Every finding on record at Paradigm at the Brazos

Based on observations, interviews, 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 reviewed for storage, preparation and sanitation. -The facility failed to seal, label the contents of the packages and date when food items were opened in the refrigerator and dry storage. -The facility failed to discard expired cooked food from the walk-in refrigerator.-The facility failed remove a scoop in the flour container. These failures could place residents who received meals and/or snacks from the kitchen at risk for food-borne illness and food contamination if consumed. Findings included: Kitchen Observation on 07/29/25 at 8:15 AM revealed the following: -1 Plastic bag of cooked Spanish rice that was not labeled or dated in the walk-in refrigerator.-1 Plastic bag cooked ham chunks that was not labeled or dated in the walk-in refrigerator.-1 plastic bag of diced tomatoes that was not labeled or dated in the walk-in refrigerator.-15 8oz glasses of orange juice that was not labeled or dated in the walk-in refrigerator.-1 -25 lb box of instant food thickener that was opened, unsealed, and undated in the dry storage area. - 1 plastic bag of opened and [NAME] Crispy cereal that was not labeled or dated in the dry storage area.- 1 opened 5 lb bag of Rotini that was not labeled or dated in the dry storage area.- 1 opened 3-gallon container of vanilla ice cream that was not dated in the walk-in freezer.- 1 container of tomato soup with an expired date of 07/22/25 in the dry storage area.- 20 Liter flour container noted with scoop left in container in the dry storage area. During an interview on 07/29/25 at 8:30 AM, Dietary Aide B said all open items should be labeled and dated. Dietary Aide B said these items should be discarded because the staff does not know when the items were opened. During an interview on 07/31/25 at 4:50 PM, [NAME] E said the kitchen staff was responsible for labeling and dating food items. She said cooked food should be labeled and dated, and it should be discarded after 2-3 days. [NAME] E said the risk of not labeling and dating food was that the residents could get sick, which could lead to food poisoning. During an interview on 07/31/25 at 5:01 PM, the Dietary Manager said the expectation was for all kitchen staff to label and date open items in the refrigerator and in the dry storage areas. She also said the scoop should not be left in the flour container because it could be an infection control concern. The Dietary manager said the risk of unlabeled, unsealed, or outdated food would not be good for residents to consume because serving outdated food could cause harm and lead to food borne illness. During an interview on 07/31/25 at 5:15 PM, the Administrator said she expected the kitchen staff to label and date all foods per policy. She said food without labels or dates should be discarded. She said outdated food can cause harm and the resident can get sick. Record review of the Nutrition Services policy and procedure, dated 08/12/19, reflected, . Food Safety in Receiving and Storage It is the policy of this facility that food will be received and stored by methods to minimize contamination and bacterial growth. Procedures: Receiving Guidelines: 7. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. General food: Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents and the date it was transferred to the new container. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging . Record review of the Food and Drug Administration Food Code, dated 2022, reflected, 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .

Based on the interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately but no later than 2 hours after the allegation was made, for 1 of 5 residents (CR#1), reviewed for freedom from abuse in that: The facility failed to report to Health and Human Services suspected alleged abuse on CR#1.This failure could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. The findings included. Record review of provider investigation report revealed the following:Date and Time of the Incident: [DATE] at 6:00 PMDate facility first learned of Incident. [DATE]Date and time facility reported the incident to HHSC - [DATE] at 5:45 PMDate facility fax the investigation report to the state: [DATE]. Record review of CR #1's face sheet indicated the [AGE] year-old female resident was admitted to the facility on [DATE]. Diagnoses included, but not limited to Dementia, mood disturbance, anxiety, hypertension, kidney disease stage 3, muscle weakness, Alzheimer's disease with late onset, cognitive communication disorder, history of falling, and difficulty in walking. Record review of CR #1's MDS dated [DATE] revealed no BIMS score but documented a memory problem with a severe cognitive impairment. Maximally assisted with ADLS, wheelchair dependent with 2 or more persons assisting. Record review of the Care Plan (revised [DATE]) for CR #1 revealed the resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia, long-term memory loss, Psychotropic drug use, and short-term memory loss. Interview with Resident #26 on [DATE] at 1:15 pm. stated the staff are great, no concerns, only one staff member who was working today was rude to her, but she had been written up. She stated the staff member could not give her pain medicine on time as the doctor has prescribed it. Th resident stated she had pain in my shoulder, back, and leg. But overall, she was fine and satisfied with the services here. Se stated she had not been abused or neglected. She was independent; and did all her stuff by herself. She stated the incident involving CR#1, she reported it to the administrator the next day. What happened was she was playing at a table and CR#1 was sitting in her wheelchair next to her table, she had been sitting there for a long time, CNA A came to get her, she yelled at her to mind my business, she pushed CR#1 too fast to her room. Resident #26 stated she felt she was being abused. I told the administrator about it the next day and when CR#1's RP came she told her about the incident. The resident stated she also told the Ombudsman. They never came until after CR#1 died in the hospital. But CR#1's death was not a result of the abuse. Telephone interview with CR#1's RP on [DATE] at 3:26 p.m., she said CR #1 passed on [DATE] from complications of pneumonia in the hospital. There was an incident that happened at the facility before CR #1 was transferred to the hospital. She stated she did not hear about it until they visited the facility, and one of the residents who always looked after CR #1 told them CNA A abused CR #1 by pushing her so forcefully. The facility did not notify her. She said she was taking CR #1 to change her. She pulled on CR #1, she was screaming, she guesses CNA A was frustrated with CR #1which was why she was forcing on CR #1. The administrator did not tell me about, CR#1's RP stated she asked the administrator, and she was told an investigation was started, but she did not want to tell me until she had finished her investigation, so she would have something to tell. CR #1 stated there was no bruise on CR #1 but was told the incident happened on [DATE] but was notified about it on [DATE]. Interview with Administrator on [DATE] at 1:25 pm. Said CR#1, is no longer in this facility. She had a change in condition and was transferred to the hospital on [DATE] hospital, where she finally died of natural death. On the incident that happened while she was in this facility, I came to work on Monday around noon, a resident by the name resident #26 came to me and told me that a resident was physically abused on Sunday late afternoon by a CNA A. She said that CR#1, was trying to stand up from her wheelchair, and CNA A forcefully pushed her back in the wheelchair. I asked her if she had told any staff, and she said no. I started an investigation immediately and removed the employee from the schedule pending investigation. After investigation, it was undetermined if staff abused the resident. Training on abuse/neglect was done on [DATE], and every month/PRN, last done on [DATE]. Examples of abuse are physical, mental, verbal, financial, and sexual. An example of neglect is not changing the residents or not providing care. She stated that she had not witnessed any abuse before. If there is any suspected abuse, all staff report to her, and she starts an investigation immediately.In another interview with Administrator on [DATE] at 4:57 pm. She said the incident happened on [DATE], knew about it on [DATE] through resident #26, and it was reported to HHSC on [DATE] at 5:45 p.m. She stated that, there was nothing to corroborate any signs of abuse. No signs of injury, no change in behaviors. The facility's process of reporting abuse is that investigation is started, to make sure the facility had done something about it, to make sure it was taken care of. The facility's investigation did not reveal that any abuse had happened. She even interviewed residents. She saw CR #1's RP that Tuesday or Wednesday and told her about the allegation. The administrator did not answer the question for reporting abuse timely. She said what was more important is that we started our investigation right away. Additional harm can happen. There was no intent to not report. Risk to the resident when RP was not notified of abuse. Potentially harm could come to the resident. Telephone Interview with ADON on [DATE] at 9:50 am., she stated she worked PRN at this facility and has not been there in the past 45 days. She stated the incident involving CR#1, she cannot remember everything; however, a regular head-to-toe assessment of CR#1 was conducted during that period of alleged abuse. The facility has a process in place that, whenever suspected abuse is reported, an assessment is performed. The facility completed a completed a head-to-toe assessment on CR#1, no physical injury found. Whenever there is a suspected or an allegation of abuse, an investigation is started. If it is resident-to-resident, the resident is removed, or staff-to-resident, the staff is removed from the care; the administrator, NP, and RP are notified. The allegation is also reported to HHSC within 2hours to 24 hours. The risk of not reporting to HHSC will be that the residents will continue to get harmed from the abuse. The risk of not notifying the resident RP is that the RP will not be aware and will not help the resident to make an informed decision at that time. ADON stated she had received in-service for abuse and neglect; the last in-service was last month, June. Examples of abuse are physical, verbal, emotional, and sexual. An example of neglect is the failure to provide care. If there is any suspected abuse, it is always reported to the administrator. A record review of the facility's policy on abuse, neglect, and exploitation revealed the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Component IV: Identification1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect.Types of abuse include BUT ARE NOT LIMITED TO:B. Mental abuse: 1) Humiliation 2) Harassment3) Threats4) Punishment or deprivation5) Intentional disrespect or disregard for an individual's right to privacy and dignity as it relates to their person and property. Component V: Reporting/ResponseAll alleged violations concerning abuse, neglect, or misappropriation of property are reported immediately but no later than 2 hours after the incident occurs or is suspected.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (B Hall) of 3 halls reviewed for environment. -The facility failed to ensure the B Hall did not have a strong odor of urine. This failure could place residents at risk for a diminished quality of life. The findings included: Observation on 11/29/2023 at 10:10 a.m., revealed a strong odor of urine in B Hall. Observation on 11/29/2023 at 10:29 a.m., revealed a strong odor of urine in room B-12. In the corner of the room and along the side of the wall where the window was located, the floor was stained a medium to yellowish-brownish color. The floor tile in the corner of the room was warped and appeared to begin detaching from the floor. Observation on 11/30/2023 at 8:00 a.m., revealed a strong odor of urine in B Hall. In an interview on 11/30/2023 at 9:34 a.m., the DON said the resident in room B-12 urinated on his bedroom floor and in his trashcan. She said staff took him to the restroom every 2-3 hours, but he had dementia and Alzheimer's. She said sometimes he used the restroom and sometimes he did not. In an interview on 11/30/2023 at 11:06, the Interim Administrator said she had been working at the facility for 2 weeks. She said she occasionally noticed an intermittent odor of urine in the building. She said it was her understanding there was a resident who had a behavior of urinating in his room. She said she was going to follow-up with corporate to see if the tiles could be replaced and it was already in process. Record review of the facility's Environmental: Resident's Room, Resident's Right policy, revised 06/2019, revealed in part .13) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public .

Based on observation, interview, and record review, the facility failed to be designed or equipped to assure full visual privacy for 1 (room [ROOM NUMBER]) of 6 residents' rooms reviewed for visual privacy. -The facility failed to provide a complete window covering to ensure Resident #1's full visual privacy. This failure could have placed residents at risk of exposure while care was being provided. The findings included: Record review of Resident #1's Admission Record, dated 11/29/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), type 2 diabetes mellitus (high blood sugar) without complications, history of falling, peripheral vascular disease (condition that affects the blood vessels outside of the heart and brain), and zoster (shingles) with other complications. Record review of Resident #1's quarterly MDS assessment, dated 10/06/2023, revealed a BIMS score of 0, indicating a severe cognitive impairment. Further review revealed resident was dependent with toileting, showering/bathing, and dressing. Record review of Resident #1's care plan, undated, revealed he had ADL self-care performance deficits. Resident #1 was a two-person total assist with bathing and transferring and a one-person total assist with bed mobility, dressing, and toileting. Observation and interview on 11/29/2023 at 10:11 a.m., revealed Resident #1 was sitting in his wheelchair watching television. The resident's bed was located next to the bedroom window. The window had a set of mini-blinds that was missing the bottom half of the plastic slats. On the other side of the window was a view to the outside of the facility. Resident #1 was able to answer questions with a yes and/or no. He said yes he was doing okay. He said yes they helped changed his brief and changed him when he was lying in bed. In an interview on 11/29/2023 at 4:16 p.m., the Maintenance Supervisor, said she had been working at the facility for approximately [AGE] years. She said one of her job responsibilities was to maintain the window coverings in the residents' rooms. She said she replaced the mini-blinds as soon as she could. She said the facility used a computer platform system to enter and track maintenance work orders. She said she did not know when the last work order to replace Resident #1's mini-blinds was last submitted but the blinds were last changed approximately 4 months ago. She said the last time she changed them was because she noticed they were missing some of the plastic slats. She said no one brought it to her attention that they needed to be replaced again. She said the facility's policy was for staff to submit a work order through the computer platform system. She said no work orders were submitted in the past 4 months to replace any mini-blinds for any of the residents. She said a resident not having a full covering on their window could potentially create a privacy and dignity issue for them. In an interview on 11/30/2023 at 7:24 a.m., CNA A said she had been working at the facility since January 2023. She said she worked with Resident #1 before and knew the mini-blinds in his bedroom were messed up. She said she did not recall when she first noticed they were missing the plastic slats. She said she did not report it to anyone because she thought maybe someone else maybe had reported them. She said she did not check with other staff members to see if someone reported the blinds were messed up and/or if a work order was submitted. She said work orders were submitted through a system that was through their online computer system. She said the work order got sent to the Maintenance Director once it was entered. She said Resident #1 required maximum assistance with toileting and it was provided to him while he lied in bed. She said the potential risk to a resident when there was not full visual privacy on their window was it could affect their privacy. Record review of the facility's Environmental: Resident's Room, Resident's Right policy, revised 06/2019, reflected in part .It is the policy of this facility that the facility provides the resident with an environment that preserves dignity, privacy and contributes to a positive self-image .5) Each resident bedroom must be designed or equipped to assure full visual privacy for each resident. a. Full visual privacy means that residents have a means of completely withdrawing from public view, without staff assistance, while occupying their bed (e.g. curtain, moveable screens, private room) .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for the mini storage area in the kitchen. The facility failed to treat the facility gnats. This failure could affect all 38 residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: Observation on 5/30/23 at 8:39am revealed a group of gnats in the mini storage area of the kitchen flying around the wall. Inside of the mini storage area were dry seasoning, four pack of open napkins and 1 gallon of white distilled vinegar not completely sealed. Observation on 5/30/23 at 8:52am revealed gnats around the dirty vent area of the ceiling. During the interview on 5/30/23 at 8:25am with DM, she said she did not notice the dirty hanging vent in the mini storage area at all until the investigator brought it to her attention. She said if the dirty vent was not reported it could cause an infection control problem. She said she did notice the gnats flying around in the mini storage area. She said on 5/17/23, the exterminator for bug control came out to do monthly maintenance. During the Interview on 5/31/23 at 12:30pm an Interview with Maintenance Supervisor, she said when someone has placed a ticket in the maintenance book she would immediately respond unless a part is needed and not available. She said she check the maintenance log at least 3 or 4 times a day. During the Interview on 5/31/23 at 2:15pm with Dietary Aide, she said she never noticed any gnats in the mini storage area. She said she notice the dirty vent in the mini storage area sometimes. She said the Maintenance Supervisor would sometimes come around and clean once she noticed that the vent was dirty. She said the vent in the mini storage area had been replaced two times, but she could not remember when. During the Interview on 5/31/23 at 2:32pm an Interview with DM, she said the maintenance person come to the kitchen and change the filters for the vents. She said she did not notice the dirty hanging vent in the mini storage area at all until the investigator brought it to her attention. She said if the dirty vent was not reported it could cause an infection control problem. She said she did notice the gnats flying around in the mini storage area. During the Interview on 6/1/23 at 8:41am an Interview with Administrator, she said if the vent was not cleaned based upon the outcome of the gnats being inside of the mini storage the remanence of the insects could get inside of the food worst case scenario. She reported there have not been an ongoing issue of any insects but if so, the pest control person would come out. Review of the facility maintenance log revealed: 4/17/23 was the latest date of treatment for gnats. Review of the Policy for Pest Control dated 6/2019 revealed: it is the policy of this facility that the facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. Review of the Policy for Environmental: Resident's Room, Resident's Rights dated 6/2019 revealed: read in part: .(13) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Review of the facility paper Repair Requestion dated 5/30/23 from the kitchen requesting the vent to be cleaned in the mini dry storage area.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #12) of 6 residents observed and reviewed for medication administration. -MA A dispensed five medications for Resident #12 and presented them to the resident for administration. Resident #12 had already received the medications. -LVN B had administered Resident #12's medications earlier but did not document in the MAR. The failures placed residents at risk for overmedication and the complications related to overmedication. Findings include: Record review of the Admission Record for Resident #12 (printed 05/31/2023) revealed he was [AGE] years old, admitted to the facility on [DATE]. He was listed as being his own Responsible Party. Diagnoses included, but were not limited to, chronic kidney disease with dependence on renal dialysis and hyperlipidemia (high volumes of water-insoluble molecules). Record review of the quarterly MDS dated [DATE] revealed Resident #12 scored 15 of 15 on the BIMS, indicative of intact cognition. Record review of the Care Plan dated 10/27/2022 revealed one 'Focus' reflected Resident #12 had chronic renal/kidney failure. The 'Goal' was reflected as the resident would not have any complications related to fluid deficit or overload. One 'Intervention' was reflected as administering medications as ordered by the physician. Record review of the Physician's Order Summary Report (printed 05/31/2023) revealed Resident #12 was to receive dialysis treatments on Mondays, Wednesdays, and Fridays. The Orders reflected the resident was to receive one tablet of enteric coated aspirin (81 mg) daily related to high blood pressure. He was to receive three tablets of Sevelamer Carbonate (800 mg) on dialysis days for his kidney disease. The Orders reflected he was to receive Clopidogrel Bisulfate (75 mg) daily related to the acquired absence of one of his left fingers. The Orders reflected he was to receive Midodrine Hydrochloride (10 mg) on dialysis days to address low blood pressure during dialysis. In addition, Resident #12 was to receive one tablet of Multivitamin with minerals. Observation and interview on 05/31/2023 at 7:14 a.m. revealed MA A outside of Resident #12's room. She was standing by the medication cart. She said she was going to dispense the morning medications for Resident #12. MA A entered Resident #12's room. Resident #12 was awake, sitting in a wheelchair. MA A obtained his blood pressure and pulse. She then returned to the medication cart in the hall. Observation revealed she dispensed one 81 mg tablet of enteric coated aspirin, three 800 mg tablets of Sevelamer Carbonate, one 75 mg tablet of Clopidogrel Bisulfate, one tablet of Multivitamin with minerals, and four 2.5 mg tablet of Midodrine Hydrochloride. She acknowledged to the surveyor that she had a total of 10 tablets in a medication cup. Observation revealed none of the five medications had been signed as been administered on the electronic MAR for Resident #12. They were highlighted in yellow, indicating they were within the administration time window, but not yet administered. Continued observation revealed MA A entered Resident #12's room. She offered the medications to Resident #12. Resident #12 informed her that LVN B had already administered the same medications. MA A did not administer the medications. She returned to her medication cart and placed the medication cup into the drawer. They were later properly discarded. Observation and interview on 05/31/2023 at 7:25 a.m. revealed LVN B was in an adjacent hallway with a different medication cart. LVN B said she had administered the same medications to Resident #12 earlier that morning, because he was going to dialysis. She said she had not initialed in the electronic MAR that they had been administered. She said that she was not able to initial in the electronic MAR because the screen was not 'yellow' at the time, which would have indicated the one-hour time frame was in effect. At that time, LVN B displayed the electronic MAR for Resident #12. The five morning medications were highlighted in yellow, indicating they were within the administration time window, but not yet administered. LVN B began initialing the medications as been administered. LVN B again verbalized she had administered the medications. Interview on 05/31/2023 at 7:36 a.m. with the DON revealed she said sometimes Resident #12 would ask for his medications early on dialysis days. She said if LVN B was not able to initial the medications as administered when she gave them, it would indicate they were given outside of the time frame of the order. She said that if LVN B would have initialed the medications as been given, MA A would have known they were already administered. She said the resident could have received extra medication if he was not able to tell MA A he had already received them. Record review of the facility policy Administration of Drugs (revised June 2019) revealed .10. The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication. 11. The nurse administering the medications must initial the resident's MAR.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs (in the presence of adverse consequences which indicate the dose should be reduced or discontinued/for excessive duration/without adequate indications for use/duplicate therapy), for 2 of 12 residents (Resident #39, #20) reviewed for unnecessary [CONDITION(S)] medications. Resident #39 was started on antipsychotic [MEDICATION(S)] (for [CONDITION(S)]) without adequate indication for its use. No monitoring of behaviors and adverse consequences or effectiveness noted. Resident #20 was receiving antipsychotic [MEDICATION(S)] for dx of anxiety disorder and [CONDITION(S)] disorder without adequate indications for continuing the same dose. These failures could place residents who receive psychoactive medications at risk of receiving medications without adequate monitoring or indications for use and decline in physical and mental health status. Findings included: Resident #39 Record review of Resident #39's clinical record revealed an [AGE] year old male admitted to facility on 3/29/22 with diagnoses of mild cognitive impairment, anxiety disorder, major depressive disorder, single episode, [CONDITION(S)] and adult failure to thrive. He required 1 staff limited assist with ADLs. Record review of Resident #39's admission MDS assessment, dated 4/04/22, revealed anxiety and depression other than [CONDITION(S)] as active diagnoses. No [CONDITION(S)] disorder. No psychotic disorder and no [CONDITION(S)] diagnoses, indicating he did not have these diagnoses. Mood interview score 0, noted no thoughts that he would be hurting himself in some way and he did not feel bad about himself. No hallucination or delusion. No rejection of care behavior. He usually made himself understood and usually understand others. Record review of Resident #39 's Physician Order, dated April 07, 2022, revealed to start [MEDICATION(S)] 12.5 mg tab po three times a day for [CONDITION(S)]. Record review of Resident #39's Hospital Notes, dated 3/11/22, read in part, discharge plans: Caregiver will verbalize 100% understanding of effective strategies for interacting with the mild cognitive impairment . dementia, malnutrition, [CONDITION(S)], depression, anxiety. Record Review of Resident #39's care plan dated 3/29/22, revealed document/report any adverse reactions of [CONDITION(S)] meds, with impaired cognition due to dx dementia. He had the potential for mood problems due to dx dementia, depression, and anxiety. Keep his routine, provide consistent care givers. Record review of Resident #39's Psychiatric Initial Assessment note dated 4/07/22 read in part, Start pt on [MEDICATION(S)] 12.5 mg TID with a given diagnosis of major depression, with [CONDITION(S)]. Targeting Symptoms: Extreme anxiety, fear, depression, vague suicidal ideation, seen things, hearing voices. Record review of MAR/TAR, dated April 2022, revealed Resident #39 was started and received [MEDICATION(S)] 12.5 mg 1 tablet po TID, for [CONDITION(S)], start date 4/07/22. No monitoring of behaviors or adverse consequences and effectiveness recorded on the TAR. Record review of Resident #39's informed consent for Psychoactive Medication, dated 04/07/22, revealed the proposed course was for prolonged treatment, dx [CONDITION(S)]. Record review of Resident #39's Physician Progress notes dated 3/30/22 read in part, dx with adult failure to thrive, [CONDITION(S)], dementia, transferred to facility for long term stay .General: Awake, Alert, Pleasant .Assessment/Plan, Confusion: pleasantly confused, Dementia, supportive care. Record review of Resident #39's Nurses Progress notes dated 3/30/22 read in part, came in building with son, assessed by primary nurse, appears happy, calm, and relax at present time .previous job was schoolteacher for [AGE] years, will repeat [NAME] and [NAME] over and over per son. Record review of Resident #39's Psychiatric Initial Assessment notes dated 4/07/22 read in part, Previous Psychiatric hospitalization : None, however, pt did not endorse any plan or intent to kill himself. Pt is poorly attentive due to his extreme anxiety and fear. He is limitedly verbal . Suicidal Ideation: No plan, Homicidal Ideation: None, Risk of Aggression: None. Denied history of trauma. During observation on 4/13/22 at 10:00 am found Resident #39 calm and pleasantly confused, and required supervision to limited assist most ADLs. During Interview on 4/14/22 at 10:45 CNA D stated she had not seen Resident #39 fearful or anxious since admit, except he did not like wet brief, and need staff to timely help pull down his brief when he wanted to use bedside commode, but not anxious. She stated he was not limited verbally but knew what he wanted and specific with what he needs and was no harm to self or others. , During Interview on 4/14/22 at 10:55 am Activity director stated Resident #39 was active, participates and attentive throughout any activity he joined, with no aggressive behavior. She added she had not seen him irritable or anxious since admit but talked to residents and staff. She stated he was no harm to himself or others but pleasantly confused. During Interview on 4/14/22 at 9:30 am the DON stated will follow-up and ensure antipsychotic medications have adequate indications for its use. During Interview on 4/14/22 at 11:30 am with ADON revealed residents on antipsychotics are required to have behavioral monitoring sheets that are used each shift. Behavior monitoring sheet for Resident #39 was requested from ADON on 4/14/22, none was provided prior to exit. Resident #20 Record review of Resident #20's clinical record revealed a [AGE] year-old male admitted to facility on 5/25/21. His diagnoses included polyneuropathy, anxiety disorder, [CONDITION(S)] disorder, dementia without behavioral disturbance, history of falling, cerebral infarction, mild cognitive impairment and history of falling. Record review of Resident #20's consolidated Physician Order dated April 2022 revealed give [MEDICATION(S)] ([MEDICATION(S)]) 200 mg 1 tablet po q HS for [CONDITION(S)] disorder, and [MEDICATION(S)] 25 mg 1 tablet po q am and q pm for anxiety disorder and [CONDITION(S)] disorder, start date 12/13/21. Record review of Resident #20's care plan dated 5/25/21, revealed he had impaired cognitive function or impaired thought processes. Cue reorient and supervise as needed. To educate on why my behavior was inappropriate. Record review of Resident #20's quarterly MDS, dated [DATE], revealed [CONDITION(S)] and anxiety disorder as active diagnoses. No depression other than [CONDITION(S)]. No psychotic disorder and no [CONDITION(S)] diagnoses. His total BIMS score 14 of 15, indicated intact cognitive status. No hallucination, delusion, or [CONDITION(S)]. He received antipsychotic, antianxiety and antidepressant medications routinely for 7 days. Record review of Resident #20's informed consent for Psychoactive Medication, dated 12/13/21, noted specific condition to be treated feeling useless and talking to self. The beneficial effects expected, feeling important. Proposed course of the medication was for prolonged treatment. Record review of Resident #20's behavior monitoring dated December 2022, January 2022, February 2022, March 2022 and April 2022 revealed no behaviors noted. Record review of Resident #20's Psychiatric Assessment Note dated 3/16/22 revealed Psychiatric Hx. Unable to explain his [CONDITION(S)] .Malingerer (exaggerates or fake illness), [CONDITION(S)] disorder, [CONDITION(S)], anxiety disorder, mild cognitive impairment. Includes: [CONDITION(S)], depression. Further review noted no GDR conducted on Current [CONDITION(S)] Meds: [MEDICATION(S)] 0.5 mg tab TID, start date 9/05/21, [MEDICATION(S)] 200 mg tab q HS, start date 9/28/21, [MEDICATION(S)] 25 mg BID, start date 10/18/21, [MEDICATION(S)] 10 mg daily, start date 10/04/21 Record review of Resident #20's Psychological Progress Note dated 4/08/22 read in part, Psychomotor: Lethargic. Further noted dx. [CONDITION(S)] disorder, dementia without behavioral disturbances .Trauma Screening: Negative, Suicidal: None, Homicidal: None, Aggressive behavior: None, Attention: Average. During interview with LVN C on 4/14/22 at 10:30 am revealed the Resident #20 likes to go to an empty room but does not have behaviors. During interview on 4/14/22 at 10:50 am, CNA D stated that Resident #20 would not bother other residents although he likes to go an empty room, and had not seen any aggression verbal or physical, since his admit a year ago. During interview on 4/14/22 at 10:55 am, Activity director stated Resident #20 had no altercations with any resident or staff, with soft low voice. He likes to join parties, listen to music, outside patio, chews tobacco and watch western movies. Record review of Resident #20's Psychiatric Assessment notes dated 12/20/21 read in part, Denied non-compliance/[CONDITION(S)]. He denied auditory/visual hallucination, Pt with slow/ soft speech. Able to answer questions coherently. Psychiatric Hx. Malingerer (fake or exaggerates illness), [CONDITION(S)], [CONDITION(S)], anxiety disorder, mild cognitive impairment. Record review of Resident #20's Psychiatric Assessment notes dated 01/03/22 read in part, Pt in common room. Denied non-compliance/[CONDITION(S)]. He denied auditory/visual hallucination, Able to answer questions coherently. Pt denied increased anxiety or depression. Staff did not notice any acute changes of mood or behavior. Record review of Resident #20's Psychiatric assessment dated [DATE], noted Psych Hx. Unable to explain his [CONDITION(S)] .Malingerer (exaggerates or fake illness), [CONDITION(S)] disorder, [CONDITION(S)], anxiety disorder, mild cognitive impairment. Further noted Denied bizarre thoughts. Stated comfortable taking his meds. Very briefly with soft slow speech. Per staff no reported changes in mood or behavior. Pt himself moved back to his room. During Interview on 4/14/22 at 9:30 am the DON stated will follow-up and ensure dose reduction conducted for antipsychotic medications and have adequate indications for its use. Record review of the facility provided policy on [CONDITION(S)] Management, dated January 2022, reflected, . Anti-psychotic medications are appropriate for the following diagnoses and other indications . [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], or [CONDITION(S)]. Anti-psychotic meds are not used if one or more of the following is/are the only indication wandering .impaired memory .anxiety .unsociability .indifference to surroundings .nervousness. Each resident entire drug/med regimen is managed and monitored to promote or maintain resident highest practicable mental, physical and psychosocial well-being.

Based on observation, record review, and interview, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one of one resident reviewed for enteral nutrition (Resident #1) in that: The facility staff did not label or add a resident's name, room, date, start time, and rate to Resident # 1's tube feeding formula. LVN D failed to administer Resident #1's enteral feeding order according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] These failures could place residents who obtain enteral feedings at an increased risk for receiving expired enteral feeding formula, not receiving the correct quantity of enteral feeding formula, and/or nutritional imbalances. Findings included: Record review of the admission sheet for Resident #1 revealed a [AGE] years old female admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admission MDS dated [DATE], revealed the BIMS score was 9 out of 15, which indicated moderately impaired cognitively. She was total dependent from one person staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Further review of the MDS section K0510 revealed Resident was coded for having a feeding tube. Record review of Resident #1's Care plan initiated on [DATE] revised on [DATE] read in part: .Focus-PEG TUBE FEEDING: I have a peg tube and require assistance to eat. Goal-I will remain free of side effects or complications related to tube feeding through review period. Intervention- Turn feeding off 2 hours before meals and then turn feeding on after meals . Record review of Resident #1's MAR for the month of [DATE] for the order Enteral Feed After meals turn feeding on after meals at 0830 was coded 8 meaning =Other / see progress notes by LVN D on [DATE]. Record review of Resident #1's nurses notes dated [DATE] at 11:26am written by LVN D was documented late. The note did not indicate anything else. Observation and interview on [DATE] at 9:11a.m, revealed Resident #1 was lying in bed, head of bed was elevated. Enteral feeding formula [MEDICATION(S)] 1.2 was hung. The pump was turned off. There was 600ml formula left in the bottle. There was no resident's name, room, date, start time, and rate observed on the enteral feeding bottle. Resident #1 pointed to the enteral feeding formula and said that was her food. She said she did not know when it was supposed to be turned on. The nurses handle that. Resident #1 said she did not remember if she had her breakfast this morning. Observation and interview on [DATE] at 9:21 a.m., observed Resident #1's enteral feeding formula [MEDICATION(S)] bottle with LVN C. She confirmed the bottle was not labeled with the resident's name, room, date, time it was started, and rate. LVN C stated the bottle should have been labeled with Resident's number, date and time it was started to make sure it was for the correct resident. She said that information and [MEDICATION(S)] was good for 24 hours. She said the bottle of enteral feeding formula was started the night before by the night shift nurse. In an interview and record review on [DATE] at 11:02a.m, with LVN D, he said he worked last night and was asked to work double the morning shift as well today. He said he forgot to date/label the feeding formula bottle. He said LVN C brought it to his attention. He said, it is labeled now. It was missed. He said he knew he had to label the formula and it should include the resident ' s name and room number, the formula type and rate, the date and time of administration and the nurse ' s initials. He said before administering feeding formula he had to make sure it was a right resident, right formula, right tube and match the formula and the rate to the resident's order. He said Resident #1 was failure to thrive. LVN D said he did not know if she had her breakfast and how much she consumed. He would have to ask the aide. He said the nurses were responsible for monitoring if tube feedings were labeled correctly. Surveyor reviewed Resident #'1s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the breakfast was served between 7am to 8am. LVN D said he turned the feeding pump off at 6:00am this morning. He said it was supposed to be turned on at 10:00am. He said, I forgot to turn it back on. I will take care of that right now. LVN D said it was important to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview and record review on [DATE] at 12:05p.m., with the DON, the DON reviewed Resident #1's MAR/physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the breakfast was severed between 7:15am to 7:30am. She said the pump should have been turned on by 9:30am. She said she would notify the doctor that the pump was not turned back on and try to get an order to fix it. She said nurses brought it to her attention that the feeding formula was not labeled/dated. The DON said labeling and dating the formula at the time it was hung ensures safe medication administration. She said LVN D was an agency nurse. She said ambassadors made rounds each morning to look for those things. She said she was busy with Surveyor this morning that was why she did not make her rounds, but other managers/nurses should have. Record review of facility's Enteral Feeding: Ready-to-Hang policy (revision date: [DATE]) read in part: .procedure-4. Fill in information on label (resident's name, room, date, start time, and rate). Also mark the feeding set with the start time . Record review of facility's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 Residents (Resident #1) reviewed for infection control, in that: -Disposal containers for soiled Personal Protective Equipment were not available in the room for Resident #1 who was on droplet precautions. This failure affected one resident and placed her at risk for cross contamination and infection due to staff not having an appropriate disoposal point for contaminated PPE. Findings Include: Record review of the face sheet for Resident #1 revealed she was a 74- year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident # 1 had a BIMS score of 12 out of 15 indicating moderate cognitive impairment. Resident # 1 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She was totally dependent on staff for bathing. She was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #1's undated comprehensive care plan revealed she was on droplet precautions for pneumonia. During observation and interview on 05/14/2020 at 11:00 a.m. MA B donned PPE to enter Resident #1's room. Further observation of the room revealed no biohazard disposal receptacles located inside the room. No receptacles were observed outside the room. MA B said she did not see any biohazard disposal receptacles in the room. MA B kept the PPE on there until a bin could be brought to her. During interview with CNA D on 5/14/ at 11:15 a.m., she said the biohazard containers were not in the room when she provided ADL care for Resident #1 the morning of 5/14/20 (no time was specified). She said she placed the contaminated items into the red and yellow bags and removed the bags from the room and disposed of the biohazard bags in the appropriate area. She said she forgot to inform the nurse of the biohazard disposal receptacles not being inside the Resident's room. During observation and interview at 11:20 a.m. the Unit Manager transported clean biohazard disposal receptacles to Resident #1's room. She said the disposal containers were in the room when she provided treatment this morning. She said she was not sure why they were not in the room now. She said staff removed the disposal containers after the containers were full. During interview with the DON on 5/14/2020 at 11:27 a.m. she said the Resident Ambassadors were to monitor if the biohazard disposal containers were inside the Residents' rooms and available for use. She said she had to verify if the ambassador reported no biohazard disposal container in the room, when asked. During a follow-up interview at 11:30 a.m. on 5/14/2020 the DON said Resident #1 did not have an ambassador assigned and CNA D and the Unit Manager were supposed to monitor if the biohazard containers were inside the Resident's rooms and available for use. She said CNA D told her the disposal containers were not there, but she used red and yellow bags. She said the nurse and CNA should have checked and verified if the biohazard disposal receptacles were inside the Residents' rooms and available for use. Record Review of the facility Policy on Regulated medical waste management revised 2/2018 revealed it did not address proper disposal of PPE. Record review of the facility undated policy, Infection Prevention Surveillance, also revealed it did not address disposal of PPE.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility on shared medication rooms (used by halls A,B and C) were secured and labeled properly in that: - Medication room had Influenza Vaccine and [MEDICATION NAME] Purified Protein Derivative vials that were open and not dated in the refrigerator. This failure placed residents at risk of not receiving the therapeutic dosage of medications needed. Findings Include: Observation on 11/20/19 at 4:30 p.m. revealed the medication room refrigerator used by halls A,B and C had the following medications that were opened and not dated: -Influenza Vaccine ( [MEDICATION NAME] Quadrivalent) lot , 1 vial open and no date - [MEDICATION NAME] Purified Protein Derivative, lot 5 ,1 vial open and no date In an interview with LVN G on 11/20/19 at 4:50 p.m. regarding medications opened and not dated, she said staff were supposed to write dates on them when opened. In an interview with DON on 11/21/19 at 11:20 a.m. she said nurses were supposed to write dates when the vials were open. The DON did not have any system in place on monitoring opened a multi-dose container. Record review of the facility's Administering Medications policy and procedure,( Revised 10/28/ 2019) read in part : . Policy interpretation and Implementation . The expiration/beyond use date on the medication label must be checked prior to administering. When opening , a multi-dose container, the date opened shall be recorded on the container .If a multi-dose vial of an injectable medication has been opened or accessed ( e.g., needle -punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different ( shorter or longer) date for that opened vial .

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen in that: - Dry storage room was not free of dented cans. - Foods that were expired were stored with unexpired foods. - Soiled pans and bowls were stored with clean pans and bowls. - Table mounted can opener with greasy black stuff. These failures has the potential to affect all residents who ate food prepared by the kitchen and could placed them at risk of food borne illness and disease. Findings include: Observation on [DATE] at 06:50 AM of the kitchen revealed the following: Two gallons bottles of whole milk with an expiration date of [DATE] One gallon bottle of 2% milk about half full with an expiration date of [DATE] One bottle of mustard with best used date of [DATE] One container of Ricotta Cheese with expiration date of [DATE] Observation at 7:05 AM of the kitchen revealed the following: The table mounted can opener had greasy sticky black substance on it. Clean Muffins pans had dried food particles in them. Clean bowls had dried food particles in them. Observation at that time revealed that the DM removed the muffin pans, can opener and bowls and send them to be rewashed. Observation on [DATE] at 7:15 a.m. of the dry storage room revealed dented cans of stew tomatoes, and baked beans. Observation and interview on [DATE] at 7:20 AM revealed the dented cans were brought back to the kitchen and stored with other dented cans. Interview at that time with the DM revealed she has a special area for dented cans. Observation on [DATE] at 9:15 a.m. of the dry storage room revealed dented cans of apple sauce and chili con carne with other cans that were not dented. Observation on [DATE] at 9:25 a.m. of the walk- in - cooler revealed seven one-pint bottles of chocolate milk with an expiration date of [DATE]. Further observation at that time revealed the milk and cheese were discarded by the DM. In an interview on [DATE] at 11:05 AM with the DM she said, normally the first thing she would do when she gets in the kitchen was to check for expired foods and dispose of them. She said that morning she was running late and did not get a chance to check for expired foods. Said she will just have to in-serviced the staff to check pots, pans, bowls and utensils to ensure they did not have any food particles in them. Record review of the to facility's Policy on Food Receiving dated ,[DATE] and revised ,[DATE] read in parts .safe food handling procedures for time and temperature control will be practiced in transportation, delivery and subsequent storage of all food items .4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to the vendor or disposal, as appropriate .6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of first in-first out (FIFO) inventory management .

Based on observation, interview, and record review, the facility failed to ensure its free of medication error rate of less than 5 percent. There were 2 errors out of 27 opportunities which resulted in a 7 percent error rate involving one staff ( LVN#E) and one of seven residents (Resident #138) reviewed for medication errors, in that; -LVN [NAME] did not administer [MEDICATION NAME] 50 mg to Resident #138 as ordered by the doctor. -LVN [NAME] failed to administer [MEDICATION NAME] 250mg/5 ml suspension (antibiotic) as by pharmaceutical recommendation for Resident #138. These failures affected one resident and placed him at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Record review of Resident #138 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #138's admission MDS assessment dated [DATE] revealed the following: Resident #138 had BIMS score of 00, indicating severely impaired cognitive skills. Resident #138 was totally dependent of staff for all ADL's. Record review of Resident #138 's physician order [REDACTED]. [MEDICATION NAME] 50 mg, Give 1 tablet via pe[DEVICE] every 12 hours for hypertension. Hold for SBP <120. On 11/13/19 physician ordered Resident #138 for [MEDICATION NAME] 250mg/5 ml suspension, Give 10 ml via [DEVICE] every 12 hours for bladder infection. Record review of Resident #138's Medication Administration Record [REDACTED] Observation of medication administration with LVN [NAME] on 11/19/19 at 9:15 a.m. revealed, LVN [NAME] went to the refrigerator in the medication room with nurse surveyor. LVN [NAME] picked up [MEDICATION NAME] 250mg/5 ml suspension. LVN [NAME] poured up [MEDICATION NAME] 250mg/5 ml suspension 10 cc in a medication cup, without shaking the bottle. LVN [NAME] went in Resident #138's room, who was lying in bed asleep, she checked his blood pressure (BP) and it read ( BP 143/99). LVN [NAME] punched [MEDICATION NAME] 25 mg from the blister packet 1 tablet, crushed with other medications and administered via pe[DEVICE]. LVN [NAME] poured [MEDICATION NAME] 250mg/5 ml suspension for oral use only ( pharmaceutical recommendation on the bottle stated Shake well before using). In an interview with LVN [NAME] on 11/19/19 at 9:42 a.m. regarding medication pass, LVN said she was nervous and she forgot to flush the GT before passing the medication. She said she did shake [MEDICATION NAME] in the medication room. Record review of Resident #138's printed electronic MAR indicated [REDACTED]. In an interview with RN B on 11/21/19 at 9:40 a.m. she said Resident #138 was sent to the hospital for pulling out his GT. RN B said she always check the the physician order's and the blister pack. She said she was not aware that Resident was supposed to have 2 tablet ( [MEDICATION NAME]) and she was going to call the pharmacy to change the order and notify the DON. In a phone interview with the pharmacy representative on 11/21/19 at 11:50 a.m. revealed the order they received was for [MEDICATION NAME] 25 mg PO BID. She said there was one blister pack dispensed. She said the order was a refill of the original order from the previous facility. Interview with the DON on 11/21/19 at 11:57 a.m. regarding [MEDICATION NAME] not administered as ordered by the physician, she said she was going to check the admission orders [REDACTED]. DON said she notified the physician via phone of the significant med error. She said no new order was given. She said the physician was making rounds and would clarify Resident #138's orders. DON said she was giving in-services to all the nurses. In an interview with the LVN [NAME] on 11/21/19 at 12:03 p.m. via telephone she said she was overwhelmed the day she passed the medications. She said she did not know that the blister pack had [MEDICATION NAME] for 25 mg instead of 50 mg. LVN [NAME] further stated that the DON called her about the [MEDICATION NAME] issues. Record review of the facility's policy entitled, Medication administration dated 06/2008 revealed the following, read in parts . Procedure- 2. Verify the Medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. a. The nurse is responsible to read and follow precautionary or instructions on prescription labels.

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 7 residents (Residents #138 ) reviewed for significant medication errors. -LVN [NAME] failed to administer [MEDICATION NAME] to Resident #138 as ordered by the physician. This failure affected 1 resident and placed him at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Record review of Resident #138 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #138's admission MDS assessment dated [DATE] revealed the following: Resident #138 had BIMS score of 00, indicating severely impaired cognitive skills. Resident #138 was totally dependent of staff for all ADL's. Record review of Resident #138 's physician order [REDACTED]. [MEDICATION NAME] 50 mg, Give 1 tablet via pe[DEVICE] every 12 hours for hypertension. Hold for SBP <120. Enteral feed order every shift flush with 30-60mls water before/after meds, befor initialing feeding or when there is an interruption of feeding to maintain GTube patency. Record review of Resident #138's Medication Administration Record [REDACTED] Observation of medication administration with LVN [NAME] on 11/19/19 at 9:15 a.m. revealed LVN [NAME] punched 1 tablet of [MEDICATION NAME] 25 mg from the blister, crushed with other medications and administered via pe[DEVICE]. Record review of Resident #138's printed electronic MAR indicated [REDACTED]. In an interview with RN B on 11/21/19 at 9:40 a.m. she said Resident #138 was sent to the hospital for pulling out his GT. RN B said she always check the the physician order's and the blister pack. She said she was not aware that Resident was supposed to have 2 tablet ( [MEDICATION NAME]) and she was going to call the pharmacy to change the order and notify the DON. In a phone interview with the pharmacy representative on 11/21/19 at 11:50 a.m. revealed the order they received was for [MEDICATION NAME] 25mg PO BID. She said there was one blister pack dispensed. She said the order was a refill of the original order from the previous facility. Interview with the DON on 11/21/19 at 11:57 a.m. regarding [MEDICATION NAME] tratrate not administered as ordered by the physician, she said she was going to check the admission orders [REDACTED]. DON said she notified the physician via phone of the significant med error. She said no new order was given. She said the physician was making rounds and would clarify Resident #138's orders. DON said she was giving in-services to all the nurses. In an interview with the LVN [NAME] on 11/21/19 at 12:03 p.m. via telephone she said she was overwhelmed. She said she gave one tablet of [MEDICATION NAME], she always check the MAR indicated [REDACTED]. LVN [NAME] further stated that the DON called her about the [MEDICATION NAME] issues. Record review of the facility's policy entitled, Medications via Gastrostomy tube Orders dated 08/2012 revealed the following, read in parts . Procedure- 1. Verify the Medication order on the MAR by checking it against the physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 12 residents (Resident #26) reviewed reporting in that -The facility did not immediately report Resident #26's injury of unknown origin to state agency. This failure affected one Resident and placed her at risk for not being protected from abuse and neglect. Finding Include: Record Review of the face sheet for Resident #26 revealed a 92- year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #26's MDS dated [DATE] revealed her BIMS score was 0 out of 15, indicating severe cognitive impairment. Her functional status was classified as total dependence on two staff members for transfers, dressing, toilet use, and personal hygiene and bathing. For bed mobility Resident #28 was identified as requiring extensive assistance with bed mobility from two persons. Record review of the comprehensive care plan for Resident #26 dated 10/25/19, read in part: Problem: .I have [MEDICAL CONDITION], from a stroke. I get confused and fearful at times . Interventions: .My caregivers will cue, reorient, and supervise me as I need it . My caregivers will observe for/document/report as needed, any changes in cognitive function, specifically changes in: decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of the nurse's progress notes dated 9/23/19 read in part: . resident was found lying supine in her bed with her left eye black and stating, I hurt my eye . resident room had different items thrown around her surrounding, she seemed agitated . Further record review of nurses note dated 9/24/19 read in part: .Notified NP about treatment order for ice to swelling in left eye . Further record review of the nurses' progress notes dated 9/29/19 and 10/1/19 reflected Resident #26 was being monitored for a swollen, black eye. Record review of the incident report dated 9/23/19 read in part: .resident was fund lying supine in her bed with her left eye black and stating I hurt my eye . Further record review of the Mental status section of the incident report revealed Resident #26 was oriented to person, only. Review of the Predisposing Physiological factors section of the incident report revealed Resident #26 had impaired cognitive status and was confused. No witnesses were listed, and no predisposing situational factors were identified. Observation of Resident #26 on 11/19/19 at 6:57 a.m. revealed the Resident was in bed, asleep. Further observation of the Resident at 7:17 a.m. revealed the Resident was in bed with eyes open, she was not interviewable. The Resident appeared to be verbal, but response was slow and unclear. One dime size purple discoloration was noted on the right forearm. Interview with the DON on 11/20/19 at 10:59 a.m. she said she was familiar with the black eye identified on Resident #26 on 9/23/19. She said an incident report was completed. Interview with the Administrator on 11/20/19 at 1:45 p.m. she said the staff noticed the black eye on Resident #26 and informed the DON. She initially said she did not know what staff initially identified the black eye. She said the DON interviewed and questioned the Resident and she can tell you, she is alert. She said the Resident has a history of moving things around in a disorganized manner. She gave an example of providing a specialized cup for the Resident and was moving the items around in the room. She said the Resident hit herself with an item in the room. She said no staff witnessed the Resident hit herself. She said she would have told the family or staff if somebody hit her. She said the Resident did not allege abuse. She said the incident was not reported. She was asked what the Resident's cognitive status was as of 11/20/19, said we have to take all that into consideration to determine the Residents cognitive status, currently. During interview with the MDS nurse on 11/20/19 at 1:55 p.m. she said Resident #26 was able to recall names and can verbalize needs. She said she assessed the Resident for her BIMS score of 0 out of 15. She said she did not witness the injury. She said she did witness the Resident trying to injure staff by swinging things in a disorganized manner. In another interview with the Administrator on 11/21/19 at 9:03 a.m. she said she followed the guidelines of the provider letter referencing abuse reporting when determining which type of incidents are reported. She said she also receives feedback from the team and collectively makes a decision. She said even though the facility assessed the Resident's cognitive status and if identified severe cognitive impairment, Resident #26 can verbalize what happened to her eye. In a phone interview with the family on 11/21/19 at 9:18 a.m. she said the facility reported the incident to her. She said Resident #26 could not tell her how her eye was injured. She said Resident #26 was never able to tell her how it happened or who did it . She said the facility told her Resident #26 did it to herself, but I don't know how she could do it to herself . Record review of the policy Abuse & Neglect, Prohibition (revised (MONTH) (YEAR)), reads in part: .the facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, state survey agency . b. if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours .

Based on observation, record review and interviews the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent ulcers from developing for 1 of 12 residents (Resident #26) reviewed for pressure sores in that - LVN H failed to provide clean technique while performing wound care to Resident #26's heal. This failure affected one resident and placed her at risk for decreased quality of care. Findings include: Record Review of the face sheet for Resident #26 revealed a 92- year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #26's MDS dated [DATE] revealed her BIMS score was 0 out of 15, indicating severe cognitive impairment. For bed mobility Resident #26 was identified as requiring extensive assistance with bed mobility from two persons. Further review of the comprehensive assessments section M, skin conditions identified Resident #26 as at risk for pressure sore development Record review of Resident #26's comprehensive care plan dated 10/25/19, read in part: Problem: . My skin is fragile, and I prefer to lie on my back. I have contractures of both lower extremities. I have a history of pressure ulcers . Interventions: . My caregivers will observe for/document/report as needed any changes in skin status: appearance, color, s/sx of infection, wound development . Record review of the physician's orders for Resident #26 revealed an order dated 11/15/19 for [MEDICATION NAME] 100mg PO every 12hours for [MEDICAL CONDITION], give 1 capsule by mouth every 12 hours for [MEDICAL CONDITION] for 14 days. Resident #26's had also a physician orders written on 11/20/19 for the stage III wound to the right heel to be cleaned with normal saline, patted dry, and Alginate w/silver applied covered with dry absorptive dressing daily. Record review of the Physicians progress note for Resident 326dated 11/15/19 identified: .[MEDICAL CONDITION] significant around the right heel wound, will treat with [MEDICATION NAME] 100mg every 12 hours for 2 weeks . Review of the progress note dated 11/19/19 documented .venous doppler of right lower extremity reported [MEDICAL CONDITIONS] with decreased blood flow below the knee, probable cause to right heel wound . Record review of the wound evaluation dated 11/20/19 revealed the wound was acquired on 11/13/19. Observation of Resident #26's right heel on 11/19/19 at 9:10 a.m. revealed bilateral AFO's (ankle foot orthosis) were applied while Resident was in bed. Nursing staff removed AFO's and a dressing was noted partially detached from right heel. The dressing was moderately soiled with blood and pus drainage noted. No overt odor was noted. Observation and Interview of wound care for Resident #26 on 11/19/19 at 10: 41 a.m .LVN H said she would like to have an aide but sometimes they are shorthanded. She said nobody is available to help, but I can do it. LVN H cleaned the wound on the heel then rested the heel without a dressing directly on top of a pillow. She assessed wound measurements and again rested Resident #26's exposed wound to the heel on the pillow. She applied Santyl and a applied a new dressing without re-cleaning the wound on the heel that had touched the pillow. After Surveyor intervention, LVN D provided wound care to the resident again. During interview with LVN H on 11/19/19 at 11:17 a.m. she said she should have waited until a CNA was available before completing care. She said when she asked the CNA the first time she was assisting another staff. During interview with the DON on 11/20/19 at 2:47 PM she said LVN H should have waited until a staff CNA was available. She said the resident's heel should have not been placed on top of a pillow due to infection control. She said Resident #26's wound was acquired last week and was unavoidable. Record review of the facility policy, Skin management (revised (YEAR)), reads in part: .individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing .

Based on observation, interviews, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities for 1 of 1 resident (Resident #138) reviewed for enteral nutrition in that - LVN [NAME] did not flush Resident #138's feeding tube with 30 ml of water before medication administration per physician orders. LVN [NAME] crushed all of Resident #138's pills/tablets, mixing them together. The cocktail medications were not administered separately via Resident #138's gastrostomy tube These failures affected one resident and placed her at risk for abdominal discomfort and not receiving the full therapeutic value of the medication. Findings Include: Record review of Resident #138 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #138's admission MDS assessment dated [DATE] revealed the following: Resident #138 had BIMS score of 00, indicating severely impaired cognitive skills. Resident #138 was totally dependent of staff for all ADL's. Record review of Resident #138 's physician order [REDACTED]. -Enteral feed order every shift flush with 30-6 0mls water before/after meds, before initialing feeding or when there is an interruption of feeding to maintain GTube patency. -[MEDICATION NAME] 25 mg 1 tablet, via GTube every 12 hours [MEDICAL CONDITION]( hypertension) hold for SBP ( systolic blood pressure) <120. - Aspirin 81 mg 1 tablet, via GTube one time a day for [MEDICATION NAME]. - [MEDICATION NAME] 0.5 mg 1 tablet,via GTube one time a day for psych. -[MEDICATION NAME] 20 mg 1 tablet every 12 hours for ulcer -[MEDICATION NAME] 250mg/5 ml suspension, Give 10 ml via [DEVICE] every 12 hours for bladder infection. Observation of medication administration with LVN [NAME] on 11/19/19 at 9:15 a.m. revealed LVN [NAME] went to the refrigerator in the medication room with nurse surveyor a nd picked up [MEDICATION NAME] 250mg/5 ml suspension. LVN [NAME] poured up [MEDICATION NAME] 250mg/5 ml suspension 10 cc in a medication cup without shaking the bottle. She checked his blood pressure (BP) and it read ( BP 143/99). LVN [NAME] opened medication cart picked and punched [MEDICATION NAME] 25 mg from the blister packet 1 tablet, Aspirin 81 mg 1 tablet, [MEDICATION NAME] 0.5 mg 1 tablet, [MEDICATION NAME] 20 mg 1 tablet, placed all medications in one pouch and crushed. LVN [NAME] then poured crushed medications in a medication cup and diluted with water and administered via pe[DEVICE]. LVN [NAME] poured [MEDICATION NAME] 250mg/5 ml suspension for oral use only ( pharmaceutical recommendation had Shake well before using). In an interview with LVN [NAME] on 11/19/19 at 9:42 a.m. regarding medication pass, LVN said she was nervous and she forgot to flush the GT before passing the medication. Record review of Medline Plus revealed that Oral Suspensions are drugs mixed with, but not completely dissolved into a liquid. It needs to be shaken before administration in order to suspend the drug particles evenly.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen in that: -Dented cans in the dry storage room -Food in the freezer open not sealed. -Clean bowls, glasses, utensils, pans and muffin pans had food particles. -the Dietary Manager did not change gloves These failures have the potential to affect all residents who ate food prepared by the facility's kitchen by placing them at risk of foodborne illness. Findings include: Observation on 12/11/18 at 9:25 a.m. of the kitchen revealed the following: - Clean bowls, cups, glasses and serving utensils with food particles and food stains in them. - Clean pans with dried food particles on them. The clean pans were stored with water in them, they were not properly air dried. - In the freezer was an open box of pizza not sealed. Observation of the dry storage room on 12/11/18 at 9:40 a.m. revealed two dented cans of mandarine oranges and one dented can of sliced pears. Observation on 12/12/18 at 11:50 a.m. of lunch revealed the Dietary Manager serving lunch and she used the same gloves to pick up the seasoning container, picked up the menu cards that were handled by other staff, and then picked up the unwrapped rolls and placed them on the resident's plates without changing gloves. During an interview with the Dietary Manager on 12/13/18 01:39 pm she said she should have use a tong to pick up the rolls or should have change her gloves. The Dietary Manager further said she was going to ensure that plates, pans and utensils were properly checked by staff before they were packed away to ensure no food particles were on them. She said that it was an eye opener and they will pay more attention. Record review of the Health Services Group policy and procedure revised (MONTH) 2014 read in part: .<BR/(NAME)Washing Policy Statement It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. Action Steps 1. The Food Services Director insures that the nutrition staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. 2. The Food Services Director ensures that all dishware is air dried and properly stored .

Based on observation, interview, and record review the facility failed to review and revise the person-centered care planning for 2 of 15 residents reviewed for care plans. (Residents #9, and #14). -The facility did not care plan Resident # 9's left great toe pressure ulcer. -The facility did not revise Resident #14's care plan to address his chewing difficulties. This failure affected 3 residents and placed them at risk for decreased quality of care and quality of life. Findings include: Resident #9: Record review of the admission sheet for Resident # 9 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #9's comprehensive MDS assessment dated [DATE] revealed the BIMS score was 11 indicating intact cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident was incontinent of bowel and bladder. The Skin section indicted no skin issues or pressure sores. Record Review of Resident #9's weekly head to toe skin checks dated 12/11/18 revealed new pressure ulcer on left great toe measuring .5 x .5 centimeters. Record review of Resident #9's Physician order [REDACTED]. Record Review of Resident #9's care plan for skin dated 7/22/2018 revealed it was not updated to reflect the left great toe pressure ulcer. In an interview with MDS Coordinator on 12/13/18 at 2:45pm., she said she just saw the order while printing the requested documents for the surveyor. She further said usually the ADON updates skin related issues on the care plan or would tell the MDS Coordinator to update it. In an interview with ADON and MDS Coordinator on 12/13/18 at 2:55pm., ADON said any nurse can update the residents care plan. She will educate the nurses. She further said she was not aware of resident #9's left toe until now when the surveyor asked her about resident #9's weekly skin assessments. LVNs are not allowed to stage the wound. She said LVN B worked the evening shift and she documented and received the new order and didn't inform her. Resident #14: Record review of Resident #14 admission face sheet revealed he was an eighty-one-year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #14's Significant Change MDS dated [DATE] Section C0500 revealed the resident was coded with a BIMS score of 05 indicating severely impaired cognition and Section L0200 coded him as having no dental issues. Record review of Resident #14's revised care plan dated 06/24/18 revealed: Focus: I have dental needs with little to no teeth. Goal: I will be able to see the dental clinic as when needed and I agree between now and the next review. Intervention: Staff will refer me to the dentist as /when needed. Observation on 12/11/18 at 9:05 a.m. revealed resident in bed alert. Noted that he was missing his front teeth. Observation and interview on 12/12/18 at 12:30 pm revealed Resident #14 eating lunch. He did not eat his vegetables (corn and beans). During an interview at that time he said he did not eat his vegetables because he had no teeth and he had difficulty chewing. In an interview on 12/13/18 at 02:46 PM the MDS Coordinator said she was not aware that Resident #14 had difficulty eating and she was going to look at the care plan. Record review of the policy for comprehensive care plan revision date (MONTH) (YEAR) read in part . to provide effective and person-centered care for each resident. The plan must address the resident's individual needs, strengths, and preferences .

Based on observation, interview, and record review, the facility failed to provide quality and timely laboratory services to meet the needs of one resident of 10 residents (Resident #30) reviewed for laboratory services. -Resident #30's UA/C&S lab ordered on [DATE] was not collected in a timely manner. The failure affected one resident and placed him at risk for delayed or possibly absence of treatment if the lab tested positive for infection. Findings included: Record review of the Admission Record for Resident #30 revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident also had a [DIAGNOSES REDACTED]. Record review of the MDS) assessment, dated 10/01/18, revealed Resident #30 scored a '9' on the BIMS score indicating moderately impaired cognitive skills. The MDS revealed Resident #30 required extensive assist for most Activities of Daily Living (ADL). The MDS revealed the resident had an indwelling catheter, and was incontinent of bowel. Record review of the Care Plan (initiated on 02/02/17) revealed the resident had a history of [REDACTED]. Report results to MD (physician) and follow up as indicated. Record review of a Physician's Telephone Order dated 12/06/18 revealed an order for [REDACTED]. Record review of a lab report for a UA/C&S dated 12/08/18 revealed the urine sample for Resident #30 collected on 12/07/18 was not processed due to having three or more organisms present. The report revealed that on 12/09/18 at 9:10 a.m., the physician ordered a repeat UA/C&S. The Report revealed an order for [REDACTED]. Record review of the (MONTH) (YEAR) physician orders revealed the order for the repeat UA/C&S for 12/09/18. Interview on 12/12/18 at 3:00 p.m. with LVN D revealed he was not sure of the repeat UA/C&S order, but would search for it. Observation at that time revealed he searched the Lab Requisition Book. He located the order dated 12/07/18, but did not find the 12/09/18 requisition. LVN D checked the lab company website for results, then confirmed there was no requisition for a UA/C&S for 12/09/18. Interview on 12/12/18 at 3:05 p.m. LVN T confirmed a repeat sample should have been sent on 12/09/18 to the lab for repeat collection of urine. Observation on 12/13/18 at 9:51 a.m. revealed CNA D and CNA H provided catheter care for Resident #30. The resident had a suprapubic catheter that had a drain sponge dressing dated 12/12/18. The urine appeared to be amber, slightly cloudy, with no sediments observed. Interview on 12/13/18 at 4:00 p.m. with the DON said she reviewed the order for the repeat UA/C&S, and there was no date specified to submit the sample. When the surveyor asked what was an acceptable timeframe to submit the sample, the DON referred the surveyor to the Nurse Practitioner (NP), who was in the building. Interview on 12/13/18 at 4:05 p.m. with NP A she said the specimen should have been sent on the same day it was ordered, or the next working day, which would have been Monday, 12/10/18. Interview on 12/13/18 at 4:15 p.m. LVN D said the repeat UA/C&S sample was collected on 12/12/18 after surveyor inquiry. Record review of the facility policy Diagnostic Services Management (Revised (MONTH) (YEAR)) revealed the facility was responsible to the timeliness of the lab services. Record review of the facility policy Diagnostic Services Management (Revised (MONTH) (YEAR)) revealed b. Requires consistent documentation of requested services in the Laboratory Request Lab Book or designated record, and e. Designates daily reconciliation at a consistent time by a designated licensed nurse .

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections on A-Hall and Laundry Department. -Personal care items not labeled or bagged. -Bedside commode without top cover. -Staff not disposing soiled linen correctly. -Clean linen cart in resident room. This failure placed all residents at risk for infections. Findings Included: Observation on 12/11/18 at 9:27 a.m. in room [ROOM NUMBER]-B's bathroom revealed a bedside commode with urine and feces inside of it with no top cover on it and a tube of toothpaste and shampoo body wash that was not labeled or in a bag. Observation on 12/11/18 at 9:40 a.m. in room [ROOM NUMBER]-B's bathroom revealed a soiled towel sitting inside of a bedside commode. Observation on 12/11/18 at 9:50 a.m. in room [ROOM NUMBER]-B revealed an irrigation syringe inside of a plastic bag not labeled. Inside of the bathroom there was a dirty urinal commode hat sitting on top of commode. Observation on 12/12/18 at 8:00 a.m. in the bathroom of room [ROOM NUMBER] revealed an unlabeled body wash shampoo sitting on top of sink along with a tube of toothpaste that was not labeled. Observation on 12/12/18 at 8:05 a.m. in room [ROOM NUMBER] revealed a clean linen cart inside the room with sheets, gowns, towels, gloves, etc. Observation on 12/12/18 at 8:07 a.m. in room [ROOM NUMBER] revealed in the bathroom a soiled towel inside of a bedside commode. Observation on 12/12/18 at 8:10 a.m. in the whirlpool/shower room revealed 2 cans of shaving cream sitting on top of the sink area with no label on them. Observation and interview on 12/12/18 at 8:20 a.m. outside in the laundry room revealed a trash bag filled with clothing articles sitting on top of soiled barrel. The DON said she did not know where the bag of articles came from. The DON said the bag of articles should not have been placed on top of the barrel. The DON said the bag of articles should have been placed inside of the barrel for infection control purposes. Interview on 12/12/18 at 8:26 a.m. with CNA-A she said she had placed the clean linen cart in room [ROOM NUMBER] by mistake. CNA-A said she should have not placed the clean linen cart in room [ROOM NUMBER] because of cross contamination. Interview on 12/12/18 at 8:50 a.m. with Housekeeping Supervisor said the bag of articles found outside of the laundry room sitting on top of barrel was placed there by Hospice. The Housekeeping supervisor said the facility had told the Hospice staff not to do that in the past for infection control purposes. Interview on 12/12/18 at 9:10 a.m. the DON said personal care items should be labeled with the resident name on them. The DON said the staff should be keeping the resident rooms clean and not leaving behind soiled materials for infection control purposes. Record review of facility policy on Infection Prevention Program was revised 02/2018 revealed in part: The infection prevention program are to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection .

Based on interview and record review the facility failed to ensure 2 of 10 residents (Resident #1 and #4) 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 #1 ' s pain was not effectively controlled. --Resident #4's pain was not effectively controlled. This failure affected 2 resident whose pain was uncontrolled and placed 37 residents on pain management at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings: Record review of Resident #1 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Initial MDS assessment dated [DATE] revealed that Resident #1 had a Brief Interview of Mental Status score of 12 indicating she had moderately impaired cognitive skills. She required extensive assistance with bed mobility and transfer. She was dependent on staff for dressing, eating, toilet use, personal hygiene and bathing. She had impairment on one side of the lower and upper extremities. She was always incontinent of bowel and bladder. Further revierw of Section J of the MDS: Health Condition, on J0300: Pain Presence, Resident #1 was coded as 0, " No " , when asked, " Have you had pain or hurting at any time in the last 5 days? " Under Section M: Skin Conditions, Resident #1 had no Pressure Ulcers. Observation and interview of Resident #1 on 1/22/14 at 8:50 am revealed that she was lying on a stretcher by the nurse ' s station being pushed by an ambulance staff to go to a [MEDICAL TREATMENT] center. She said that she was in pain. She said that her knee hurt. The ambulance staff was given a medicine " [MEDICATION NAME] " inside a small, clear plastic bag to be given to the [MEDICAL TREATMENT] nurse. There was no to go snacks or lunch seen given to Resident #1 or to the ambulance staff. Record review of Resident #1 ' s Physician ' s Progress Notes/History and Physical dated 1/13/14 revealed, " ..at 9 AM 1/14/14 - Pt. in bed c/o LUE pain with slight movement. Will need adequate pain control, so that pt. can work with Physical Therapy. Will order Dilauded prn. " Further review of the Physician ' s progress notes revealed, " Rt. heel gangrene, +2 LUE [MEDICAL CONDITION] dependent +bruit at AVG site ." Record review of Resident #1 ' s Physician order [REDACTED]. Record review of Resident #1 ' s physician's order [REDACTED]. Please give [MEDICATION NAME] 30 minutes before each Physical Therapy or Occupational Therapy session. Record review of Resident #1 ' s Physician order [REDACTED]. Record review of Resident #1 ' s January 2014 summary of physician's order [REDACTED]. Record review of Resident #1 ' s January 2014 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The dates were 1/2/14, 1/3/14 and 1/19/14. Observation on 1/22/14 at 2:15 pm revealed that Resident #1 came back to the facility from [MEDICAL TREATMENT]. She was lying in bed in her room. Her call light was clipped on the right, upper side of her pillow. Interview with Resident #1 on 1/22/14 at 2:15 pm revealed that she was in pain. She said that on the scale of 1-10 with 10 as the highest pain. Her pain scale was at 10. She said that her left arm, right heel and her right knee hurt. Observation on 1/22/14 at 3:41 pm revealed that LVN A was doing wound care on Resident #1. Resident #1 had Stage II Pressure ulcers on the following areas: Right buttocks - 3.8 cm x 2.8 cm Left buttocks, 4 areas which measured .5 cm x .3 cm, .5 cm x .6 cm, 1cm x .5 cm, .5 cm x .4 cm. Left hip - 3 cm x .5 cm. Resident #1 said " ouch " when LVN A cleaned this pressure ulcer. Right heel - 2.5 cm x 2 cm x .2 cm depth. Interview with Resident #1 during wound care at 1/22/14 at 3:41 pm she said that she was in pain and that her pain was a nine in a scale of ten. She said that her right knee, left hip and her left elbow were hurting. Interview with LVN A on 1/22/14 at 4:01 pm revealed that she had not medicated Resident #1 for pain before completing the wound care treatment. Observation of Resident #1 on 1/22/14 at 4:50 pm revealed that the Physical Therapist was working on Resident #1inside her room while she was lying in bed. Resident #1 was having electrical stimulation of her right knee. Interview with the Physical Therapist on 1/22/14 at 4:50 pm revealed that Resident #1 was in pain, " constantly especially when she is moved " . She said that she didn ' t know if Resident #1 had pain medications before therapy was started. Interview with the DON on 1/22/14 at 4:54 pm revealed that [MEDICATION NAME] was discontinued because " it made her too lethargic " . Interview with the DON on 1/22/14 at 5:16 pm revealed that Resident #1 never had a dose of [MEDICATION NAME]. She said that the pharmacy would not fill the medication because it needed a triplicate. She said that Resident #1 ' s Physician was informed that it needed a triplicate but he didn ' t call the pharmacy after he was reminded by his Nurse Practitioner. DON said that nothing was done for Resident #1 ' s pain medication from 1/14/14-1/22/14, " nothing documented that I can see. I agree with you totally. " DON said that another pain medication should have been ordered, and the charge nurse should have followed up with the Physician about ordering another pain medication. Interview with the Occupational Therapist on 1/23/14 at 10:00 am revealed that she had not asked the nurses if Resident #1 have had pain medication prior to therapy. She said that Resident #1 was having a hard time with arthritic pain and her left arm. Observation on 1/23/14 at 11:30 am revealed that Resident #1 was inside the therapy room working with the Physical Therapy. Interview with Physical Therapist on 1/23/14 at 11:30 am revealed that Resident #1 was " doing well, she had pain medications this morning. " Interview with LVN D on 1/23/14 at 2:23 pm revealed that the [MEDICATION NAME] order for Resident #1 was never filled because it needed a triplicate and the physician did not call the pharmacy. She said that there was no follow up because last week she was off for 2 days after it was ordered and this week, " I didn ' t think about it " . Record review of Resident #1 ' s care plan for pain dated 1-22-14 revealed a goal of reducing pain with the following approaches: administer [MEDICATION NAME] as ordered, implement pain management flowsheet, observe for signs and symptoms of pain, notify physician if intervention are not effective, medicate for pain prior to treatments and therapy ... Resident #4: Record review of facility face sheet of resident #4 revealed he was an [AGE] year old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS asessment dated 12/21/13 revealed that the pain section was marked 0. Record review of care plan to address pain with last revision of 12/21/13 revealed that the resident had actual and potential pain due to recent fall (12/14), joint pain, chronic disease process and history of chest pain. Approaches included in part: administer [MEDICATION NAME] as needed, medicate resident prior to treatments and thereapy, if indicated and give [MEDICATION NAME] 650 mg every 4-6 hours as needed. Observation and interview on 01/22/14 at 1:10 pm revealed that LVN D was performing wound care to Resident #4. The wound care procedure was not explained to the resident and pain medication was not administered before the procedure. Before the procedure started, Resident #4 was lying flat on his back on top of a pad. LVN D started pulling the pad and pushing the resident to try to reposition him without verbalizing what she was doing. During the procedure Resident #4 complaint of being in pain and being cold in Spanish, and LVN D continued with the procedure as she did not speak Spanish. LVN D just responded "I will change the dressing now". During the procedure, the surveyor asked Resident #4 if he was in pain and he said that he was in pain and that he wanted a cream for pain to be applied. Further interview with LVN D right after the procedure, she said that she did not speak spanish. She said that they usually will call a housekeeper or other employees to help translate, but that she did not call anybody this time. In an interview on 1/22/2014 at 1:25 pm with family interpreting, Resident #4 was asked if he felt any pain during wound care and he said yes and that when they take the briefs off it hurt. Record review of resident #4' s MAR for December 2013 and January 2014 revealed Resident #4 had a PRN order for Tylenol 500mg for pain but it had not been administered during the last 22 days. Record review of the facility ' s policy and procedure on pain management dated 7/12/13 taken from Lippincott Procedures- Pain assessment, long term care, revealed, read in parts, " ...It ' s crucial for nurses to communicate with other health care providers and assess and address a resident ' s pain because residents are more likely to return to baseline when pain is recognized and treated early. Pain is defined as an " unpleasant sensory and emotional experience associated with actual or potential tissue damage. The inadequate treatment of [REDACTED]. The assessment, identification and treatment of [REDACTED]. As a nurse, you ' re responsible to conduct a comprehensive assessment for pain that ' s consistent with the resident ' s age, medication condition, and mental status. Treatment and interventions to reduce pain are a resident ' s right ...Pain assessments should also be completed on admission, at preset intervals, and whenever a new report of pain is received. A resident should be reassessed for pain after every intervention or treatment ... " Review of the facility ' s CMS 672 revealed that a census of 39 received pain management.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessments and plan of care for 2 of 7 residents reviewed for assessments. (Resident #5 and #7) Resident #5's pain medication was not given before pressure ulcer treatment as ordered by the physician. Resident #7's pain medication was not given before pressure ulcer treatment as ordered by the physician. These failures affected 2 residents and placed 41 residents at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Findings include: Resident #5 Record review Resident #5's Face Sheet revealed she was an [AGE] year female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of a physician's order dated 12/02/13 revealed [MEDICATION NAME] ( Tylenol) 325 mg 2 tablets by mouth for pain every 6 hours not to exceed 4 grams/24 hours. Record review of physician's order dated 03/26/2014 revealed to administer [MEDICATION NAME] 50 mg tablet by mouth as needed for pain, give 30 minutes before wound care treatment. Further review revealed [MEDICATION NAME] 50 mg was not given for the month of 03/14 and 04/14 before wound treatment. Record review Resident #5's Quality Assessment, Minimum Data Set ((MDS) dated [DATE] revealed her cognitive skills for daily decision making were moderately impaired (decisions poor; cues/version required). Resident #5 required limited assistance for transfer and used a wheelchair. She required physical assistance for dressing, personal hygiene, bathing and pressure ulcer treatment. Resident #5 was occasionally incontinent of bowel and frequently incontinent of bladder. Observation on 04/23/14 at 1:15 p.m. revealed LVN A and CNA D assisting during pressure ulcer treatment to Resident #5. LVN A and CNA D repositioned the resident on her right side, LVN A sprayed wound cleanser on Resident #5's stage II sacral area, using 4 x 4 gauze to cleaned the area, Resident #5 was screaming "ouch, ouch it's hurting". LVN A asked Resident #5 if she was in pain and the location, Resident #5 said yes and pointed and touched the sacral area. LVN A measured Resident #5 Stage II sacral pressure ulcer: 4.0 cm (length) x 1.4 cm (width) x 0.1 cm (depth). In further observation at the time, LVN A went outside and got [MEDICATION NAME] Topical Anesthesia Spray, sprayed it on the wound and waited for 2 minutes. LVN A then changed gloves and used hand sanitizer, gloved and took off the old dressing from Resident #5's right heel stage II pressure ulcer, measuring 2.0 cm (length) x 1.5 cm (width) x 0.1 cm (depth). Resident #5 was very restless during the procedure. LVN A sprayed [MEDICATION NAME] Topical Anesthesia Spray, waited for 2 minutes before finishing the wound care. Interview with LVN A on 04/23/14 at 1:30 p.m. regarding wound care assessment for pain before treatment was performed, she said that she gave Resident #5 pain medication before treating her. LVN #5 said that she gave the resident Tylenol "earlier." Review of Resident #5's MAR indicated [REDACTED]. The rest of the month of April was blank. Review of Resident #5's physician's order dated 04/23/14 at 10:03 a.m. revealed administered Tylenol 325 mg 2 tablets 30 minutes before wound care and every six as needed for pain. Resident #7 Record review Resident #7's Face Sheet revealed a [AGE] year female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 7's quarterly MDS assessment dated [DATE] revealed her BIMS was a 15 ( no cognitive impairment). The functional status section of the assessment revealed she needed supervision and set up for bed mobility, needed limited assistance of one person for transfers, dressing, toilet use, and personal hygiene. She needed limited assistance of one person for bathing and she fed herself. Review of the facility care plan for pain dated 3/2/14 revealed medicate resident for pain prior to treatments and therapy if indicated, administer [MEDICATION NAME] as ordered, implement pain management flowsheet,observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions ( facial grimacing, bracing, restlessness, rubbing, other). Frequency of monitoring as needed. Notify physician if interventions are not consistently effective. In and interview with Resident #7 on 04/23/14 at 11:00 a.m. regarding pain medication, she said she received pain medication today at 7:30 a.m. or 8:00 a.m. but it did not help because she was still in pain. She said that on the scale of 1-10 with 10 as the highest pain, her pain was at 6. She said that her back side was hurting. Observation on 04/23/14 at 11:12 a.m. revealed LVN A performing wound care on Resident #7. The Resident had a Stage IV sacral pressure ulcers that measured: 3.1 cm (length) x 2.8 cm (width) x 1.4 cm (depth). LVN A did not ask Resident #7 if she was in pain before the procedure or assessed Resident #7 for pain. LVN A repositioned the resident on her side and sprayed [MEDICATION NAME] Topical Anesthesia Spray in the sacral wound and waited for 2 minutes and then sprayed wound cleanser and finished the procedure. LVN A did not ask Resident #7 about her pain level throughout the procedure. Review of Resident #7's physician's order dated 03/26/14 revealed an order to administer [MEDICATION NAME]-[MEDICATION NAME] 5 mg -325 mg tablet, 1 tablet by mouth twice daily for pain NOT TO Exceed 4 grams/24 hour, medicate prior to wound care. Record review of the MAR for 04/2014 revealed that Resident #7 was to receive [MEDICATION NAME]-[MEDICATION NAME] 5 mg -325 mg tablet, 1 tablet by mouth twice daily for pain at 8:00 a.m. and 8:00 p.m. Further review of the MAR indicated [REDACTED]. Review of Resident #5's pain management flowsheet for 4/1/14 through 4/22/14 revealed no documentation that pain symptoms were assessed of for pain medication administration. On 4/23/14 at 9:55 a.m. Resident #5 ' s pre- pain medication administration pain score was 2 on the pain management flowsheet. Tylenol 325 mg 2 tablets was given. Post- Administration pain assessment was not done. Review of Resident #7 ' s pain management flowsheet ( pre- administration) revealed it was done on 4/1/14 and 4/19/14 with pain score of 3 and [MEDICATION NAME] 5/325 mg was given. Post- Administration assessment was not done. There was no documentation on the pain management flowsheet from 4/2/14 through 4/18/14,4/20/14, 4/21/14, 4/22/14 and 4/23/14. In an interview with the Administrator on 04/23/14 at 10:40 a.m.regarding monitoring pressure sores and pain management, he said that the DON did that daily with the wound care nurse and would discuss it in their morning meetings. During an interview with LVN A on 04/23/14 at 1:30 p.m. regarding wound care assessment for pain , she said she gave Resident #5 pain medication before treating her, she said she gave Resident #5 Tylenol earlier. Also regarding Resident #7 pain medication assessment, LVN A said Resident #7 was assessed "earlier" and she was not in pain. During an interview with the DON on 04/23/14 at 4:00 p.m. she said she monitored LVN A (treatment nurse ) daily and LVN A medicated the residents with pressure ulcers before treatment. The DON said that LVN A tried to complete the wound treatments early but she had to delay those treatment today. The DON then checked the facility medication cart for [MEDICATION NAME] 50 mg and said the facility did not have it in stock. Review of the facility plan of correction dated 1/31/14 revealed : System Change .... Monitoring 1. DON will monitor wound care and pain management policy and procedure adherence daily. 2. DON, MDS coordinator and Administrator will monitor general compliance to physician order, care planning, pain management policy and procedure during daily stand up and monthly QA meetings. Review of the facility policy and procedure " Lippincott procedures- Pain Assessment revised: October 04, 2013 page 2 of 6... Ask the patient whether he is experiencing any pain. If he answer yes, then ask about the pain's character, quality, onset, location and whether it radiates, duration, and frequency. Determine what exacerbates the pain and what relieves it. Determine whether the patient has a current pain regimen and, if he does, how it relates to his level of pain. Findings from these assessments provide information about the patient's current pain level of pain and provide a baseline for future assessments. The facility form CMS 642 revealed a census of 43.