01/17 at 11:40AM he stated the DON had secured the gun in her car. He said he was not aware that she had the gun in the facility and he was not aware of any allegations of physical or verbal abuse made against the DON. When told of the allegations and asked what he planned to do to keep the residents safe he said he was going to talk with the DON. He then said he was writing a new procedure regarding having weapons in the facility and would start in-servicing the staff at 6:00PM this evening and not wait until the regular payday in-service time. He said he had not started in-servicing any staff because he wanted to finish the new procedure first. When asked what the facility's policy and procedure was for abuse, neglect he said he did not know but when he was through writing the new procedure on the weapon he was going to read the abuse/neglect policy and procedure page by page to see what he was to do. When asked who the Abuse Prohibition Coordinator was he said it was him. So when he was asked what the first step he should take regarding the allegations of abuse against the DON he said he was going to talk to her later but first he wanted to finish the new procedure. When asked if she was still in the facility he said yes. When asked if she had access to residents and all areas of the facility he said she was only allowed to go from the administration office to the Nurse's station and not work with residents. When asked if residents were ever present at the Nurse's station he said yes but the DON was only getting information that the State Surveyor needed. He was then asked what he would do if the same allegations were made against a different staff member and he said he would talk to them. When asked if he would suspend the person and do and investigation he said he would talk to them as part of checking into what happened. When asked if we was going to suspend the DON and investigate the physical and verbal abuse allegations against her he said that he would talk to her but would keep her at the facility in case the State Surveyor had questions for her or needed anything. He was then told he should not keep the DON at the facility for the Surveyor. The DON could be contacted by phone if there were any questions and anyone at the facility could get information that was requested, it did not have to be the DON. He then said okay he was going to talk to her and then send her home. Interview on 06/06/17 at 3:30pm the Administrator said that he believed the IJ occurred because the DON did not do her job. When asked what he did to monitor the DON to ensure she performed her job duties he mentioned an admission check list was put in place, he talked with Activities, Social Worker, Physicians and Pharmacy but he never explained how he monitired the DON. In an interview on 06/01/17 at 1:07 PM the Administrator stated he spoke with the owner and the DON was given verbal permission to have the gun in the facility but not sure if she had written permission. In an interview on 06/01/17 at 1:14 PM the DON stated she did not have written permission to have a gun in the facility. Local law enforcement told her if she wanted to bring the gun back in the facility she would need written permission by the owner. Local law enforcement let her go. In an interview on 06/02/17 at 2:32 PM the Administrator stated he was not sure of the abuse protocols when asked what the facility's procedure was when an allegation of abuse or neglect is brought to his attention. He stated he needed to get the facility policy because he was not sure of the procedure. He did not suspend the DON because he wanted her at the facility to answer questions in case the surveyor needed to talk with her. He had a staff monitor the DON while at the facility. Observation on 06/02/17 at 2:15 PM at the front door revealed the wander guard system did not respond to resident with bracelet on right arm go out the front door. Observation on 06/02/17 at 7:46 PM at the front of the facility revealed 2 residents outside siting on patio and 2 resident in the lobby. One resident greeted the Surveyors Merry Christmas. No staff in the lobby monitoring residents. The Business Office was closed and the lights were off. Observation on 06/03/17 at 9:30 AM revealed one resident in lobby no staff in front of building. Observation on 06/07/17 at 5:45 PM revealed 2 of 4 wander guard systems did not go off when tested . System is not working completely for all door for all residents. In an interview on 06/02/17 at 11:45 AM the ADON stated the nurses check for placement of the wander guard but they don't have a system to check the wander guard daily to determine if it is working. She is going to create something today to check the wander guard system daily. In an interview on 06/02/17 at 2:58 PM the Administrator stated the wander guard system has not been working for about 3 weeks now. The system goes in and out. He thought the DON was testing the system but he would try and find out. In an interview on 06/02/17 at 3:08 PM the Maintenance Director stated they have been having issues with the wander guard system for about a week and a half. Some of the parts needed to be reordered due to late payments by the facility. The nurses have been locking the doors at night and during the day the business office would check on residents and make sure that anyone that is not supposed to be out the facility was outside. In an interview on 06/03/17 at 11:58 AM LVN E stated the nurses checked for placement but thinks the Maintenance Director checks to make sure the system is working she was not sure. In an interview on 06/03/17 at 12:00 PM the Maintenance Director stated he thought the Nurse Aides were supposed to check the wander guard system. The Administrator told him today that they are going to create something to monitor the system. He told me to start documenting the checks today. In an interview with CNA Q on 06/02/2017 at 2:30 pm she said that she was aware that you wipe an indwelling catheter away from the resident. CNA Q also said that gloves were always donned outside of the room prior to providing care per policy. In an interview on 06/05/17 at 6:27 PM CNA J stated she was never trained on how to use the Hoyer lift while was at the facility she knew how at another facility. In an interview on 06/05/17 at 6:29 PM CNA I stated she was never trained on how to use the Hoyer lift at the facility. She knew from another facility. In an interview on 06/06/17 at 10:15 AM CNA G stated she was trained on safety regarding the Hoyer lift but nobody actually did a demonstration at the facility on how to use the Hoyer lift. She was trained at another facility so she knows how to use the lift. In an interview on 06/06/17 at 11:50 AM the Acting DON stated when she was at the facility a year ago the staff would have a skills check off completed during orientation and given to the HR Department. In an interview on 06/06/17 at 11:52 AM Human Resource Coordinator stated the nursing department stopped giving Human Resources the skills check off sheets a few year ago. The nursing department would keep them in the nursing office. After on the job training the skills check off would be given to the nursing department. In an interview on 06/06/17 at 1:00 PM the Acting DON stated she was going to check with sister facility to see if they have any of the information on staff skills check off. The facility does not have any documentation in the office. In an interview on 06/06/17 at 1:10 PM CNA L stated she was not sure if she left the soiled linens behind the bed or if it was from someone on the night shift. She last checked on Resident #18 before lunch and does remember asking the nurse to give her something for her constipation. In an interview on 06/06/17 at 2:00 PM CNA F stated it was a normal practice to take Resident #5 her lunch bag and put it back into the refrigerator in the nutrition room. CNA F said that they have never used disposable cups, plates or utensils for residents on contact isolation. In an interview on 06/07/17 at 1:43 PM the Acting DON stated she could not find any of the staff skills check off for orientation so she has compiled a list and is currently working on getting staff trained. Record review of employee files revealed no documentation of skills check off sheets for the Wander Guard System, the Mechanical Lift or infection control in the employee files. The Administrator was notified on 06/01/17 at 2:15pm of the IJ situation due to the above failures and PoR was requested. The PoR was received and after multiple revisions it was accepted on 06/08/17 at 3:32pm. The PoR included in part: Abuse Reporting: .The DON was terminated on 06/05/17. The DON will not be allowed in this facility for any reason. Self-report for all allegations of verbal and physical abuse made against the DON was called into the DADS (Department of Aging and Disability) Hot Line .06/03/17 at 10:15am. The facility's abuse coordinator letter had been placed in all resident rooms by 06/01/17. Any new residents .admitted to the facility will be given the facility abuse coordinator letter. This was added to the admit package on 06/01/17. All residents in the facility have been interviewed to check for any type of abuse and to inform them of the facility abuse coordinator. This was completed by 06/01/17. .All staff in the building will be in-serviced on reporting abuse and who the abuse coordinator is. Staff will be informed that any and all reports need to be reported immediately no matter .All reports must be taken seriously and reported . This was started 06/01/17 and will be completed 06/05/17. All staff will be in-serviced. PRN (as needed) staff that were not available to be in-serviced (by completion date) will be in-serviced before they start their next shift. Resident/Patient Safety: One Hoyer Lift was taken out of service. A new Hoyer Lift was ordered and it is slated to be in the facility 6/7/2017. Training for Hoyer Lift operation In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. The PRN or any staff that were not available to be in-serviced will be in-serviced before they started their next shift. In-services will be completed by: The Acting DON, the ADON and LVN E. Resident/Patient Assessment - Change of Condition. Nursing staff will be in-serviced on completing a Resident/Patient Assessment for any Change of Condition. As Nurses will must be aware of any changes in the Residents . status . The Nurse must complete an assessment and report findings to the next shift. In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. PRN or any staff that were not available to be in-serviced will be in-serviced before they start their next shift . Wander Guard: Until a new wander guard system is installed and tested , as a temporary fix to our wander guard not activating 100% of the time we have placed door alarms on all doors that will sound when the door has been opened. This is effective starting today, 06/08/17. The new system will be in-place within 14 days. All staff to be in-serviced that they must go to the door to ensure that no resident/patient has went outside. This needs to be done 24 hours a day. PRN and other staff that were not available to be in-serviced will be in-serviced before they start their next shift. This will be completed by 6/8/2017 1400. In-services will be completed by: The Acting DON, and the ADON. The facility was monitored from 06/07/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Interview with different staff including nursing staff from both shifts on 06/06/17, 06/07/17, 06/08/17, and 06/09/17 revealed they had been in-serviced on reporting allegations of abuse, who the Abuse Prohibition Coordinator was, and the Abuse Neglect policy and Procedure. Interview with 15 residents on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed the Administrator had been into visit with them. He discussed what abuse and neglect meant, he told them he was the Abuse Prohibition Coordinator and placed a letter in with their TV guides. He told the residents that they should report any allegations of abuse or neglect to him but if they did not feel comfortable talking to him they could call the DADS hotline number. Record review of the Abuse Prohibition Coordinator dated 06/01/17 revealed it contained information regarding types of abuse and neglect, the Administrator was the Abuse Prohibition Coordinator, the Administrator's contact information, and the DADS Hotline number. Observations of the resident rooms selected for review revealed there was a copy of the Abuse Prohibition Coordinator letter present. Record review of in-services conducted included the abuse and neglect policy and procedure, who the abuse prohibition coordinator was, types of abuse and what to do if witnessed abuse and when to report. Interview with different staff including nursing staff from both shifts on 06/07/17, 06/08/17 and 06/09/17 revealed they had been in-serviced on the use of the mechanical lift and the new alarm system on all exit doors. Observations of two new mechanical lifts that revealed that they were in good working order and there were alarms on all exit doors that sounded when they were opened. Interview with 15 residents on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed the Administrator had been into visit with them. He discussed what abuse and neglect meant, he told them he was the Abuse Prohibition Coordinator and placed a letter in with their TV guides. He told the residents that they should report any allegations of abuse or neglect to him but if they did not feel comfortable talking to him they could call the DADS hotline number. Record review of the Abuse Prohibition Coordinator dated 06/01/17 revealed it contained information regrading types of abuse and neglect, the Administrator was the Abuse Prohibition Coordinator, the Administrator's contact information, and the DADS Hotline number. Record review revealed staff in-services were conducted on the subjects mentioned above and 95% of the staff attended the in-services. Resident/Patient Safety: One Hoyer Lift was taken out of service. A new Hoyer Lift was ordered and it is slated to be in the facility 6/7/2017. Training for Hoyer Lift operation In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. The PRN or any staff that were not available to be in-serviced will be in-serviced before they started their next shift. In-services will be completed by: The Acting DON, the ADON and LVN E. Resident/Patient Assessment - Change of Condition. Nursing staff will be in-serviced on completing a Resident/Patient Assessment for any Change of Condition. As Nurses will must be aware of any changes in the Residents . status . The Nurse must complete an assessment and report findings to the next shift. In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. PRN or any staff that were not available to be in-serviced will be in-serviced before they start their next shift . Wander Guard: Until a new wander guard system is installed and tested , as a temporary fix to our wander guard not activating 100% of the time we have placed door alarms on all doors that will sound when the door has been opened. This is effective starting today, 06/08/17. The new system will be in-place within 14 days. All staff to be in-serviced that they must go to the door to ensure that no resident/patient has went outside. This needs to be done 24 hours a day. PRN and other staff that were not available to be in-serviced will be in-serviced before they start their next shift. This will be completed by 6/8/2017 1400. In-services will be completed by: The Acting DON, and the ADON. Issues that have been addressed on Infection Control: Mini-Fridges have been located in the Resident/Patient rooms that are on Isolation so they may have access to cold items in their room. Completed 6/6/2017. Boxes that were used for Isolation waste and linen have been replaced with cans with lids. Completed 6/6/2017. Dietary is now using disposables for Residents/Patients on Isolation. Completed 6 June 2017. We will utilize a live Infection Control Map that the ADON will update daily based on any changes that might have happened the previous day. This will be started 6 June 2017. Infection Control In-Service for staff subjects to include: Hand Washing, Isolation, Blood & Body Fluids, Cleaning & Disinfection, Soiled Laundry & Bedding, Trash Removal, Standard Precautions, Dietary Isolation, Catheter Care Peri Care. In-services will start 6 June 2017. All employees will be in-serviced by 7 June 2017. PRN or any staff that were not available to be in-serviced will be in-serviced before they start their next shift. In-services will be completed by: The Acting DON, The ADON, and LVN E. The facility was monitored from 06/07/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Interview with different staff including nursing staff from both shifts on 06/06/17, 06/07/17, 06/08/17, and 06/09/17 revealed they had been in-serviced on reporting allegations of abuse, who the Abuse Prohibition Coordinator was, and the Abuse Neglect policy and Procedure. Interview with 15 residents on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed the Administrator had been into visit with them. He discussed what abuse and neglect meant, he told them he was the Abuse Prohibition Coordinator and placed a letter in with their TV guides. He told the residents that they should report any allegations of abuse or neglect to him but if they did not feel comfortable talking to him they could call the DADS hotline number. Record review of the Abuse Prohibition Coordinator dated 06/01/17 revealed it contained information regarding types of abuse and neglect, the Administrator was the Abuse Prohibition Coordinator, the Administrator's contact information, and the DADS Hotline number. Observations of the resident rooms selected for review revealed there was a copy of the Abuse Prohibition Coordinator letter present. Record review of in-services conducted included the abuse and neglect policy and procedure, who the abuse prohibition coordinator was, types of abuse and what to do if witnessed abuse and when to report. Interview with different staff including nursing staff from both shifts on 06/07/17, 06/08/17 and 06/09/17 revealed they had been in-serviced on the use of the mechanical lift and the new alarm system on all exit doors and infection control measures. Observations on 06/09/17 revealed there were two new mechanical lifts that revealed that they were in good working order and there were alarms on all exit doors that sounded when they were opened. A mechanical lift transfer was completed with good technique. There was a mini fridge in Resident #5's room, the boxes used for isolation waste and linen had been replaced by cans with lids, dietary utilized disposable dishes and plastic ware for residents in isolation. Record review revealed staff in-services were conducted on the subjects mentioned above and 95% of the staff attended the in-services. The Administrator was informed on 06/09/17 at 10:03am that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to train the staff. The facility's CMS 672 listed a census of 55 residents.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 1 of 18 residents (Resident #7) reviewed for abuse and neglect in that: The facility failed to ensure Certified Nursing Assistant (CNA) B, LVN N and the ADON provided immediate care for Resident #7 following an injury where CNA B slammed the door on Resident #7's hand. An Immediate Jeopardy (IJ) was identified in the area of abuse and neglect on 06/01/17. While the IJ was lowered on 06/09/17, the facility remained out of compliance at a scope of wide spread and a severity of potential for more than minimal harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed 54 other residents at risk of harm, injury, or diminished quality of life. Intake# 8, 0, 4, 7 Findings included: Resident #7 Record review of face sheet for Resident #7 revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. Resident #7 required extensive assistance with two person physical assist for bed mobility, locomotion on and off unit, dressing and personal hygiene. Resident #7 was total dependence with two person physical assist for transfer, toilet use and bathing. Care plans requested from facility Assistant Director of Nursing for Resident #7. Records not received prior to exiting the facility. Record review of Abuse and neglect in-service dated 06/02/17 revealed CNA B had signed her name to indicate she attended the in-service. The in-service conducted was regarding types of abuse, reporting suspected or witnessed abuse and the new policy and procedure of having weapons at the facility. Observation on 06/02/2017 at 12:51 pm revealed Resident #7 propelling down the 200 hall way in her wheelchair. Resident #7 was observed using handrails, doors and entry ways/door frames to propel down hall way. Resident #7 was observed in wheelchair next to the wall with her hand near the door frame. Resident #7 screamed loudly in pain and nurses at the nursing station and the certified nurse aids in the hall way continued their work and did not respond. Resident #7 screamed loudly again and said You closed the door on my hand. Resident #7 continued screaming and said she wanted to cry when CNA B pulled the door open and came out of the room and said I didn't do it and Resident #7 said yes you did. CNA B continued to argue with Resident #7 and said I didn't close the door on you. The ADON and LVN N approached and quickly looked at Resident #7's fingers and right hand and the ADON told Resident #7 she was fine. Resident #7 continued to tell the ADON, LVN N and CNA B that she was hurting and she wanted to cry. LVN N looked at her right hand and told Resident #7 that she was fine. The Surveyor intervened on and asked Resident #7 to hold up her right hand so it could be assessed. Resident #7 complied and showed surveyor her hand. Resident #7's right middle and right ring finger had chipped nail polish across middle of nail. No other nails were chipped. Observation of right hand and right middle and ringer fingers further revealed indentions on both fingertips (palm side) that went completely across her fingers. Fingers and palm of hand were red and Resident #7 kept grabbing her right hand and fingers. ADON and LVN N continued to tell Resident #7 that she was fine. Surveyor went and notified Administrator of the issue. In an interview with ADON on 06/02/2017 at 12:56 pm, she said that it was not normal to argue with a resident about an injury. ADON said that Resident #7 had behaviors and hollers all the time. ADON said that maybe staff thought it was a behavior at first and not an injury. ADON said the hollering this time was different and the nurse should have been notified so she could assess Resident #7. Observation and interview on 06/02/2017 at 1:02 pm revealed Administrator at Resident #7's side holding her hand which was wrapped in a wet wash cloth. Administrator asked surveyor if the nurse had called physician and was told by surveyor that he would have to ask the nurse. Administrator said that he was handling the situation and consoling Resident #7. Interview with Resident #7 at same time revealed that she still had a lot of pain to her right hand. Administrator said he would make sure physician and family was notified. In an interview with CNA B on 06/02/2017 at 1:05pm, she said that when she went into the room to provide care for another resident that Resident #7 was sitting outside of doorway to the room and both of her hands were in her lap. CNA B said she went into the room to provide care to a resident but she did not close the door. CNA B said that while she was in the room she heard a scream and she exited the room and Resident #7 said that she (CNA B) closed the door on her hand. CNA B said she told Resident #7 No I didn't after Resident #7 accused her of closing the door on Resident #7's hand. CNA B said she looked at Resident #7's hand and then went back into the room when LVN H arrived. CNA B said she just wanted it to be clear that she did not close the door on Resident #7's hand. Interview with Administrator on 06/02/2017 at 2:54pm, he said that the nurse (LVN N) had notified the physician about Resident #7's hand but maybe did not provide all the information or suggest anything to the physician. The Administrator said that he called the physician after LVN N and an order was received for an x-ray of Resident #7's right hand and orders were received for physical therapy to evaluate and treat. The Administrator said he would in-service the nurses and CNA B was removed from the floor following the incident. Record review of incident investigation dated 06/02/2017 at 5:10 pm revealed the following: Resident #7 yelling in the hallway. Complaints of pain to right hand. Assessed area and noted reddened areas to right finger and middle finger anterior tips. Resident very close to wall near open door frame. Resident stated that the door closed on her fingers. Ice was applied to fingers. Pain was rated at a 10 out of 10. No witnesses found. Physician and family notified. Record review of the facility policy Abuse Investigations dated 02/2014 revealed .8. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation . Record review of the facility policy Reporting Abuse to Facility Management dated 02/2014 revealed .Policy Interpretation and Implementation 2. a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish e Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .f. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse 6.Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information The Administrator was notified on 06/01/17 at 2:15PM of the IJ situation due to the above failures and PoR was requested. The PoR was received and after multiple revisions it was accepted on 06/06/17 at 3:00PM. The PoR included in part: Abuse Reporting: The DON was terminated on 06/05/17. The DON will not be allowed in this facility for any reason. Self-report for all allegations of verbal and physical abuse made against the DON was called into the DADS (Department of Aging and Disability) Hot Line .06/03/17 at 10:15am. The facility's abuse coordinator letter had been placed in all resident rooms by 06/01/17. Any new residents .admitted to the facility will be given the facility abuse coordinator letter. This was added to the admit package on 06/01/17. All residents in the facility have been interviewed to check for any type of abuse and to inform them of the facility abuse coordinator. This was completed by 06/01/17. .All staff in the building will be in-serviced on reporting abuse and who the abuse coordinator is. Staff will be informed that any and all reports need to be reported immediately no matter .All reports must be taken seriously and reported . This was started 06/01/17 and will be completed 06/05/17. All staff will be in-serviced. PRN (as needed) staff that were not available to be in-serviced (by completion date) will be in-serviced before they start their next shift. The facility was monitored from 06/06/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Interview with different staff including nursing staff from both shifts on 06/06/17, 06/0717, 06/08/17, 06/09/17 revealed they had been in-serviced on reporting allegations of abuse, who the Abuse Prohibition Coordinator was, and the Abuse Neglect policy and Procedure. Observations of the resident rooms selected for review revealed there was a copy of the Abuse Prohibition Coordinator letter present. Record review of in-services conducted icluded the abuse and neglect policy and procedure, who the abuse prohibition coordinator was, types of abuse and what to do if witnessed abuse and when to report. The Administrator was informed on 06/09/17 at 10:03am that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that was not immediate jeopardy due to the facility needing more time to train the staff. The facility's CMS 672 revealed a census of 55 residents.

Based on observation, interview, and record review the facility failed to ensure the environment remained as free from accidents and hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 18 residents (Resident #11, Resident #4 and Resident #18) who were reviewed for accidents and hazards in that: The facility failed to ensure the wander guard system was working correctly. There were no documented checks that the alarm sounded when it should. Resident #11 was found outside of the facility three times in April 2017 and May 2017. The facility failed to ensure the mechanical lift was working properly. CNA AA and CNA BB dropped Resident #4 while transferring him with the mechanical lift. The facility failed to train staff on the proper use of the mechanical lift. The Facility staff did not operate the mechanical lift properly while providing care for Resident #18. The facility failed to ensure the DON complied with Texas Government Code (TGC), Title 4, Chapter 411, §411.204, as amended by House Bill 910 (84th Texas Legislature, Regular Session, 2015). She had an unsecured, loaded gun at the facility located in her purse under the desk in her office. Her office door was unlocked, open and her office was accessible by residents, staff and visitors. An Immediate Jeopardy (IJ) was identified in the area of abuse and neglect on 06/01/17. While the IJ was lowered on 06/09/17, the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure placed all 55 residents, staff and visitors in the facility at risk for harm or injury. Findings included: Resident #11 Record review of Resident #11's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #11's MDS dated [DATE] revealed she had BIMS score of 99, Resident was unable to complete the interview. Record review of Resident #11's last Wandering Risk Scale dated 03/23/17 revealed Resident #11 had a score of 11 which indicated she was a high risk for wandering. Record review of Resident #11's Comprehensive Care Plan dated 06/13/16 revealed Resident #11 was at risk of elopement due to mental status. Resident #11 required a wander guard bracelet and staff were to check for placement every shift and monitor every 24 hours for proper functioning. Observation on 06/02/17 at 2:15pm at the front door revealed the wander guard did not alarm when Resident #11 was wheeled out the front door by a family member. Resident #11 had a wander guard bracelet on her right arm. Observation on 06/02/17 at 7:46pm at the front of the facility revealed 2 residents outside sitting on the patio and 2 resident in the lobby. One resident greeted the Surveyors Merry Christmas. No staff in the lobby monitoring residents. The Business Office was closed and the lights were off. Observation on 06/03/17 at 9:30am revealed one resident in lobby no staff in front of building. Observation on 06/07/17 at 5:45pm revealed 2 of 4 wander guard systems did not alarm when tested . The Wander Guard System was not working completely for all door for all residents. In an interview on 06/02/17 at 2:58pm the Administrator stated the wander guard system had not been working for about three weeks. The system would go in and out of working. He thought the DON was testing the system but he will try and find out. In an interview on 06/02/17 at 3:08pm the Maintenance Director stated they have been having issues with the wander guard system for about a week and a half. Some of the parts needed to be reordered due to late payments by the facility. The nurses have been locking the doors at night and during the day the business office would check on residents and make sure that anyone that was not supposed to be out the facility was outside. In an interview on 06/02/17 at 11:45am the ADON stated the nurses would check for placement of the wander guard but they did not have a system to check the wander guard daily to determine if it was working. She was going to create something today to check the wander guard system daily. In an interview on 06/03/17 at 11:58am LVN E stated the nurses checked for placement of the wander guard bracelet but she thought the Maintenance Director checked to make sure the system was working but she was not sure. In an interview on 06/03/17 at 12:00pm the Maintenance Director stated he thought the Nurse Aides were supposed to check the wander guard system to make sure it was working. He said the Administrator told him today that they were going to create something to monitor the system. The Administrator said to start documenting the checks today. In an interview on 06/06/17 at 10:40am LVN K said she was not aware that the wander guard system was not working properly. LVN K stated she was told by staff that Resident #11 was out in the parking lot. Resident #11 always goes outside a lot attempting to go to her daughter's house. LVN K said she wrote an incident report for one of the incidents and just put the other two in a progress note. She did not say why she did not do an incident report for all three. In an interview on 06/08/17 at 9:46am the Administrator said he was going to just put alarms on all the doors until they could fix the wander guard system. He said there was something blocking the signal for residents with wheel chairs. In an interview on 06/09/17 at 12:25 AM LVN K stated when a resident had an elopement the charge nurse was supposed to complete an incident report. Complete an assessment, wander risk assessment, contact the physician, administration, and the family. The Charge Nurse also completed the initial wander risk assessments for residents as well as the quarterly assessments. The Charge Nurse also would update the care plans. She did not answer why she did not complete and incident report for 2 of 3 incidents involving Resident #11 or why she did not complete a wandering risk assessment for 3 of 3 incidents of elopement attempts involving Resident #11. Record review of the staff in-service binder revealed the last in-service for elopement training was conducted on 02/16/17 and 33 staff attended the training. Record review of Resident #11's Incident Report dated 04/26/17 revealed Resident #11 was observed in the parking lot. Record review of Resident #11's Progress Note dated 05/13/17 revealed Resident #11 was observed sitting on the front porch with her clothes in her lap. The Nurse redirected Resident #11 back into the dining room for meal resident refused to eat. Record review of Resident #11's Progress Note 04/29/17 revealed Resident #11 was observed in her wheel chair going near the parking lot asking people who passed by which way do her daughter . live Resident #11 was brought back into the facility by a visitor. ****************************************************** Resident #4 Record review of face sheet for Resident #4 revealed an admission date of [DATE] with a readmitted [DATE]. [DIAGNOSES REDACTED]. Minimum Data Set was requested from facility. MDS not received prior to exit. Record review of Care Plans for Resident #4 revealed the following care plans which read in part . Resident has an activity of daily (ADL) self-care deficit related to limited mobility dated 03/20/2017. Interventions- Encourage resident to use bell for assistance. Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The resident was high risk for falls dated 03/20/2017. Interventions- Anticipate and meet the resident's needs. Be sure the residents call light was in reach. Follow facility fall protocol. The resident has chronic pain related to sacral wound and lower back pain dated 03/20/2017. Interventions- Administer analgesia as ordered by physician. Evaluate the effectiveness of pain interventions 30 minutes to 1 hour after administration. Monitor/document for probable cause of each pain episode. In an interview with Resident #4 on 06/02/2017 at 1:15 pm, he said that CNA's dropped him from the gurney lift a few days ago. Resident #4 said that he was told the cable broke from the lift and that was why he was dropped. Resident #4 said that he hit the metal arms of wheelchair and the legs of lift when he was dropped. Resident #4 said he landed on his lower back but hit his right and left hip, too. Resident #4 said the CNA's put him back in bed and the medication aide brought him a pain pill. When asked if he was assessed by a nurse, Resident #4 said the nurse did not assess him. Resident #4 said the pain pill did not help him and no one returned to check his pain status. When asked if he called for more pain medication, Resident #4 said the staff doesn't answer call lights and if they do it takes 15-20 minutes for them to answer. In an interview with CNA AA on 06/05/2017 at 5:40 pm, she said that she (CNA AA) and CNA BB were using the manual mechanical lift to move Resident #4 from his bed to his wheelchair. CNA AA said she was pumping up the mechanical lift to lift Resident #4 and the mechanical lift started lowering down. CNA AA said that she (CNA AA) and CNA BB were able to slow it down so Resident #4 wouldn't hit hard. CNA AA said he didn't hit hard. CNA AA said that Resident #4 landed on the floor between the metal legs/feet of the mechanical lift and complained of pain. CNA AA said Resident #4 complained of pressure to his lower back which he did not have prior to the fall. CNA AA said that the nurse was notified, assessed Resident #4 and he was assisted back to bed. In an interview with LVN CC on 06/05/2017 at 7:16 pm, she said that she was passing medications and heard CNA's hollering in Resident #4's room. LVN CC said she entered Resident #4's room and found Resident #4 laying on the legs/feet of the mechanical lift with the sling under him. LVN CC said Resident #4 complained of back pain but he had been medicated prior to the fall for back pain. LVN CC said she assessed Resident #4 and there was no bruising or injury and he was assisted back to bed. When asked by surveyor if physician was notified, LVN CC said she called physician's office and spoke to the Nurse Practitioner and she (LVN CC) told him that Resident #4 didn't hit hard and had no injuries and the Nurse Practitioner said ok, then and no new orders were received. When LVN CC was asked if an SBAR was completed, she said that she had not filled out a special form or an SBAR because the facility did not have any. LVN CC said she had heard about the forms but had never seen one. LVN CC said she did complete a fall assessment. In an interview with CNA BB on 06/05/2017 at 7:30 pm, she said that she (CNA BB) and CNA AA were cranking up the manual mechanical lift and heard an air shock noise the lift was lowering faster than they could crank it. CNA BB said they hurried and cranked the knob to slow down the lift and they were able to slowly get Resident #4 to his shower chair and he did not hit the floor. CNA BB said the nurse was notified and she looked at Resident #4 and he was put back into bed. CNA BB said Resident #4 complained of back pain after the fall but he had back pain already. Record review of incident report dated 05/31/2017 at 7:25 pm with a revision date of 06/02/2017 at 2:40 am read in part Called to residents room by CNA, observed resident lying on lift legs; CNA states that she was raising lift to transfer resident from wheelchair to bed and lift began to fall so CNA's lowered resident to the floor. CNA states that resident did not hit his head. Resident states that he didn't hit hard. Assessed for injury, no redness or bruising noted. Assisted into bed x3 staff members. Staff told not to use lift until checked by maintenance. Pain level 6. Record review of Nurse Note dated 05/31/2017 at 8:45 pm read in part . Called to resident's room by CNA, observed resident lying on top of lift legs on the floor. CNA states that while lifting resident the lift began to lower, therefore CNA's lowered resident to the floor. Assessed for injury, no redness or bruising noted. ROM WNL. Continue to complain of back pain as to prior to fall. Family and physician notified. In an interview with the Administrator on 06/07/2017 at 1:20 pm he said that he spoke to the nurses about assessing residents when there was a problem. The Administrator said the nurses should check the residents' history, medications and assess. The Administrator said any changes in a resident's status should be documented on the 24 hour report and passed on to the next shift. Valuable time could be lost if resident was not assessed properly when there was a change in condition or injury. Resident #18 Record review of face sheet for Resident #18 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] for Resident #18 revealed a BIMS score of 15, which indicated no cognitive impairment. MDS was not complete and did not offer any information regarding Resident #18's needs. Record review of care plans for Resident #18 revealed the following care plans read in part . Resident has an activities of daily living (ADL) self-care deficit related to [DIAGNOSES REDACTED] and stroke dated 04/17/2017. Interventions- assist resident with bathing and dressing and encourage resident to use call bell. Admission care plan dated 04/04/2017 revealed Resident #18 had left sided weakness and needed 2 person assist for bathing, hygiene, dressing, toileting and transferring. Observation and interview on 06/06/2017 at 7:50 am of mechanical lift transfer for Resident #18 provided by CNA T and CNA L revealed mechanical lift sling with a chucks pad on top of it was placed on bed next to Resident #18 and baby powder was applied to the inside of the sling and chucks pad before rolling resident over onto the sling per Resident #18's request by CNA L. A rolled up towel was placed under Resident #18's neck between her neck and the sling by CNA L. The Mechanical lift was moved to the bedside, the legs of the mechanical lift were not spread open and sling was connected to mechanical lift. Resident #18 was lifted off of the bed by the manual mechanical lift operated by CNA L. The mechanical lift was moved to the wheelchair and Resident #18 was positioned over her wheelchair. No back support or reassurance was provided to Resident #18 during transfer as CNA T was on the opposite side of the bed and not near the mechanical lift or Resident #18 during transfer. CNA L requested the assistance of CNA T because she needed assistance to lower Resident #18 over her wheelchair and CNA T grabbed handle at the back of the sling and CNA L released the hand dial which released Resident #18 quickly onto the wheelchair. Interview at same time with CNA L, she said the legs on the manual mechanical lift did not work properly so she was unable to spread the legs of the mechanical lift. In an interview with Resident #18 on 06/06/2017 at 8:00 am, she said she did not like the manual mechanical lift as it scares her. Resident #18 said that she believed the lifts at the facility are worn out and they needed new ones. Interview with CNA Ton 06/06/2017 at 9:16 am, she said that you have to use the hand crank and use the lever to pull out the legs on the manual mechanical lift. CNA T said that to lower the resident into the bed or a chair you have to use the knob and the mechanical lift sometimes drops the residents too quickly. CNA T also said that the electric mechanical lift did not work all the time. CNA T said the remote for the electric mechanical lift did not work and they would tell the nurse when it was not working and a note was put on it so no one will use it. CNA T said she could not recall if there was a maintenance log but that the CNAs would sometimes tell maintenance if the mechanical lifts were not working. Observation on 06/05/17 at 5:59 PM revealed CNA G and CNA H used the battery operated lift to transfer resident but the legs on the Mechanical lift would not close and could not move. In an interview on 06/03/17 at 4:45 PM the Administrator stated the facility had two Mechanical lifts that would be available for staff to use. In an interview on 06/05/17 at 5:20 PM the Maintenance Director stated both of the Mechanical lifts work at the facility. The battery operated lift's remote was not working but it was fixed now. In an interview on 06/05/17 at 5:59 PM CNA G said the legs on the lift would not close. Staff did not test the lift before they used it because it was being used throughout the day by other staff so they figured it worked. CNA G said the legs on the lift went out about a week ago. In an interview on 06/05/17 at 6:01pm CNA H stated when they tried to move the legs with the remote it just made a noise but the legs did not move. In an interview on 06/05/17 at 6:06pm CNA I said the legs on the Mechanical lift had been broken for a least a month. In an interview on 06/05/17 at 6:08 PM CNA J stated the legs on the Mechanical lift had been broken since she had been at the facility which was in March 2017. In an interview on 06/05/17 at 6:16 PM the Maintenance Director stated he just found out that the legs were broken on the battery operated Mechanical lift. He was going to put it out of service. In an interview on 06/05/17 at 6:27 PM CNA J stated she was never trained on how to use the Mechanical lift at the facility. In an interview on 06/05/17 at 6:29 PM CNA I stated she was never trained on how to use the Mechanical lift at the facility. In an interview on 06/06/17 at 10:15am CNA G stated she was trained on safety regarding the Mechanical lift but nobody actually did a demonstration on how to use the Mechanical lift. *************************************************** Record review of Complaint Investigation Worksheet Intake # 7 dated 05/31/17 revealed The DON would put a pink bag with a gun in it in residents' faces to intimidate and threaten them and would tell them if they did not get away from her they would find out what's in the bag. The DON called CR#1's (family member) a stupid cunt when she asked for his medication list. Upon entering the facility, local law enofcement was notified and arrived at the facility on 06/01/17 at 10:10am to investigate the allegation of the DON having a weapon in her purse. Observation on 06/01/17 at 10:12am in the DON's office revealed local law enforcement secured a loaded gun in a pink purse under the DON's desk. In an interview on 06/01/17 at 10:15am with the DON, with the Administrator present, she stated the owner of the facility knew she carried a gun in her purse and in her car. She stated she had never threatened any residents or staff members. The staff were just aware of the gun through conversations where she may have brought it up. She stated she had the gun for protection due to a shooting at another facility. The Administrator was made aware of the allegations of verbal/mental/physical abuse made against the DON. In an interview on 06/01/17 at 10:42am the Administrator stated he was not aware that the DON was carrying a gun at the facility. In an interview on 06/01/17 at 11:40am CNA A stated she heard that the DON had a gun but did not know for sure. In an interview on 06/01/17 at 11:43am CNA B stated she knew the DON had a gun. She told everyone she kept one in her purse and one in her car. In an interview on 06/01/17 at 12:02pm CNA C stated she was aware that the DON had a gun at the facility. She would tell us she had a gun in her purse and car. In an interview on 06/01/17 at 1:07pm the Administrator stated he spoke with the owner and the DON was given verbal permission to have the gun in the facility but not sure if she had written permission. In an interview on 06/01/17 at 1:14pm the DON stated she did not have written permission to have a gun in the facility. She said the police officers told her in order for her to bring the gun back in the facility she would need written permission by the owner. In an interview on 06/03/17 at 10:30am CNA D stated that the DON told her that if anything happened she had a gun in her purse that could be used on staff and the residents. She would tell residents to not make her go get her purse. She would tell staff that she kept a gun in her purse under her desk. Staff knew the gun was there and they were terrified of the DON. In an interview on 06/06/17 at 2:01pm CNA M stated the DON would yell at residents sometimes, she told one resident if she did not want to be at the facility she could be discharged and gave her a list of home health agencies. The DON was mad because the resident was telling her about an incident that occurred at the facility. That resident was no longer here. The DON was very unprofessional at times. The Administrator was notified on 06/01/17 at 2:15pm of the IJ situation due to the above failures and PoR was requested. The PoR was received and after multiple revisions it was accepted on 06/08/17 at 3:32pm. The PoR included in part: Abuse Reporting: .The DON was terminated on 06/05/17. The DON will not be allowed in this facility for any reason. Self-report for all allegations of verbal and physical abuse made against the DON was called into the DADS (Department of Aging and Disability) Hot Line .06/03/17 at 10:15am. The facility's abuse coordinator letter had been placed in all resident rooms by 06/01/17. Any new residents .admitted to the facility will be given the facility abuse coordinator letter. This was added to the admit package on 06/01/17. All residents in the facility have been interviewed to check for any type of abuse and to inform them of the facility abuse coordinator. This was completed by 06/01/17. .All staff in the building will be in-serviced on reporting abuse and who the abuse coordinator is. Staff will be informed that any and all reports need to be reported immediately no matter .All reports must be taken seriously and reported . This was started 06/01/17 and will be completed 06/05/17. All staff will be in-serviced. PRN (as needed) staff that were not available to be in-serviced (by completion date) will be in-serviced before they start their next shift. Resident/Patient Safety: One Hoyer Lift was taken out of service. A new Hoyer Lift was ordered and it is slated to be in the facility 6/7/2017. Training for Hoyer Lift operation In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. The PRN or any staff that were not available to be in-serviced will be in-serviced before they started their next shift. In-services will be completed by: The Acting DON, the ADON and LVN E. Resident/Patient Assessment - Change of Condition. Nursing staff will be in-serviced on completing a Resident/Patient Assessment for any Change of Condition. As Nurses will must be aware of any changes in the Residents . status . The Nurse must complete an assessment and report findings to the next shift. In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. PRN or any staff that were not available to be in-serviced will be in-serviced before they start their next shift . Wander Guard: Until a new wander guard system is installed and tested , as a temporary fix to our wander guard not activating 100% of the time we have placed door alarms on all doors that will sound when the door has been opened. This is effective starting today, 06/08/17. The new system will be in-place within 14 days. All staff to be in-serviced that they must go to the door to ensure that no resident/patient has went outside. This needs to be done 24 hours a day. PRN and other staff that were not available to be in-serviced will be in-serviced before they start their next shift. This will be completed by 6/8/2017 1400. In-services will be completed by: The Acting DON, and the ADON. The facility was monitored from 06/07/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Interview with different staff including nursing staff from both shifts on 06/06/17, 06/07/17, 06/08/17, and 06/09/17 revealed they had been in-serviced on reporting allegations of abuse, who the Abuse Prohibition Coordinator was, and the Abuse Neglect policy and Procedure. Interview with 15 residents on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed the Administrator had been into visit with them. He discussed what abuse and neglect meant, he told them he was the Abuse Prohibition Coordinator and placed a letter in with their TV guides. He told the residents that they should report any allegations of abuse or neglect to him but if they did not feel comfortable talking to him they could call the DADS hotline number. Record review of the Abuse Prohibition Coordinator dated 06/01/17 revealed it contained information regarding types of abuse and neglect, the Administrator was the Abuse Prohibition Coordinator, the Administrator's contact information, and the DADS Hotline number. Observations of the resident rooms selected for review revealed there was a copy of the Abuse Prohibition Coordinator letter present. Record review of in-services conducted included the abuse and neglect policy and procedure, who the abuse prohibition coordinator was, types of abuse and what to do if witnessed abuse and when to report. Interview with different staff including nursing staff from both shifts on 06/07/17, 06/08/17 and 06/09/17 revealed they had been in-serviced on the use of the mechanical lift and the new alarm system on all exit doors. Observations of two new mechanical lifts that revealed that they were in good working order and there were alarms on all exit doors that sounded when they were opened. Interview with 15 residents on 06/06/17, 06/07/17, 06/08/17, 06/09/17 revealed the Administrator had been into visit with them. He discussed what abuse and neglect meant, he told them he was the Abuse Prohibition Coordinator and placed a letter in with their TV guides. He told the residents that they should report any allegations of abuse or neglect to him but if they did not feel comfortable talking to him they could call the DADS hotline number. Record review of the Abuse Prohibition Coordinator dated 06/01/17 revealed it contained information regrading types of abuse and neglect, the Administrator was the Abuse Prohibition Coordinator, the Administrator's contact information, and the DADS Hotline number. Record review revealed staff in-services were conducted on the subjects mentioned above and 95% of the staff attended the in-services. The Administrator was informed on 06/09/17 at 10:03am that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to train the staff. The facility's CMS 672 listed a census of 55 residents.

Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition in that: The facility failed to ensure the wander guard system was working correctly. There were no documented checks that the alarm sounded when it should. Resident #11 was found outside of the facility three times in April 2017 and May 2017. The facility failed to ensure the mechanical lift was working properly. CNA AA and CNA BB dropped Resident #4 while transferring him with the mechanical lift. The facility failed to train staff on the proper use of the mechanical lift. The Facility staff did not operate the mechanical lift properly while providing care for Resident #18. An Immediate Jeopardy (IJ) was identified in the area of abuse and neglect on 06/01/17. While the IJ was lowered on 06/09/17, the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This deficient practice could affect 6 residents with wander guards and 7 residents that required hoyer lifts at risk of harm or injury. The findings were: Observation on 06/02/17 at 2:15 PM at the front door revealed wander guard did not go out when resident was wheeled out the front door by a family member. Resident had a bracelet on her right arm. Observation on 06/07/17 at 5:45 PM revealed 2 of 4 wander guard systems did not go off when tested . System is not working completely for all door for all residents. In an interview on 06/02/17 at 2:58 PM the Administrator stated the wander guard system has not been working for about 3 weeks now. The system goes in and out. He thought the DON was testing the system but he would try and find out. In an interview on 06/02/17 at 3:08 PM the Maintenance Director stated they have been having issues with the wander guard system for about a week and a half. Some of the parts needed to be reordered due to late payments by the facility. The nurses have been locking the doors at night and during the day the business office would check on residents and make sure that anyone that is not supposed to be out the facility was outside. In an interview on 06/02/17 at 11:45 AM the ADON stated the nurses check for placement of the wander guard but they don't have a system to check the wander guard daily to determine if it is working. She was going to create something today to check the wander guard system daily. In an interview on 06/03/17 at 11:58 AM LVN E stated the nurses check for placement but thinks the Maintenance Director checks to make sure the system is working she was not sure. In an interview on 06/03/17 at 12:00 PM the Maintenance Director stated he thought the Nurse Aides were supposed to check the wander guard system. The Administrator told him today that they were going to create something to monitor the system. He told me to start documenting the checks today. In an interview on 06/08/17 at 9:46 AM the Administrator stated he was going to just put alarms on all the doors until they could fix the wander guard system. He said there was something blocking the signal for residents with wheel chairs. ******************************************************* Observation on 06/05/17 at 5:59 PM revealed CNA G and CNA H used the battery operated lift to transfer resident but the legs on the Hoyer lift would not close and could not move. In an interview on 06/03/17 at 4:45 PM the Administrator stated the facility had two Hoyer lifts. In an interview on 06/05/17 at 5:20 PM the Maintenance Director stated both of the Hoyer lifts work at the facility. The battery operated lift's remote was not working but it is fixed now. In an interview on 06/05/17 at 5:51 PM family member stated why would they lift Residents in a Hoyer lift that was not working. In an interview on 06/05/17 at 5:59 PM CNA G stated the legs on the lift can not close. Staff don't test the lift before they use it because it is being used throughout the day by other staff so they figure it works. The legs on the lift went out about a week ago. In an interview on 06/05/17 at 6:01 PM CNA H stated when they try to move the legs with the remote it just makes a noise but the legs can't move. In an interview on 06/05/17 at 6:06 PM CNA I stated the legs on the Hoyer lift has been broken for a least a month. In an interview on 06/05/17 at 6:08 PM CNA J stated the legs on the Hoyer lift have been broken since she has been at the facility which was in March 2017. In an interview on 06/05/17 at 6:16 PM the Maintenance Director stated he just found out that the legs were broken on the battery operated Hoyer lift. He was going to put out of service. Record review of the Incident Log Binder revealed an incident was occurred on 04/16/17 at 2:55 PM where a resident was found outside by CNA and wander guard bracelet did not set off alarm. See F323 for further evidence of deficient practice. The Administrator was notified on 06/01/17 at 2:15pm of the IJ situation due to the above failures and PoR was requested. The PoR was received and after multiple revisions it was accepted on 06/08/17 at 3:32pm. The PoR included in part: Resident/Patient Safety: One Hoyer Lift was taken out of service. A new Hoyer Lift was ordered and it is slated to be in the facility 6/7/2017. Training for Hoyer Lift operation In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. The PRN or any staff that were not available to be in-serviced will be in-serviced before they started their next shift. In-services will be completed by: The Acting DON, the ADON and LVN E. Resident/Patient Assessment - Change of Condition. Nursing staff will be in-serviced on completing a Resident/Patient Assessment for any Change of Condition. As Nurses will must be aware of any changes in the Residents . status . The Nurse must complete an assessment and report findings to the next shift. In-services will start June 6, 2017. All employees will be in-serviced by June 7, 2017. PRN or any staff that were not available to be in-serviced will be in-serviced before they start their next shift . Wander Guard: Until a new wander guard system is installed and tested , as a temporary fix to our wander guard not activating 100% of the time we have placed door alarms on all doors that will sound when the door has been opened. This is effective starting today, 06/08/17. The new system will be in-place within 14 days. All staff to be in-serviced that they must go to the door to ensure that no resident/patient has went outside. This needs to be done 24 hours a day. PRN and other staff that were not available to be in-serviced will be in-serviced before they start their next shift. This will be completed by 6/8/2017 1400. In-services will be completed by: The Acting DON, and the ADON. The facility was monitored from 06/07/17 to 06/09/17 to verify the plan was implemented. Monitoring of PoR included in part: Interview with different staff including nursing staff from both shifts on 06/07/17, 06/08/17 and 06/09/17 revealed they had been in-serviced on the use of the mechanical lift and the new alarm system on all exit doors. Observations on 06/09/17 revealed there were two new mechanical lifts in good working order, a transfer was completed with good technique and there were alarms on all exit doors that sounded when they were opened. The Administrator was informed on 06/09/17 at 10:03am that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that is not immediate jeopardy due to the facility needing more time to train the staff. According to the CMS 672 dated 06/01/17 listed 6 residents with wandering or exit seeking behaviors and seven residents requiring mechanical lift transfers.

Based on observation, interview, and record review the facility failed to ensure 3 of 12 residents (Residents #2, #3 and #9) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: Resident #2's pain medication was not given as ordered, her pain was not controlled and her physician was not notified of the uncontrolled pain. Resident #3's catheter bag and tubing was removed by CNA Z and placed in the trash can. Resident #9 did not have a completed assessment done prior to being sent to [MEDICAL TREATMENT] nor upon return and the communication between the facility and [MEDICAL TREATMENT] center were not completed. These failures affected three residents and placed 22 residents on pain management, with an indwelling catheter and receiving [MEDICAL TREATMENT] care at risk of not receiving care and services required which could cause a decrease in their quality of life and a decline in their health status. Findings Include: Resident #2 Record review of Resident #2 ' s face sheet revealed an [AGE] year old female with an initial admitted to the facility on [DATE] and a readmitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate impairment. Resident #2 required extensive assistance of one person for bed mobility, dressing, eating, bathing and toilet use. Record review of Resident #2 ' s Care Plans dated 3/02/2016 revealed: Pain related to chronic back pain. Approaches: Monitor for signs and symptoms of pain, discomfort-assess resident for possible causes-give medications, provide pressure relieving devices, assist with comforting measures and activities of daily living, allow to verbalize pain and discomfort, assess and document pain. Resident and family refused incontinent care, therapy treatment and repositioning frequency related to chronic severe pain and spinal stenosis. Approach: provide for calm environment, approach in calm manner, speak slowly and maintain eye contact, talk while giving care and allow time for response, do not rush, encourage appropriate behavior, when refuses activities of daily living-reproach at a later time, psych consult per order, be firm when approaching resident for care, and allow resident to make decisions when she wants to participate in care, and return at the designated time to perform care. Observation and interview on 3/08/2016 at 7:08 am revealed Resident #2 was lying in bed with the head of her bed elevated at 10 degrees. Resident #2 was tearful and complaining of pain. Resident #2 said she was up all night in pain and was not being medicated as often as needed. Resident #2 ' s family member was at her bedside and said he was concerned for Resident#2 as she was unable to sleep due to the pain, He said he felt the staff was not medicating her per the physician's order [REDACTED].#2 ' s family member said Resident #2 had been at the facility for approximately 2 weeks and had yet to see the facility physician. He said he and Resident #2 had requested to meet with her physician and they were still waiting. Observation on 3/09/2016 at 9:14 am of incontinent care and indwelling catheter care for Resident #2 provided by CNA I and CNA J revealed during incontinent care Resident #2 asked staff to stop several times due to pain. Resident #2 was crying during incontinent care and stated Oh, dear God, help me . Resident #2 kept apologizing for crying and complaining of pain. Resident said her pain was 7 out of 10. Interview on 3/09/2016 at 9:30 am with Resident #2 ' s family member revealed that Resident #2 was up all night in pain. He said Resident #2 cried all the time with pain and did not believe the staff was medicating Resident #2 per physician's order [REDACTED]. In an interview with Licensed Vocational Nurse (LVN) R on 3/09/2016 at 9:32 am she said that Resident #2 had been medicated with [MEDICATION NAME] at 8:29 am prior to catheter care and wound care. When asked if Resident #2 ' s physician had been notified of her continued pain LVN R said physician had not been notified but she would call him. When asked about why Resident #2 had not been given her pain medication as ordered LVN R responded that she could not speak for other nurses but she administered her pain medication per physician's orders [REDACTED]. In an interview on 3/09/2016 at 12:25 pm Resident #2 rated her pain 8 out of 10. In an interview on 3/10/2016 at 12:40 pm with Resident #2 regarding facility food. Resident #2 said she did not have a problem with the food but she does not eat a lot of the time because she is in so much pain and rarely gets relief. In an interview at same time with RP, he said there are many times that Resident #2 doesn ' t eat due to the pain. Record review of physician order [REDACTED]. Record review of MAR (medication administration record) for February 2016 revealed Resident #2 was not administered [MEDICATION NAME] 100 mg capsule by mouth 2 times a day per physician's orders [REDACTED]. 2/19/2016, 2/20/2016, and 2/21/2016 - doses were missed at 7am and 7pm 2/22/2016 - the 7am dose was not given. Record review of MAR for February 2016 further revealed Oxyfast 20mg/ml oral concentrate was not given per physician orders [REDACTED].> 2/19/2016, 2/20/16, 2/21/16, 2/22/16, 2/23/16, 2/24/16, 2/25/16- Oxyfast was not given at all scheduled times(3:00 am, 7:00 am, 11:00 am, 3:00 pm, 7:00 pm and 11:00 pm). 2/26/2016- Oxyfast was not given at 3:00am, 7:00 am, or 11:00 am. Record review of MAR for Resident #2 dated February 2016 revealed an order for [REDACTED]. MAR indicated [REDACTED]. Record review of physician order [REDACTED]. Record review of MAR for Resident #2 dated March 2016 revealed an order for [REDACTED]. MAR indicated [REDACTED]. Resident #3 Record review of Resident #3 ' s face sheet revealed the [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 03/08/16 at 7:10 AM in room [ROOM NUMBER] revealed Resident #3 ' s catheter bag and tube were in his trashcan. In an interview on 03/08/16 at 7:10 AM LVN Q stated, the CNA Z took off his bag and put on a leg bag. In an interview on 03/08/16 at 2:10 PM the DON stated the CNAs were not supposed to be doing catheter care because it was beyond their scope of practice. The DON said she spoke with the CNA Z and she stated she took off Resident #3 ' s catheter bag and tubing because it was a dignity issue. In an interview on 03/10/16 at 10:48 AM CNA Z stated she did not see Resident #3 ' s catheter bag cover in the room so she just changed his bag to a leg bag due to not having the catheter covered was a dignity issue. CNA Z also said CNA's can perform catheter care at the facility. Resident #9 Record review of Resident # 9's clinical record revealed a [AGE] years old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review Resident #9 ' s clinical record revealed she was scheduled for [MEDICAL TREATMENT] every Monday, Wednesday and Friday. Record review of Resident # 9's Care Plan dated 12/17/2015 revealed Resident #9 was at risk for renal complications. The goal was the Resident would not have complications from [MEDICAL TREATMENT]. Interventions were to check dressing daily and monitor/document changes in level of consciousness. Record review of the [MEDICAL TREATMENT] Communication and/or Information Form post [MEDICAL TREATMENT] revealed no assessments or the time that Resident #9 returned to the facility from [MEDICAL TREATMENT]. Observation on 3/10/2016 at 8:50 am of Resident #9 in the dining room she stated she was feeling fine today and was not in any pain. In an interview on 3/10/2016 at 3:00 pm. LVN Q stated Resident #9 was not checked before or after [MEDICAL TREATMENT] due to not being something that was done at the facility. LVN Q stated she would make sure Resident #9 would have a lunch and ask if she was feeling well, but did not check her vitals before or after returning from [MEDICAL TREATMENT] in the evening. In an interview on 3/10/2016 at 3:15 pm the DON stated there was no formal assessment done when the resident leaves to go to [MEDICAL TREATMENT] or when they returned from [MEDICAL TREATMENT]. They check on them to make sure they were okay and she also said there was no nursing communication binder for residents on [MEDICAL TREATMENT]. Record review of [MEDICAL TREATMENT] Contract dated 2/14/2013 read in part, .retain written reports . and coordinate follow-up actions based on those reports. Record review of Pain Management Policy and Procedure date 2001 with a revised date of October 2010 read: Monitoring and Modifying Approaches: 1. Re-assess the resident ' s pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain . 3. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g., approved pain scales, etc.) . 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated . The facility CMS 672 listed 21 residents on pain management, three residents with indwelling catheters and one resident on [MEDICAL TREATMENT].