Every finding on record at Park Manor of Cyfair

Based on observation, interview, and record review, the facility failed the resident the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #1) of 5 residents reviewed for resident rights.-The facility failed to ensure Resident #1's call system was within reach.This failure could place residents at risk of not receiving assistance when required or needed.The findings included:Record review of Resident #1's admission Record, dated 04/30/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included other cerebral infarction (ischemic stroke), weakness, type 2 diabetes mellitus without complications (high blood sugar), and unspecified symptoms and signs involving the nervous system.Record review of Resident #1's MDS Assessment, dated 04/10/26, revealed a BIMS score of 13, indicating her cognition was intact. Further review revealed resident was dependent (helper does all of the effort) with lower body dressing and required substantial/maximal assistance (helper does more than half the effort) with toileting and shower/bathe self.Record review of Resident #1's Care Plan, dated 04/06/26, revealed she had bowel incontinence r/t CVA and was unable to control urination AEB: Always incontinent.Observation and interview on 04/30/26 at 10:39 a.m., revealed Resident #1 was sitting in her wheelchair, next to her bed, with her back turned toward the entry door. The back of Resident #1's wheelchair was approximately 5-6 inches away from the footboard and she was facing her bedroom wall. Her bedside table was in front of her with her breakfast tray, and in front of the bedside table was her nightstand. Her bed was made and the call light was clipped up toward the pillow. Resident #1 said she spilled her coffee on the floor and her pants this morning, 04/30/26, approximately around 9:00 a.m.-9:30 a.m. She said the coffee was lukewarm and did not burn, hurt, or injure her. She said a CNA (could not recall name) came to her room, cleaned up the spilt coffee, and said she would tell CNA C to change her, but she never got changed and was still wet. Resident #1 said she could not reach her call light to get the help she needed because it was too far away from where she was. She extended her arms out and demonstrated how she could not reach the call light.During an interview on 04/30/26 at 11:18 a.m., CNA C said no one told her Resident #1 spilled coffee on her pants nor that the resident requested to be changed after she finished eating her breakfast. CNA C said she had not checked on the resident since showering her this morning and after the resident was retrieved by therapy staff. She said she clipped Resident #1's call light by her pillow and was not aware that she could not reach her call light. She said if a resident's call light was not within reach, something serious could be going on and they would not be able to push their button for help. During an interview on 04/30/26 at 12:20 p.m., the DON said her expectation was for all staff to answer a call light to see what the resident may need. She said staff should report to the charge nurse and that charge nurse was to let the CNA or any CNA was working the floor know what resident(s) needed. She said they always told staff, residents call lights should be within reach and for those residents who have more of a difficult time reaching it from a long-distance range, the call light should be placed on the resident, in a location of their choosing, so they can use the call light to call for assistance.During an interview on 04/30/26 at 1:16 p.m., CNA B said it was after breakfast, maybe around 9 a.m.-ish, that Resident #1 had her call light on. She said she helped clean up Resident #1's spilled coffee off of her bedroom floor and around her bedside table. She said she noticed her clothes were wet when she was cleaning the resident's floor and told the resident that she needed to change her. She said Resident #1 told her she wanted to finish her breakfast first. She said the resident asked her to pour her milk into her cereal which she did and told the resident that she would let her assigned CNA, (CNA C) know to go back to her room after breakfast and change her clothes. She said she never saw CNA C or told her Resident #1 needed to be changed. She said a resident's call light had to be close to them so they could be able to push it to ask for assistance when they needed help.Record review of the facility's policy, Answering the Call Light, revised March 2012, revealed .The purpose of this procedure is to respond to the resident's requests and needs.5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on interviews and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (CR #1) of 5 residents reviewed for accidents and supervision. The facility failed to ensure CNA A and CNA B did not improperly transfer CR #1. CNA A and CNA B transferred CR #1 without a gait belt from the bed to the shower chair on 04/01/25. This failure could place residents at risk for harm, pain, and injury. The findings included: Record review of CR #1's admission Record, dated 04/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), type 2 diabetes mellitus (high blood sugar) without complications, obstructive sleep apnea (sleep disorder that causes breathing pauses at night due to blocked upper airway), and functional quadriplegia (complete inability to move). Record review of CR #1's MDS Assessment, dated 03/31/25, revealed a BIMS score of 13, indicating cognition was intact. Further review revealed resident was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers was required for the resident to complete the activity with toileting hygiene, shower/bathe, and sit to stand. Record review of CR #1's Care Plan, undated, revealed resident was at risk for falls. Record review of CR #1's progress notes, entered by Nurse A and dated 04/01/25 at 19:30 [7:30 p.m.], revealed CNA came and reported to the nurse that patient was lowered on the floor while transferring her from bed to chair. Patient was being transferred x2 persons to shower chair when her legs gave in. Assessment done; no new skin alteration noted . During a telephone interview on 04/11/25 at 10:17 a.m., CNA A said CNA B got her and told her he needed her to assist him with a shower. She said she went to CR #1's room and the resident was in a sitting position on the bed. She said the resident's family member was in the room. She said they tried to transfer the resident to the shower chair, but the resident was so weak that they had to sit her down in front of the bed on the floor. She said she was holding up the resident by her arm under her armpit. She said they called the nurse on duty (did not know their name) and called another CNA (did not know their name) and resident was transferred from the floor to the shower chair. During an interview on 04/11/25 at 2:02 p.m., Nurse A said CNA A came to her and told her that CR #1 was being transferred to the shower chair and got lowered to floor because the resident was weak. She said she checked for bruises when resident was on the floor, she checked her head, body, and ran her hands through her head. She said she took her vital signs when she was still on the floor. She said she completed change in condition, incident report, and doctor was notified. She said she did not ask them what technique they used to transfer the resident. She said a gait belt should be put on the resident with one person on the right and the other on the left side. She said she did not see a gait belt. She said she did not ask if a gait belt was used. During a follow-up interview on 04/11/25 at 2:26 p.m., CNA A said they were not using a gait belt. She said she had one she used but that day she did not bring it. During an interview on 04/11/25 at 2:45 p.m., CNA B said he went and got CNA A to assist him and in the middle of transferring CR #1 to the shower chair, her legs got weak, and they lowered her to the floor. He said he stood behind the resident until CNA A went and got the nurse and another CNA. He said they should have had a gait belt, but they did not have one. He said he did not really think they needed one. He said she did not have any injuries. He said CR #1 did not express any pain and there was no bruising. During an interview on 04/15/25 at 10:30 a.m., the Director of Rehabilitation said a gait belt should be used for every situation whether it's a 2-person or 1-person transfer. She said it was not a proper technique to lift from under the shoulders because one could pull arm out of socket or hurt themselves. Record review of the facility's Safe Lifting and Movement of Residents policy, revised October 2009, read in part .2. Manual lifting of residents shall be eliminated when feasible .4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary .

Based on observation, interview, and record review the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment, for 3 of 6 residents (Resident #19, Resident #47, and Resident #13) reviewed for residents' rights. The facility failed to keep Resident #19's and Resident #47's room free of trash. The facility failed to keep Resident #13's wall clean. These failures could place residents at risk of an unsanitary environment. Findings included: Record review of Resident #47's face sheet dated 6/6/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included type 2 diabetes, major depressive disorder, and adjustment disorder with mixed disturbance of emotions and conduct. Record review of Resident #47's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #47's care plan updated 6/4/24 revealed the resident had a behavior problem related to keeping his room unclean due to leaving trash from snacks around room. Interventions were to anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. In an observation on 6/4/24 at 10:29 a.m. of Resident #47's room revealed there were crumbs on the floor under the bed near the wall including a sugar packet, opened straw, and other debris. In an observation on 6/4/24 at 10:54 a.m. of Resident #47's room revealed the crumbs were still on the floor with the addition of an opened snack wrapper. In an observation and interview on 6/4/24 at 1:33 p.m. in Resident #47's room revealed a fly was flying around. The crumbs from previous observations were still on the floor. The resident said housekeepers cleaned his room and the facility always had flies. In an observation on 6/5/24 at 3:16 p.m. in Resident #47's room revealed the crumbs were still on the floor under the bed near the wall. In an observation and interview on 6/6/24 at 10:43 a.m. with the Housekeeping Manager of Resident #47's room revealed trash was underneath his bed. The Housekeeping Manager said she did not like the condition of Resident #47's room and said it did not appear to be swept good. She said the trash on the floor could cause ants, slipping or falling. Record review of Resident #19's face sheet dated 6/6/24 revealed an [AGE] year old male who admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified psychosis, dementia, and anxiety disorder. Record review of Resident #19's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. In an observation on 6/4/24 at 1:30 p.m. of Resident #19's closet revealed there were food crumbs and a cup with tan liquid on the floor. The tan liquid was also on the wall. In an observation on 6/5/24 at 3:15 p.m. of Resident #19's closet revealed the crumbs and liquid were still present. In an observation and interview on 6/6/24 at 10:27 a.m. of Resident #19's closet with LVN A, he said the substance on Resident #19's wall and floor appeared to be formula and crumbs. He said the resident might have finished the formula and threw it in the closet. He said the closet should not look like that because it was supposed to be clean, and it could bring ants. He said the housekeeper was responsible to clean the entire room and may not have opened the closet. In an observation and interview on 6/6/24 at 10:43 a.m. of Resident #19's closet with the Housekeeping Manager revealed a tan liquid substance on the floor and wall, along with food crumbs. The Housekeeping Manager said the area appeared to be a drink that spilled down the wall. She said it was dirty and needed to be cleaned. Record review of Resident #13's face sheet dated 6/6/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included dementia, heart failure, bipolar disorder, and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #13's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15 which indicated severe cognitive impairment. She was dependent on staff for ADL care. In an observation on 6/4/24 at 10:48 a.m. in Resident #13's room revealed there was a brown area smeared on the wall above Resident #13's bed. In an observation and interview on 6/6/24 at 10:43 a.m. of Resident #13's wall with the Housekeeping Manager revealed a brown colored smear above the resident's bed. The Housekeeping Manager said the spot appeared to be a bug or blood from a bug that should not be there. She said she started at the facility on Monday (6/3/24) and was identifying areas that they needed to improve on. She said housekeeping staff were expected to sweep and mop the floors, clean the walls, bathroom, furniture, and bedside trays and were responsible for anything that needed to be cleaned. She said she expected the facility to be clean. She said she was responsible for ensuring the facility was clean but was still getting acclimated. In an observation and interview on 6/6/24 at 11:06 a.m. the Administrator and this Surveyor observed the areas of concern in Resident #19, Resident #47, and Resident #13's room. She said the areas needed attention and should be cleaned right away. She said she expected the resident rooms to be maintained and clean due to infection control and quality. She said department heads were expected to conduct room rounds and report any concerns to housekeeping. She said the Housekeeping Manager was brand new and the facility transitioned to a new housekeeping company on Saturday (6/1/24) due to quality concerns with the previous company. She said she and the Housekeeping Manager were responsible for ensuring the rooms were clean. Record review of the facility's Quality of Life - Homelike Environment policy dated August 2009 read in part, .Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible .Characteristics of a personalized, homelike setting 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. cleanliness and order .

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (100 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 100 Hall Nursing Cart did not contain insulin pens with no open dates for Resident #10, Resident #37 and Resident #77. This failure could place residents at risk of adverse medication reactions. Findings Included: Resident #10 Record review of Resident #10's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: hypoglycemia and type 2 diabetes. Record review of Resident #10's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #10's undated Care Plan revealed, focus- type 2 diabetes; intervention- diabetes medication/insulin as ordered by doctor. Record review of Resident #10's Physician Order dated [DATE] revealed, Admelog Insulin- Inject as per sliding scale under the skin before meals and at bedtime for type 2 diabetes; if ,d+[DATE] = 0 units, ,d+[DATE]= 4 units, if greater than 250, give 4 units and call the NP. Resident #37 Record review of Resident #37's Face Sheet dated [DATE] revealed. a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes. Record review of Resident #37's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor, observe/document for side effects and effectiveness. Record review of Resident #37's Physician's Order dated [DATE] revealed, HumaLOG insulin- inject as per sliding scale under the skin two times a day. If ,d+[DATE] = 0 units, ,d+[DATE] = 5 units, call MD/NP if blood sugar is greater than 350. Resident #77 Record review of Resident #77's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: dementia and type 2 diabetes. Record review of Resident #77's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, supervision for all ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #77's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor. Record review of Resident #77's Physician Order dated [DATE] revealed, Lantus ( Insulin Glargine)- Inject 30 units under the skin in the evening for diabetes. Record review of Resident #77's Physician Order dated [DATE] revealed, NovoLIN N ( Insulin NPH Human)- inject as per sliding scale subcutaneously in the morning. If ,d+[DATE] = 0, ,d+[DATE] =25 units, BG greater than 350 call MD/NP and hold for BG under 120. An observation and interview on [DATE] at 07:30 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - an open and in-use Lantus Insulin pen and NovoLIN N Insulin vial for Resident #77, with no open date. - an open and in-use Admelog Insulin pen for Resident #10, with no open date. - an open and in-use Humulin Insulin for Resident #37, with no open date. LVN A said nursing staff are expected to check their carts daily for expired and inappropriately labeled medications. He said when an insulin pen or vial is opened nursing staff are expected to label the vial with the date in order to track the expiration date. LVN A said when insulin expires it becomes ineffective and since the insulin pens/vial did not have an open date their expiration dates could not be determined so they have to be discarded in the sharps container. He said use of expired insulin could place residents at risk for uncontrolled blood sugars. In an interview on [DATE] at 11:50 AM, the DON said nursing staff must check their medication carts daily as used for expired and inappropriately labeled medications. She said multidose insulin containers should be labeled with the date opened in order to track the expiration date, and any containers with no open dates cannot be used because their expiration date cannot be determined. The DON said she did not know what happened to insulin after it expires but it must be discarded in the drug disposal bin because use of expired insulin could result in residents experiencing adverse effects. Record review of the facility policy titled Administering Medications dated ,d+[DATE] revealed, 9- 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. Record review of the facility policy titled Storage of Medication dated ,d+[DATE] revealed, 3- drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 15 percent based on 7 errors out of 44 opportunities, which involved 4 of 7 residents (Resident #37, Resident #159, Resident #16 and Resident #6) reviewed for medication errors. - LVN A failed to administer medications as ordered to Resident #37 as ordered by attempting to administer HumaLOG Insulin (Insulin Lispro) outside of parameters instead of Basaglar Insulin as ordered. - MA A failed to administer medication to Resident #159 as ordered by administering Multivitamin instead of Multivitamins with Minerals as ordered, Calcium Carbonate 500 mg instead of Calcium Carbonate 600 mg as ordered and by failing to administer Hydrocodone/Acetaminophen 5-325 mg (medication for pain) as ordered due to the medication being unavailable in the facility. - MA B failed to administer medications to Resident #16 as ordered by administering Multivitamin with minerals instead of plain Multivitamins as ordered. - MA B failed to administer medications to Resident #6 as ordered by administering Multivitamin with minerals instead of plain Multivitamins as ordered. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications, and adverse reactions such as hypoglycemia (low blood sugar) and hospitalization . Findings Included: Resident #37 Record review of Resident #37's Face Sheet dated 04/24/23 revealed. a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes. Record review of Resident #37's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor, observe/document for side effects and effectiveness. Record review of Resident #37's Physician's Order dated 04/21/23 revealed, Basaglar Insulin 100 unit/mL- Inject 18 units under the skin one time a day. Record review of Resident #37's Physician's Order dated 02/16/23 revealed, HumaLOG insulin- inject as per sliding scale under the skin two times a day. If 70-249 = 0 units, 250-350 = 5 units, call MD/NP if blood sugar is greater than 350. An observation and interview on 04/24/23 at 07:20 AM revealed, LVN A preparing for insulin administration to Resident #37. He took his blood glucose (sugar) testing supplies into Resident #37's room and measured her blood sugar which resulted in 249 mg/dL. LVN A informed Resident #37 of her blood sugar, exited the resident's room, discarded the testing supplies and then cleaned the glucose meter. LVN A said since Resident #37's BG was 249 mg/dL he would not administer the sliding scale HumaLOG but he would administer Resident #37's long acting Basaglar Insulin. LVN A then retrieved an Insulin Lispro (HumaLOG) insulin pen labeled for Resident #37 from his nursing cart, cleaned the rubber septum, attached a pen needle, dialed 18 units on the pen, closed his cart, knocked on Resident #37's door frame and proceeded to enter into Resident #37's room to administer the 18 units of HumaLOG. Right after LVN A knocked on Resident #37's door frame and as he stepped into the resident's room the surveyor stopped LVN A, asked him what medication he was about to administer and LVN A said Basaglar. The surveyor alerted him to the wrong medication he selected HumaLOG instead of Basaglar. LVN A said prior to medication administration nursing staff are expected to double check the medication being administered against the EMR but he must have read it incorrectly. LVN A said if he had administered fast acting HumaLOG to Resident #37 the medication would have dropped the resident's blood sugar too low and failure to administer the long acting Insulin would have resulted in Resident #37's blood sugar being inadequately controlled over the duration of the day. LVN A said Resident #37's Basaglar was not in the cart, so he would have to retrieve it from the med room in order to administer it. Resident #159 Record review of Resident #159's Face Sheet dated 04/24/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: bacterial skin infection, depression, hypertension, generalized muscle weakness and age-related physical debility. Record review of Resident #159's Admission MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance to total dependence on most ADLs, use of a wheelchair and always incontinent of both bladder and bowel. Record review of Resident #159's undated Care Plan revealed, no related focus areas. Record review of Resident #159's Physician Orders dated 04/05/23 revealed, Calcium Carbonate 600 mg- give 1 tablet by mouth one time a day for calcium supplement; Multivitamin w/ Minerals- give 1 tablet by mouth for vitamin supplement. Record review of Resident #159's Physician Orders dated 04/20/23 revealed, Hydrocodone-Acetaminophen 5-325 mg, give 1 tablet by mouth four times a day for pain for 10 days. Scheduled for 12:00 AM, 06:00 AM, 12:00 PM and 06:00 PM. An observation and Interview on 04/24/23 at 08:17 AM revealed, MA A preparing medication for administration for Resident #159. She retrieved 1 tablet of Multivitamin, 1 tablet of Calcium Carbonate 500 mg and 7 other oral medications, which did not include Hydrocodone-Acetaminophen 5/325 mg, entered into Resident #159's room and administered the medication to the resident. LVN A said she did not administer Hydrocodone scheduled for 06:00 AM to Resident #159 because it was not available and she would contact her nurse to determine what further action to take. In an interview on 04/24/23 at 11:45 AM, MA A said that Multivitamins and Multivitamins w/ minerals are not the same and the products are not interchangeable. She said Resident #159 was supposed to receive 1 tablet of a Multivitamin with Minerals but she grabbed the wrong bottle. She said failure to administer medication as ordered could place residents at risk for adverse reactions or over supplementation. In an interview on 04/24/23 at 01:15 PM, MA A said she administered 500 mg of Calcium Carbonate to Resident #159 instead of 600 mg because there was no 600 mg available in the facility. She said when OTC medications/supplements are not available, MAs are required to notify their nurse who then contacts the physician to receive an order for an alternative of the unavailable medication. MA A said she notified the facility staff responsible for ordering the correct Calcium supplement but could not confirm if she notified her nurse. Resident #16 Record review of Resident #16's Face Sheet dated 04/24/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: lack of coordination, age related cognitive decline and high cholesterol. Record review of Resident #16's Quarterly MDS dated [DATE] revealed, impaired vision, severe cognitive impairment as indicated by a BIMS score of 06 out of 15, extensive assistance for most ADLs, use of a wheelchair, and always incontinent of both bladder and bowel. Record review of Resident #16's undated Care Plan revealed, no focus areas related to failure. Record review of Resident #16's Physician Order dated 12/12/18 revealed, Multivitamin- give 1 tablet by mouth one time a day for vitamin deficiency. An observation and interview on 04/24/23 at 08:37 AM revealed, MA B preparing for medication administration to Resident #16. She retrieved 1 tablet of Multivitamin w/ Minerals and 5 other oral medications, entered into the resident's room and administered the medications. Resident #6 Record review of Resident #6's Face Sheet dated 04/24/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: seizures, joint pain, anxiety disorder, pressure ulcer, dementia and type 2 diabetes. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 06 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #6's Physician Order dated 09/17/20 revealed, Multivitamin- give 1 tablet by mouth one time a day for vitamin deficiency. An observation and interview on 04/24/23 at 08:53 AM revealed, MA B preparing for medication administration to Resident #6. She retrieved 1 tablet of Multivitamin w/ Minerals and 3 other dietary supplements, entered into the resident's room, and administered the medications. In an interview on 04/24/23 at 11:30 AM, MA B said prior to preparing medication for administration, staff must verify the patient identifiers, and the medications against the MAR. She said she administered Multivitamin w/ Minerals to both Resident #16 and Resident #6 and she did not know if there was a difference between Multivitamin w/ Minerals and Multivitamins. MA B said she believed they were interchangeable but she would confirm with her DON. MA B said she failure to administer medications as ordered could place residents at risk for upset stomach or over supplementation. In an interview on 04/24/23 at 11:50 AM, the DON said prior to administering medications nursing staff must verify the patient identifiers and then the MAR against the medication blister pack for the right dose, route and frequency. She said Multivitamins and Multivitamins with Minerals are not the same thing, and not interchangeable. The DON said HumaLOG was a fast acting insulin meant to control anticipated blood sugar increases as a result of meals, and Basaglar was a long acting insulin meant to control blood sugars over a longer period of time. She said if LVN A administered HumaLOG instead of Basaglar to Resident #37 the resident's blood sugar would have dropped significantly and failure to administer Basaglar insulin would leave the resident's blood sugars uncontrolled over the day. The DON said failure to administer supplements and insulin as ordered could place residents at risk for adverse reactions, over or insufficient dietary supplementation and hypoglycemia. Record review of LVN A's competency assessment titled Medication Pass Observation dated 02/10/23 revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of MA B's competency assessment titled Medication Pass Observation dated 02/10/23 revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of MA A's competency assessment titled Medication Pass Observation dated 02/14/23revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, 3- Medications must be administered in accordance with orders, including any required time. 7- The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 2 of 6 residents (Resident #42 and Resident #159 ) reviewed for pharmacy services. - The facility failed to ensure that the 100 hall nursing cart did not contain expired insulin for Resident #42 - The facility failed to have Hydrocodone- Acetaminophen, a pain medication, available for administration to Resident #159 and failed to administer it according to physician orders. This failure could place residents at risk of not receiving the therapeutic benefit of medications. Findings Included Resident #42 Record review of Resident #42's Face Sheet dated 04/24/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), difficulty swallowing and type 2 diabetes. Record review of Resident #42's Quarterly MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance with most ADLs, use of a wheelchair, and always incontinent of both bladder and bowel. Record review of Resident #42's undated Care Plan revealed, focus- Resident #42 has diabetes and is at risk for complication; interventions- give diabetes medication/insulin as ordered. Record review of Resident #42's Physician's Order dated 10/16/21 revealed, Lantus Insulin 100 units/mL - inject 10 units under the skin in the morning for diabetes. Lantus Insulin 100 units/mL- inject 6 units subcutaneously at bedtime for DM. An observation and interview on 04/24/23 at 07:30 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - an open, in use and expired vial of Lantus Insulin for Resident #42 with an open date of 03/20/23 with manufacturer's instructions of use within 28 days (04/17/23) after opening. LVN A said nursing staff are expected to check their carts daily as used for expired medications. He said once insulin expires it could lose efficacy so it must be taken out of circulation and discarded in the sharps container after reorder. LVN A said use of expired insulin could place residents at risk of uncontrolled blood sugars. Resident #159 Record review of Resident #159's Face Sheet dated 04/24/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: bacterial skin infection, depression, hypertension, generalized muscle weakness and age-related physical debility. Record review of Resident #159's Admission MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance to total dependence on most ADLs, use of a wheelchair and always incontinent of both bladder and bowel. Record review of Resident #159's undated Care Plan revealed, no related focus areas. Record review of Resident #159's Physician Orders dated 04/20/23 revealed, Hydrocodone-Acetaminophen 5-325 mg, give 1 tablet by mouth four times a day for pain for 10 days). Scheduled for 12:00 AM, 06:00 AM, 12:00 PM and 06:00 PM. Record review of Resident #159's Individual Patient's Antibiotic/Narcotic Record with a received date of 04/08/23 revealed, 54 tablets of Hydrocodone/Acetaminophen 5-325 mg were received and the last tablet was administered at 05:13 PM on 04/23/23. Resident #159 did not have any Hydrocodone/Acetaminophen after 04/23/23 at 05:13 PM. An observation and Interview on 04/24/23 at 08:17 AM revealed, MA A preparing medication for administration for Resident #159. She retrieved 9 oral medications, which did not include Hydrocodone-Acetaminophen 5/325 mg, entered into Resident #159's room and administered the medication to the resident. LVN A said she did not administer Hydrocodone to Resident #159 because it was not available and she would contact her nurse to determine what further action to take. Resident #159 appeared to be in no immediate distress. In an interview on 04/24/23 at 11:39 AM revealed, Resident #159 said she was not in pain. She said she received a lot of pain medications and the nurses did a good job administering her pain medications. In an interview on 04/24/23 at 11:45 AM, MA A said the last time Resident #159 received her Hydrocodone was at 11:58 PM on 04/23/23 . She could not provide the control sheet for the medication. In an interview on 04/24/23 at 11:50 AM, the DON said nursing staff are expected to check their nursing carts for expired medication daily. She said Insulin once expired can become less effective and if used could result in uncontrolled blood sugars. She said all expired insulin must be discarded in the drug disposal bin located in the med room. In an interview on 04/25/23 at 10:31 AM, the DON said the last dose of Hydrocodone/Acetaminophen 5-325 mg for Resident #159 was administered on 04/23/23 per the resident's control log, the resident had no more medication and it was only meant to be administered for 10 days and the resident had no more Hydrocodone/Acetaminophen. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, Medications must be administered in accordance with the orders . Record review of the facility policy titled Storage of Medication dated 10/2014 revealed, 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance for 4 of 4 residents (#159, #15, #40, #10) on puree and regular diets. The facility failed to ensure that puree diet was prepared by methods that conserve nutritive value, flavor, and appearance. This failure could place residents on regular and pureed diet at risk of experiencing a decreased quality of life and possible weight loss. Findings included: Interviewed on 4/23/23 at 9:20 am Resident #159 stated the food is not good tasting. Resident #159 said the food was not seasoned enough and the meat is cooked too much. Interviewed on 4/23/23 at 9:21 am Resident #15 stated the food is terrible and has no flavor. Interviewed on 4/23/23 at 9:45 am Resident #40 stated the food is not good and the meat is hard, chewy and not easy to eat. Interviewed on 4/23/23 at 10:20 am Resident #10 stated the food is not great, has no flavor and the meat is hard. Observation of the Surveyors taste tested meal trays on 04/23/23 at 12:08 pm, revealed 1) puree diet and 2) regular diet. The pureed meal revealed the pureed carrots and turkey patty were tasteless. The regular meal revealed the roast beef was difficult to chew. Observed on 04/23/23 at 12:08 pm, The Dietary manager when he tested the puree meal with surveyors, he stated there is no flavor in the carrots and he did not personally like the turkey patty puree. For the regular meal the Dietary manager stated, The meat could have been more tender, resident with bad teeth could have a hard time chewing this. Interviewed on 4/25/23 at 7:40 am the Dietary Manager stated regarding pureed carrots served on 4/23/23, the staff do use chicken broth when pureeing vegetables, but for some reason on 4/23/23 Cook J added too much water, and Dietary Manager stated he was embarrassed at the taste of the carrots that day. He stated the cooks are instructed to cook as if they are cooking for their family. Interviewed on 4/25/23 at 10:18 am the Dietary Manager stated the cook was nervous and prepared the chicken broth with too much water on 4/23/23. Record Review: Food Quality and Palatability: Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Definitions: Food Palatability refers to the taste and/or flavor of the food. Procedures: 1. the Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 3. Food and liquids/beverages are prepared in a manner, form and texture that meets the resident's needs. 4. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences , as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention.

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 6 residents (Residents #37 ) reviewed for significant medication errors; - LVN A failed to administer medications as ordered to Resident #37 by attempting to administer 18 units of HumaLOG Insulin (Insulin Lispro), a fast acting insulin, instead of 18 units of long acting Basaglar Insulin. This failure could place residents at risk of adverse reactions such as hypoglycemia (low blood sugar) and hospitalization . Findings Included: Record review of Resident #37's Face Sheet dated 04/24/23 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes . Record review of Resident #37's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor, observe/document for side effects and effectiveness. Record review of Resident #37's Physician's Order dated 04/21/23 revealed, Basaglar Insulin 100 unit/mL- Inject 18 units under the skin one time a day. Record review of Resident #37's Physician's Order dated 02/16/23 revealed, HumaLOG insulin- inject as per sliding scale under the skin two times a day. If 70-249 = 0 units, 250-350 = 5 units, call MD/NP if blood sugar is greater than 350. An observation and interview on 04/24/23 at 07:20 AM revealed, LVN A preparing for insulin administration to Resident #37. He took his blood glucose (sugar) testing supplies into Resident #37's room and measured her blood sugar which resulted in 249 mg/dL. LVN A informed Resident #37 of her blood sugar, exited the resident's room, discarded the testing supplies and then cleaned the glucose meter. LVN A said since Resident #37's BG was 249 mg/dL he would not administer the sliding scale HumaLOG but he would administer Resident #37's long acting Basaglar Insulin. LVN A then retrieved an Insulin Lispro (HumaLOG) insulin pen labeled for Resident #37 from his nursing cart, cleaned the rubber septum, attached a pen needle, dialed 18 units on the pen, closed his cart, knocked on Resident #37's door frame and proceeded to enter into Resident #37's room to administer the 18 units of HumaLOG. Right after LVN A knocked on Resident #37's door frame and as he stepped into the resident's room the surveyor stopped LVN A, asked him what medication he was about to administer and LVN A said Basaglar. The surveyor alerted him to the wrong medication he selected, HumaLOG instead of Basaglar. LVN A said prior to medication administration nursing staff are expected to double check the medication being administered against the EMR but he must have read it incorrectly. LVN A said if he had administered fast acting HumaLOG to Resident #37 the medication would have dropped the resident's blood sugar too low. In an interview on 04/24/23 at 11:50 AM, the DON said prior to administering medications nursing staff must verify the patient identifiers and then the MAR against the medication blister pack for the right dose, route and frequency. The DON said HumaLOG was a fast acting insulin meant to control anticipated blood sugar increases as a result of meals, and Basaglar was a long acting insulin meant to control blood sugars over a longer period of time. She said if LVN A administered HumaLOG instead of Basaglar to Resident #37 the resident's blood sugar would have dropped significantly. The DON said failure to administer insulin as ordered could place residents at risk for adverse reactions such as hypoglycemia. Record review of LVN A's competency assessment titled Medication Pass Observation dated 02/10/23 revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, 3- Medications must be administered in accordance with orders, including any required time. 7- The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision. -The facility failed to provide adequate supervision to prevent, bruising, swelling and pain as a result of an injury of unknown origin to Resident #1's right arm, armpit and chest. This failure could place residents at risk of minor and major injuries due to inadequate supervision. Findings Include: Record review of Resident #1's face sheet revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, muscle weakness and repeated falls. Record review of Resident #1's MDS dated [DATE] revealed she used corrective lenses, had severely impaired cognition as indicated by a BIMS score of 5 out of 15, no potential indications of [CONDITION(S)],, and behavioral symptoms, Resident #1 required extensive assistance needed for bed mobility, transfer, dressing, toilet use and personal hygiene. She was total dependent for bathing, use of a wheelchair, and always incontinent of both bladder and bowel. Record review of Resident #1's care plan with last revision date of 04/26/22 revealed, focus- Resident #1 was dependent on staff for activities, cognitive stimulation, social interaction r/t cognitive deficits/dementia and physical limitations. Focus- Resident #1 was at risk of sustaining bruises and hematoma r/t being on anticoagulant, interventions- keep resident in bed at all times per r/p's request, ensure to avoid hard surface areas, handle resident carefully during ADLs. Focus- resident has limited physical mobility r/t fractures. An observation and interview on 06/06/22 at 2:37 PM revealed, Resident #1 lying in bed well-groomed in no immediate distress. She appeared immobile with bed raised high above the ground and a sign above her bed saying do not take out of bed. The resident appeared to have severe cognitive impairment and could not recall any injuries from the month prior to the interview in which the incident occurred. She was not able to answer most of the surveyor's questions. In an interview on 06/06/22 at 4:58 PM the Police Officer said, he was sent to investigate an allegation of abuse at the facility on 05/08/22 and when he arrived, he observed Resident #1 to have bruising on her right upper outer and inner arm, armpit and a huge hematoma the size of a softball on her upper chest. He said it looked like someone had hit her, but he could not be sure and the doctor from the hospital said the injury was due to [MEDICATION(S)] force trauma. The Police Officer said on the day of the incident he talked to 2 staff members, who stated they were not on duty when the injury was identified and could not provide a reason for the injury. An observation and interview on 07/26/22 at 11:54 AM revealed, Resident #1 lying in bed well-groomed in no immediate distress with no visible bruising and a bed tray across her bed. The resident could not recall any injuries and could not answer most of the surveyor's questions. In an interview on 07/26/22 at 09:40 AM, CNA A said Resident #1 required total assistance with all ADLs and was a 2 person transfer. She said she worked the weekend of 5/7/2022-5/8/22 and she never observed any bruising on the resident. CNA A said Resident #1 had no falls to her knowledge and she had no idea about how the resident got the injury. She said on 05/7/22 Resident #1 was scheduled to get a bed bath but she declined it, so she washed her face , cleaned her up and provided incontinence care. CNA A said when she cleaned the resident up she did not remove her shirt so she was would not have seen any bruising to the resident's chest or arm. In an interview on 07/26/22 at 10:12 AM, RN A said that Resident #1 required total assistance with most ADLs. She said she worked with the resident on the weekend of 05/07/22 to 05/08/22 and she did not observe any bruising on the resident. RN A said there were no reports made of any falls or injuries to Resident #1 during the weekend and she doesn't know how the injury occurred. In an interview on 07/26/22 at 10:30 AM, the DON said on 05/08/22 Resident #1's family member reported to her that the resident had a new bruise so she went to investigate. The DON said she performed a head-to-toe assessment in which she observed yellow to bluish bruising on Resident #1's inner arm and upper right chest indicating it was not an acute injury but instead a healing bruise. She said Resident #1 was bed bound, was able to move her upper extremities but required total assistance with most ADLs. The DON said that Resident #1 had no reported falls before the bruise was observed and no staff had reported any bruising or injuries. She said Resident #1 was not able to get up herself and needed at least 3 people to move her and since no one reported a fall, a fall was not possible because she would have been found on the floor. The DON said her investigation of the incident did not reveal any staff that observed the bruise prior to being alerted by Resident #1's family member and she was not able to determine how the resident got injured. In an interview on 07/26/22 at 12:45 AM, the DON said, facility staff are expected to provide sufficient supervision to prevent injuries to residents and insufficient supervision placed residents at risk for late identification/treatment of injuries and pain. Record review of Resident #1's Progress Notes dated 05/08/22 at 7:50 PM, signed by the DON revealed, [family member] at bed side to visit and after a few minutes, [family member] called writer to the room and showed writer redness to the mid upper arm with what appeared to be collection of fluids under the redness and fading bruise to the surrounding area. Resident expressed tenderness to touch. NP made aware. Requested an order for Stat X Ray of the right upper arm and the R upper chest. NP agreed. Resident is on [MEDICATION(S)] 2.5 mg and Aspirin 81 mg daily for a history of DVT. Neighborhood X Ray made aware of order. Assessment conducted by DON, no other injuries or bruising noted. Cold compress applied intermittently as the resident allowed. Record review of Resident #1's Progress Notes dated 05/09/22 at 4:10 PM, signed by the NP revealed, received call yesterday, patient noted with right axillary/arm bruising and swelling. Seen today during rounds, she was found resting in bed. She has no specific complaints. Mentation at baseline. On assessment, does complain of pain to the RUE with movement, guarding axillary (armpit) region with flex/extension of arm. Mild swelling of axillae extending to right chest pain. Record review of Resident #1's Progress Notes dated 05/09/22 at 7:50 PM signed by the DON revealed, resident's family member came to the facility with the sheriff. Record review of Resident #1's Investigation Follow-up dated 05/09/22 at 7:55 PM by the DON revealed, Summary of investigation- resident is not able to be interviewed. Resident's BIMS is 05. Resident noted to have some tenderness, redness to the right upper chest near the axillary area. Resident did not have a recent fall . Record review of Resident #1's Pain assessment dated [DATE] at 8:50 PM revealed, that the resident revealed no signs, indicators of pain or possible pain, reported no pain in the last 5 days, rarely experienced pain in the last five days and she had not experienced any difficulty sleeping due to pain. Record review of Resident #1's Hospital Medical Records dated 05/10/22 revealed, resident received a CT of her chest without contrast due to the clinical indication of Chest trauma, [MEDICATION(S)], low energy, rib fracture, traumatic, that showed no acute fracture or malalignment. Record review of Resident #1's Progress Notes dated 05/12/22 at 5:30 PM, signed by the NP revealed, resident skin was assessed per licensed nurse, writer and DON present. Skin issues present are as follows 1- hard protrusion to the right chest, just above the axilla, no pain present upon palpation. 2- old bruising present at various stages of healing the right breast in circular fashion around the breast; majority of the areas are yellowish and fading. The lateral aspect and below the breast remain in purplish bruising. 3- old bruising present at various stages of healing; the right upper extremity, around the brachial area. Overall skin is intact . Record review of the facility policy titled Routine Resident Checks revised December 2007 revealed, Staff shall make routine resident checks to help maintain resident safety and wellbeing. Policy Interpretation and Implementation 1- to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on ach unit at least once per each 8-hour shift. 2- routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns . 3- The person conducting the routine check shall report promptly to the nurse supervisor/charge nurse any changes in the resident's condition and medical needs.

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain grooming and personal care for residents who are unable to carry out activities of daily living for 2 (Resident #1 and #2) of 7 residents reviewed for ADL care, in that: The facility failed to provide nail care and hand care to Resident #1. The facility failed to provide hand care to Resident #2. This failure placed residents requiring assistance with personal hygiene at risk of not receiving the proper care assistance they needed to improve their quality of life. Findings include: Resident #1 Record review of Resident #1's face sheet printed on 4/6/2022 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], coded him as moderately impaired for cognition indicating he had poor decision-making skills. For Functional Status he was coded for bed mobility, transfer, dressing, eating, toilet use, personal hygiene as extensive assistance with one-person physical assist. For bathing he was total dependence with one-person physical assist. For functional limitation in Range of Motion he was coded as impairment to one side of his upper extremity. Record review of Resident #1's Care Plan dated 03/04/2022 read in part . The resident had an ADL self-care deficit performance related to Parkinson disease. The care reflected the following: Goal: the resident will maintain current level of function in personal hygiene and ADL score through the next review date. Approaches: He is a limited assist and required one staff member. Check skin when assisting with ADL's x 1 staff personal hygiene or oral care. Bathing requires total person participation with bathing. In an interview on 03/25/2022 at 11:05 a.m. with Resident #1's family, revealed the resident had a broken finger and the facility was not taking care of it. She also alleged that the resident had a wound to his left hand, and it has an odor. Observation on 03/25/2022 at 11:05 a.m. revealed Resident #1 was contracted to the left hand with no roll. His nails were long and was pressed into the palm of his left hand. His left hand was folded into a fist. Observation on 3/25/2022 at 11:10 a.m. revealed the DON tried to clean Resident #1's left hand which was in a fist. The DON took a wet gauze and tried to clean the left hand. The cloth had brown stuff stuff on it when the DON tried to clean his left hand. Resident#1 started expressing pain and the DON said she was going to medicate him and then she could try to continue cleaning the hand. In an interview on 3/25/2022 at 11:45 a.m. with CNA C she said she was the one who got Resident #1 up that morning. She said she cleaned his face but did not clean his hands. She said the family had complained the day before about the resident's nails being long, but she did not report it to the nurse because she was busy. Further interview with CNA C revealed that when providing ADL care she was taught to provide oral care, clean the face and hands, and ensure that incontinent care was done. She said she forgot to clean the hands. She said the nurses usually trimmed non -diabetic residents and the CNA's trims the non-diabetic residents' nails. Further interview revealed that she usually put a washcloth in his left hand, but he usually pulls it out. In an interview on 3/25/2022 at 12:18 p.m. the DON said she had completed cleaning Resident #1's left hand and she looked at the hand and it only had dried skin but no wound. She said she was going to have PT reassessed the hand. Resident #2 Record review of Resident #2's face sheet printed on 4/6/2022 revealed a [AGE] year-old female that was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 13 indicating the resident was cognitively aware. For Functional Status the resident was total dependence with one-person physical assist for personal hygiene and for bathing activity itself did not occur. Record review of Resident #2's Care Plan, dated 03/25/2022, read in part . The resident had an ADL self-care deficit performance related to ADL self-care deficit, the resident requires assistance: Goal: Resident will be cleaned, well-groomed and appropriately dressed: Interventions: Bathing the resident requires total assist X 1 staff participation, bath as schedule. Observation on 04/06/2022 at 11:00 a.m. revealed Resident #2 in bed with no odor. The Wound Care Nurse provided treatment to her right foot. Further observation revealed her right hand was folded in a fist. At that time CNA C was asked to open Resident #2's right hand. When the hand was opened it had a brown stain in the palm of the hand. The CNA took a rag and wiped the wiped the right hand and the cloth had brown stain. Interview on 04/06/2022 at 2:15 p.m. with CNA C revealed she was not the one who provided care to Resident #2 that morning. She stated they were in-service on ADL care. She further stated CNA's were supposed to get residents up in the mornings as per their request and ensure that oral care was done, and their hands and face were cleaned. Interview on 04/06/2022 at 3:07 p.m., CNA S stated she and another staff got Resident #2 up. She said they provided ADL morning care to the resident. She said usually when they provide morning care they would provide oral care, clean their face and hands. She said she was sure they had cleaned Resident #2's hands that morning. She said she did not know where the brown stain came from. Interview on 04/06/2022 at 3:30 p.m. the DON said the aides were supposed to assess residents from head to toe on their shower days or as needed and report any changes to the nurse. She said they should also ensure the morning care was done. She said she was going to in-service the nursing staff. Record review of the facility's functional Impairment- Clinical Protocol, dated September 2012, reflected in part . Assessment and Recognition: 2. The staff will identify individuals with a significant decline in functions, including ability to perform activities of daily living (ADLs).

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 out of 4 medication carts ( 200 Hall- Medication Aide Cart and 100 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 200 Hall- Medication Aide Cart did not contain medication stored outside of specified manufacturer temperature ranges. - The Facility failed to ensure the 100 Hall Nursing Cart did not contain medication stored outside of specified manufacturer temperature ranges and medications with no unreadable expiration dates. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: 200 Hall Medication Aide Cart In observation and interview on [DATE] at 02:10 PM, inventory of the 200 Hall Medication Aide Cart with CNA A revealed. - An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening. CNA A said that staff are supposed to check their carts daily for expired and inappropriately stored medications daily as used. She said that since the bottle of acidophilus was not stored in the refrigerator it could no longer be used because storage at the wrong temperature can result in loss of efficacy. CNA A said that since the medication could not be used it should be discarded in the drug disposal bin located in the medication room and a new bottle should be pulled for the cart and stored in the refrigerator. 100 Hall Nursing Cart In observation and interview on [DATE] at 02:20 PM, inventory of the 100 Hall Nursing Cart with LVN B revealed. - An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening. - An open bottle of [MEDICATION(S)] Sulfate 220 mg/5 mL, an iron supplement, with an open date of [DATE] with an incomplete expiration date. The bottle only had the month 02 visible, the year was not present. LVN B said that nursing staff should check their carts for loose pills, inadequately labeled and inappropriately stored medications weekly. She said she was not aware the acidophilus had to be refrigerated and since it was at room temperature it could no longer be used. LVN B said since the bottle of Iron did not have a visible expiration date, it could be expired. She said when a medications expired or are stored at the wrong temperature they can deteriorate and loose efficacy so they should not be used. LVN A said the bottle of acidophilus and Iron should be discarded in the drug disposal bin located in the medications storage room. In an interview on [DATE] at 02:30 PM, the DON said that unit managers audit nursing carts weekly for expired, inappropriately stored, and inadequately labeled medications weekly while nursing staff should check their carts daily as medications are used. She said all medications should be stored within manufacturer specified temperature ranges and medications stored outside of this specified range could no longer be used. The DON said all medications must have visible expiration dates and if they do not they cannot be used because they might be expired. The DON said when medications are stored at the wrong temperature or expire they can become ineffective placing residents at risk for insufficient therapy. Record review of the facility's policy Storage of Medications revised [DATE] revealed, 3- drug containers that have missing, incomplete, improper, or incorrect labeled shall be returned to the pharmacy for proper labeling after storage. 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 9- medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse was reported immediately, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term facilities) in accordance with State law through established procedures for 2 of 5 residents (Resident #52 and Resident #105) reviewed for abuse. - The facility failed to report allegations of abuse on Resident #52. - The facility failed to immediately report an allegation of abuse of Resident # 105 These failures could place residents at risk for abuse and neglect. Findings included: Resident #52 Record review of Resident #52's face sheet revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #52's Quarterly MDS sated 12/29/21 revealed, the resident was moderately impaired in cognition as indicated by a BIMS score of 09 out of 15, limited assistance with most ADLs, an indwelling catheter and ostomy . Record review of Resident #52's care plan last revised on 12/06/21 revealed, focus - potential to demonstrate verbally abusive and combative behaviors related to poor impulse control, [CONDITION(S)]. Focus- ineffective coping; verbal aggression towards staff and other residents related to anger, poor impulse control. Interventions- do not express your anger or impatience verbally or with physical movements (i.e Shaking head, pointing finger). These responses are likely to increase confusion and agitation. Record review of Social Progress Notes dated 01/28/22 signed by the Social Worker revealed, she spoke with Resident #52 and he denied having a fall recently and he had not gotten up that day. Resident #52 was calm and displayed no signs of any emotional distress or anxiety. He stated he had no current concerns and he denied that any staff helped him off the floor in a negative or harmful way and denied any falls. Record review of Social Progress Notes dated 01/20/22 signed by LVN B revealed, I do not know anything regarding the accusation and it never happened. I cannot independently transfer the patient in question by myself or without any help. Record review of Resident #52's EMR revealed, no record of any assessments or incident notes regarding the alleged abuse by LVN B. In an interview on 02/09/22 at 05:25 AM, CNA C said sometime in December of 2021 she observed LVN B throw Resident #52 on a bed aggressively during a transfer when she requested help. She said she reported this incident to the DON later in January of 2022 but nothing was done about it. CNA C said the DON said due to the fact that she reported the incident late, too much time had passed and there was no way to investigate the allegation. CNA C said the DON failed to report and investigate the incident and report it to state. In an interview on 02/10/22 at 01:00 PM, Resident #52 said he had no issues or incidents of abuse or neglect with LVN B. He said he was never treated aggressively by any staff and that the staff were nice and respectful. In an interview on 02/10/21 at 02:10 PM the HR Coordinator said in January of 2022 CNA C asked to be removed from LVN B's hall. She said CNA C informed her that she could no longer work with her and LVN B slammed Resident #52 in bed and LVN B was mean and rough with resident. The HR Coordinator said she reported this to the Social Worker, who then interviewed CNA C. In an interview on 02/10/22 at 02:28 PM, the Social Worker said in January 2022 CNA C expressed she observed LVN B pick up Resident #52 off the floor and threw him in bed. She said she did not create any incident/accident/abuse reports and she spoke with CNA C over the phone and requested CNA C provide a written statement. The Social Worker said CNA C wrote a statement but failed to sign it. She said she notified the Administrator and the DON about the allegation on the day she was informed of the incident by CNA C and spoke briefly with LVN B and Resident #52 about the incident, but neither of them remembered such an incident occurring. The Social Worker said the Administrator was the facility's abuse coordinator and when abuse was suspected facility staff are required to intervene in the situation and report appropriately to facility management, the ombudsman, and the state agency. She said the facility did not report the incident because of the time frame in which the incident was reported was over a month after the alleged incident occurred. Record review of an unsigned witness statement dated 01/28/22 revealed, when I was working with LVN B on 100 hall, when I passed down the hall I seen Resident #52 on the floor and there was no one else to help but LVN B. CNA C asked LVN B to come quick because Resident #52 was on the floor. LVN B was upset and said, Resident #52 does this all the time. LVN B moved the wheelchair and grabbed Resident #52 by the arm, picked him up and threw him down and started talking crazy to Resident #52, saying don't do it again, she was upset. In an interview on 02/10/22 at 10:41 AM, the DON said CNA C reported an allegation of LVN B aggressively tossing Resident #52 into bed in January while the incident occurred in December of 2021. She said she did not believe the allegation to be true since the resident was heavy and would not be able to be tossed on a bed by a single staff. The DON said she did not report the incident to the state agencies because it was reported late and CNA C did not say it was abuse. She said there was no abuse report or accident/incident report or investigation report completed for the alleged incident. In an interview on 02/10/22 at 12:20 PM, the Administrator said she was never informed of the allegation CNA C made about LVN B throwing Resident #52 in bed. She said she just learned about the incident today and she was out due to COVID at the time the DON received the complaint. The Administrator said per the facility policy the incident should have been reported and investigated properly and as of today there was no investigation initiated regarding the allegation of abuse of Resident #52 . She said that per the facility policy once an allegation is received an investigation is initiated immediately, the social worker does rounds with the resident, while the nursing department under the supervision of the DON perform assessments on the residents involved. She said all the information from the investigation should be submitted to the state in the 5 day report. The Administrator said residents are placed at risk for continuation of abuse if allegations of abuse are not investigated or reported appropriately. Resident #105 Record review of Resident # 105's face sheet revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #105's MDS dated [DATE] revealed, resident used corrective lenses, had intact cognition as indicated by a BIMS score of 15 out of 15, needed extensive assistance for most ADLs, was frequently incontinent of both bladder and bowl. Record review of Resident #105's care plan dated 01/29/22 revealed, focus areas- anticoagulant therapy, moderate risk of falls and had no interest in participating in any activities. In an Interview on 02/08/22 at 09:56 AM, the Student said on 02/02/22 she was walking with CNA B in the hallway when she saw CNA C struggling to move Resident #105 from her wheelchair to the shower chair. She said CNA C was verbally aggressive to the resident, her tone was not appropriate and she said[OBSCENITY]girl to the resident. The Student said following the incident she reported it to the Instructor who then reported it to the DON. In an interview on 02/08/22 at 10:10 AM, the Instructor said on 02/02/22 the Student reported to her that a staff member was using inappropriate language to Resident #105. She was informed that CNA C said[OBSCENITY]in the residents present so she immediately informed the HR Coordinator. In an interview on 02/10/21 at 02:10 PM, the HR Coordinator said she immediately informed the DON and the Administrator of the allegation of verbal abuse by CNA C immediately when she was informed on 02/02/22. She said prior to this incident she had not heard about any incidents of abuse involving CNA C. In an interview on 02/08/22 at 10:21 AM, CNA B said on 02/02/22 she was walking in the hallways with the Student when she heard CNA C say, I told you to stand up, she said she did not here CNA C curse at the resident. She said CNA C was trying to transfer the resident herself but was unable to because Resident #105 was a 2 person assist. She said the tone CNA C used with the resident was inappropriate and it should have been treated as verbal abuse. CNA B said the facility abuse coordinator was the Administrator but CNA C was usually that loud but looking back she should have reported the incident. In an interview on 02/09/22 at 02:42 PM, Resident #105 said she didn't feel verbally threatened by CNA C on 02/02/22. She said on 02/02/22 CNA C had trouble getting her in the chair for her shower last week, she felt she was going to fall and basically collapsed in the CNAs hand. Resident #105 said although CNA C was loud she had not been victim of any verbal, physical or emotional abuse from CNA C or any other staff. In an interview on 02/09/22 at 05:25 PM, CNA C said on 02/02/22 she was struggling to transfer Resident #105 to her shower chair when CNA B came to assist. She admitted to saying[OBSCENITY]but it was not addressed at the resident but it was due to distress she experience because she thought the resident and herself were going to fall. She said on 02/02/22 after the Student reported the incident she was suspended pending an investigation. CNA C said on 02/07/22 when she was interviewed by the DON and the Administrator she felt attacked because she did not remember saying[OBSCENITY]and was upset because when she informed the DON of alleged verbal abuse against LVN B in December of 2021 and January no action was taking. She said in the meeting on 02/07/22 she informed the Administrator and the DON that she would report the facility to the state for failure to report allegations of abuse and she was immediately terminated. CNA C, said following the meeting on 02/07/22 she reported the facility to the state. In an interview on 02/10/22 at 10:41 AM, the DON said the allegations of abuse made against CNA C on 02/02/22 were unsubstantiated so it was not reported to the state. She said on 02/07/22 CNA C threatened to call the corporate office and the state to report the facility for failing to investigate and report allegations of abuse she made back in December of 2021 and January of 2022. The DON said the facility reported the incident involving CNA C and Resident #105 to the state because CNA C threatened to report the facility. In an interview on 02/10/22 at 12:20, the Administrator said she was the abuse coordinator, and that staff were required to report substantiated allegations of abuse to the state within 2 hours of occurrence. She said on 02/02/22 she was informed of an allegation of abuse of Resident #105 and the facility immediately started to investigate. The Administrator said within two hours the Social Worker conducted life satisfaction surveys on all residents, including Resident #105, and all staff and the allegation was unsubstantiated. She said that Resident #105 denied the incident occurred and other staff that were in the hallway could not corroborate the allegations made by the Student and CNA B. The Administrator said since the allegations were unsubstantiated she did not report it to the state and that to her understanding she only had to report substantiated allegations of abuse to the state . The Administrator said on 02/02/22 she attempted to inform CNA C that the allegations were not substantiated but she walked off so she was surprised when CNA C called back on 02/07/22 asking when she could return to work. She said during the conversation CNA C was angry and threatened to report the facility for failing to report allegations of abuse to the state. The Administrator said she reported the allegation of abuse involving CNA C and Resident #105 on 02/07/22 because on that day CNA C threatened to report the facility for failing to investigate and report allegations of abuse she made back in December and January. She said at that time she was unaware of the allegations CNA C was referring to. The Administrator said CNA C was eventually terminated due to her failure to corporate with the investigation and attitude, she said due to CNA C walking off on 02/02/22 the investigation had to be extended Record review of the facility in-service record Abuse and Neglect dated 01/05/22 and conducted by the DON revealed, employee group(s) present- direct care team, RN/LVN, CNA and all staff. The abuse coordinator was the Administrator, if you witness or hear of any suspected or alleged abuse or neglect, report it immediately to the abuse coordinator. Your responsibility was to report it and the abuse coordinator to proceed. Record review of the facility in-service record Abuse and Neglect dated 01/14/22 and conducted by the DON revealed CNA C was in attendance. Record review of the facility policy titled Reporting Abuse to Facility Management revised 12/2008 revealed, It is the responsibility of our employees, facility consultants, attending physicians, family member, visitors to promptly report any incident or suspected incident of neglect or resident abuse . to facility management. 3- Employees . must immediately report any suspected abuse or incidents of abuse to the DON . 5- When an alleged or suspected case of mistreatment, neglect, injuries of unknown source is reported, the Administrator, or his/her designee will immediately (within 24 hours of the alleged incident or as indicated in the state reportable guidelines) notify the following persons or agencies of such incident: a- the state licensing/certification agency responsible for surveying/licensing the facility; b- the local/state ombudsman, . d-adult protective services, e- law enforcement officials. 12- when an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. 18- Staff members and persons affiliated with this facility shall not knowingly: b- fail to report an incident of mistreatment or other offense; d- screen reports or withhold information to reporting agencies Record review of the facility policy titled Abuse and Neglect- Clinical Protocol revised 04/2007 revealed, assessment and recognition 1. The nurse will assess the individual and document related finding. Assessment date will include a- injury assessment(bleeding, bruising deformity, swelling etc.) . d- vital signs, e- behavior over the last 24 hours. Treatment/Management- 1- The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2- the management and staff, with the support of the physicians (as needed), will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Monitoring and Follow up 1- The staff and physician will monitor individuals who have been abused at least until their medical condition, mood and function have stabilized, and periodically thereafter.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 3 of 3 residents (Residents #12, Resident #56 and Resident #100) reviewed for PASRR Level 1 screenings. The facility failed to verify the accuracy of the negative PASRR Level 1 Screening for Resident # 12, Resident #56, and Resident #100, who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] These failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings Included: Resident #12 Record review of Resident #12's face sheet dated 02/09/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #12's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, no behaviors in the reviewed period, extensive assistance with most ADLs, use of a wheelchair, frequent incontinence of both bladder and bowel, anxiety disorder, depression, [CONDITION(S)] disorder and psychotic disorder. Record review of Resident #12's PASRR Level I Screening dated 07/03/2017 completed at the facility revealed, Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record review of Resident #12's Physician Order Summary dated 02/09/22 revealed active prescriptions of [MEDICATION(S)] 30 mg Delayed Release give 1 capsule by mouth at bedtime for depression, may provide psychological services, to provide psychiatric services. Record review of Resident #12's care plan revised 11/17/21 revealed, focus area of- use of antidepressant medication related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions- give antidepressant medication ordered by physician, monitor/document side effects and effectiveness. Resident #56 Record review of Resident #56's face sheet revealed a [AGE] year old female who was originally admitted on [DATE]. She had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #56's PASRR Level I dated 09/17/2018 read ,no next to mental illness. Record review of Resident #56's Quarterly MDS dated [DATE] revealed she had a BIMS of 14 out of 15 indicating she had no cognitive impairment. Her current active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications received Antidepressant for 7 out of 7 days. Record review of resident #56's February Medication Review report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #56's care plan revealed: -Date initiated 5/05/2021: Resident #56 uses antidepressant medication due to depression. At risk for side effects. Depression, poor coping skills. Interventions: Social Services to evaluate and provide emotional support as needed. The resident is taking anti-depressant meds. Resident # 100 Record review of Resident #100's face sheet dated 02/09/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #100's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, no behaviors in the reviewed period, independent with most ADLs, used a wheelchair, occasionally incontinent of both bladder and bowel. Record review of Resident #100's PASRR Level I Screening dated on 01/12/22 completed by the resident's physician's office revealed, Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record review of Resident #100's Physicians Order Summary dated 02/09/22 revealed, behavior monitoring for mood swings, behavior monitoring for sadness, psychological services, [MEDICATION(S)] Delayed Release Particles 6 mg I capsule by mouth two times a day for depression, [MEDICATION(S)] 500 mg Delayed Release 1 tablet by mouth three times a day for [CONDITION(S)] disorder. Record review of Resident #100's care plan dated 01/21/22 revealed, focus area- deficit in memory, judgement, decision making and though process related to: dementia/[CONDITION(S)] disorder, risk of side effects related to anti-anxiety medication, risk of side effect related to antidepressants related to [CONDITION(S)] disorder Interventions- give medications as ordered by physician, observe side effects, observe signs and symptoms of depression, report to nurse signs and symptoms of mood change, change in normal behavior, hallucinations/delusions, suicidal ideation, decline in function. In an interview on 02/09/22 at 10:55 AM, the MDS Nurse said before admission the hospital or referring facility completes and send the PL 1 and the facility reviews the documents for the medications, diagnoses, and psychological hospitalization . She said mental illness was defined as diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Nurse said Resident #12, Resident #56 and Resident #100 did not have a documented PASRR level 2 of PASRR Evaluation because even though they had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said failure to complete or report an accurate MDS places residents at risk of not having the needs met or receiving adequate services. Record review of the facility policy titled PASRR Clinical Policy dated 05/2014 revealed, The PL 1 Screening Form is designed to identify persons who are suspected of having MI, ID, DD also referred to as a related conditions. The PE is designed to confirm the suspicion of MI, ID, or DD and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning. If documentation entered on the PL 1 indicated MI/ID/DD, a PE must be completed. A mental disorder is defined as the following: a [CONDITION(S)], mood, paranoid, panic or other sever anxiety disorder, personality disorder, other psychotic disorder; or another mental disorder that may lead to a chronic disorder.

Based on observation, interview, and record review the facility failed to ensure the medication error rate was not 5 percent (%) or greater. The facility had a medication error rate of 8%, based on 3 errors out of 34 opportunities, which involved 1 of 5 residents (Resident #35) and 1 of 4 staff (CNA A) reviewed for medication errors. - CNA A failed to administer the full dose of [MEDICATION(S)] ([MEDICATION(S)]), a stool softener, to Resident #35 when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - CNA A failed to administer the full dose of Artificial Tears, a lubricant eyedrop, to Resident #35. - CNA A crushed [MEDICATION(S)] SR 100 mg, a medication used to treat depression that should not be crushed and administered it to Resident #35. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects and a decline in health. Findings Included: Record review of Resident #35's face sheet revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's Quarterly MDS dated [DATE] revealed, resident used of corrective lenses, had moderately impaired cognition as indicated by a BIMS score of 11 out of 15, required extensive assistance for most ADLs, used a wheelchair and was always incontinent of both bladder and bowel. Record review of Resident #35's care plan revised on 02/08/2022 revealed focus areas of: antidepressant use related to a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 02/09/22 at 08:45 AM revealed CNA A preparing medication for administration to Resident #35. CMA A retrieved a bottle of Artificial Tears, [MEDICATION(S)]-[MEDICATION(S)] (25-250 mg) 1 tablet, [MEDICATION(S)] 100mg 1 tablet, [MEDICATION(S)] 500 mg 1 tablet, Aspirin 81 mg 1 tablet, [MEDICATION(S)] SR 100 mg 1 tablet, [MEDICATION(S)] 10 mg 1 tablet, [MEDICATION(S)] Sulfate (iron) 325 mg 1 tablet, [MEDICATION(S)] 5 mg 1 tablet, Multivitamin with Minerals 1 tablet, [MEDICATION(S)] 1.5 mg 1 tablet, [MEDICATION(S)] 25 mg1 tablet, Acetaminophen 500 mg 1 tablet, Zinc Sulfate 220 mg 1 tablet and 17 grams of [MEDICATION(S)]. She crushed all the tablets and opened the capsules and mixed them with pudding in an administration cup. CNA A mixed the 17 grams of [MEDICATION(S)] into a cup of 4-6 ounces of water. At 08:50 AM CNA A entered into Resident #35's room placed the cup of [MEDICATION(S)] mixed with water on Resident #35's bed side tray and informed him she would be administering his medications; she did not inform him that the cup was water that contained PEG. CNA A administered the crushed medications mixed with pudding to Resident #35 and the resident used the cup of stool softener to rinse his mouth, he did not drink the balance of the stool softener . CNA A put on a pair of gloves and attempted to administer the eye drop to the resident. She tilted the resident's head back slightly, held his bottom eyelid and positioned the eye drop above the resident's upper eyelid. CNA A instilled 1 drop which hit the resident's right upper eye lid, the medication did not enter his eye and ran down his face. The CNA wiped the liquid off Resident #35's face and then attempted to administer the medication to his left eye. CNA A titled the Resident #35's head back, held the resident's upper and lower left eye lid and instilled a drop which hit the resident's upper eyelid and only a small portion entered the resident's eye while the rest ran down his face. After administering the eye drops CNA A walked away to wash her hands and Resident #35 poured the balance of the [MEDICATION(S)] dissolved in water into his water jug, the resident did not drink the balance of the PEG before CNA A walked out of the resident's room, ending medication administration and documented the administration of the medication to Resident #35. In an interview on 02/09/21 at 08:55 AM, CNA A said that extended release medications should not be crushed because they release medication in the system over a longer period of time and that crushing that kind of medication altered the release pattern of extended release medications. She said Resident #35 required all his medications to be crushed and she had not noticed that his [MEDICATION(S)] SR 100 mg was an extended release medication. CNA A said since the resident could not swallow medication and the extended release medication could not be crushed, she would contact Resident #35's physician to see if his prescription could be changed to a liquid or immediate release formula. CNA A said she did not notice Resident #35 did not finish his PEG because the resident normally finishes his fluids. She said she should have informed the resident that the water contained his stool softener, prompted him to continue drinking and she should have observed him until he finished the solution. CNA A said Resident #35 had a tight neck and was unable to tilt his head further back and this in addition to his fear of eyedrops made it difficult to administer eye drops to him. She said that she should have alerted his nurse about the failure to administer the full dose of PEG and artificial tears and then attempted to administer the medication again. In an interview on 02/10/22 at 12:30 PM, the DON said that prior to medication administration nursing staff should first verify the medication against the MAR and double check the resident against the MAR. Once medication is prepared, nursing staff should enter into the resident room and introduce themselves informing the resident of the medication that will be administered. She said that nursing staff should administer the medication and remain with the resident to confirm the medication is swallowed or in the case of liquid medications, the volume is finished. The DON extended/sustained release medication should not be crushed because it would interfere with how the medication is distributed in the body and that any medication that is not administered correctly should be marked as so in the MAR and the physician should be contacted for any discrepancies. She said failure to administer the correct volume of medication places residents at risk of inadequate therapy and adverse events. Record review of CNA A's Medication Pass Observation competency assessment dated [DATE] revealed: 6- Medication Pass, a. Staff informs resident what medication is for. 7- Medication Preparation, a. Prepared by the same person and staff stays with resident until the medication is taken. 13- directions for preparation/administration/manufactures specification Clinical Skills (Procedures). CNA A met all listed performance criteria. Record review of the facility's policy Administering Oral Medications revised October 2010 revealed: 11- explain the procedure to the resident, 21- remain with the resident until all medications have been taken. Record review of the facility's policy Crushing Medications revised April 2018 revealed: The nursing staff and/or consultant pharmacy shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or [MEDICATION(S)] coated medications). Record review of the undated facility's policy Proper Administration of Eye Drops revealed: Tilt head backward, gently grasp lower outer eyelid below eyelashes and pull eyelid away from eye to create a pouch, place dropper over eye by looking directly at it.

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 of 5 residents (Resident #65) reviewed for pharmacy services. - The facility failed to ensure that Resident #65 was not administered medications stored outside of specified manufacturer temperature ranges. This failure could place residents receiving medications at risk of adverse medication reactions. Findings Included Record review of Resident #65's factsheet revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, heart failure, unstageable pressure ulcers, immobility syndrome, kidney failure, gastrostomy and muscle weakness. Record review of Resident #65's Quarterly MDS dated [DATE] revealed, resident had a memory problem, a BIMS should not be conducted, was totally dependent with most ADLs and had an ostomy, . Record review of Resident #65's care plan revised 12/01/21 revealed, focus areas- resident required tube feeding related to trouble swallowing, indwelling foley catheter and has an ADL self-care performance deficit related to disease process Record review of Resident #65's Physicians Orders dated 12/30/21 revealed, Lactobacillus Capsule give 1 capsule via g-tube three times a day for GI health. Flush G-tube with 30 mL of water before and after meds, flush with 10 ml of water between meds. An observation on 02/09/22 at 07:27 AM revealed, LVN A prepared medication for administration to Resident #65 via G-tube. She retrieved 1 capsule of Acidophilus, a probiotic, with manufacturer instructions of Refrigerate After Opening, and other solid and liquid medications stored at room temperature in the cart drawer for administration to the resident from the nursing cart and placed them in individual medication cups. LVN A crushed all the tablets and opened the Acidophilus, emptying the contents into a medication cup. At 07:40 she entered into Resident #65's room, retrieved room temperature water and diluted the crushed medication with 10 mL of water. LVN A checked the resident's g-tube for placement, performed a 30 mL flush and then administered the medications to Resident #35 with 10 mL flush between each medication. In an interview on 02/09/22 at 02:20 PM, LVN A said she checked her cart for expired medications and those stored at the wrong temperature weekly and daily as medication were used. She said Acidophilus administered to Resident #65 was stored in her nursing cart and never refrigerated. LVN A said she did not know the Acidophilus had to be stored in the refrigerator and since the medication was stored at the wrong temperature, it should not be used, and she should not have administered it. She said medications that require refrigeration can lose their efficacy because they deteriorate when stored at room temperature. She said since the bottle of acidophilus was stored incorrectly it should be discarded in drug disposal bin located in the medication room. Record review of the facility in-service record titled Survey Ready Medication Administration dated 07/27/21 and completed by the DON revealed LVN A was in attendance. Record review of the facility's policy Storage of Medications revised April 2007 revealed. 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 9- medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Record review of a blank facility competency assessment titled Med Pass Observation revealed, 23. Expired medications a- medications are not expired when administered and stored under proper condition. An interview on 02/10/22 at 12:30 PM. with the DON said that she could not locate LVN A's Med Pass Observation competency assessment In an interview on 02/09/22 at 02:30 PM, the DON said that unit managers audit nursing carts weekly for inappropriately stored medications weekly while nursing staff should check their carts daily as medications are used. She said all medications should be stored within manufacturer specified temperature ranges and medications stored outside of this specified range could no longer be used. The DON said when medications are stored at the wrong temperature or expire they can become ineffective placing residents at risk for insufficient therapy and adverse reactions. The DON said she did not know that the bottle of Acidophilus had to be refrigerated once opened.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse are thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 (Resident #52) of 7 residents reviewed for abuse. - The facility failed to properly investigate allegations of abuse of Resident #52. These failures could place residents at risk of abuse and neglect. Findings Included Record review of Resident #52's face sheet revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #52's Quarterly MDS fated 12/29/21 revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, limited assistance with most ADLs, an indwelling catheter and ostomy. Record review of Resident #52's care plan last revised on 12/06/21 revealed, focus - potential to demonstrate verbally abusive and combative behaviors related to poor impulse control, [CONDITION(S)]. Focus- ineffective coping; verbal aggression towards staff and other residents related to anger, poor impulse control. Interventions- Do not express your anger or impatience verbally or with physical movements (i.e Shaking head, pointing finger). These responses are likely to increase confusion and agitation. Record review of Resident #52's progress notes from 08/27/21 to 02/10/22 revealed, no record of the alleged abuse by LVN B. In an interview on 02/09/22 at 05:25 AM, CNA C said sometime in December she observed LVN B throw Resident #52 on a bed aggressively during a transfer when she requested help. She said that she reported this incident to the DON later in January but nothing was done about it. CNA C said that the DON said due to the fact that she reported the incident late, too much time had passed and there was no way to investigate the allegation. CNA C said the DON failed to report investigate the incident and report it to state. In an interview on 02/10/22 at 10:41 AM, the DON said that CNA C reported an allegation of LVN B aggressively tossing Resident #52 into bed in January but the incident occurred in December. She said that she did not believe the allegation to be true since the resident was heavy and would not be able to be tossed on a bed by a single staff. The DON said that she did not report the incident to the state agencies because it was reported late and CNA B did not say it was abuse. She said there was no abuse report or accident/incident report or investigation report completed for the alleged incident. In an interview on 02/10/22 at 12:20 PM, the Administrator said she was never informed of the allegation CNA C made about LVN B throwing Resident #52 in bed. She said she just learned about the incident today and she was out due to COVID at the time the DON received the complaint. The Administrator said per the facility policy the incident should have been reported and investigated properly and as of today there was no investigation initiated regarding the allegation of abuse of Resident #52 . She said that per the facility policy once an allegation is received an investigation is initiated immediately, the social worker does rounds with the resident, while the nursing department under the supervision of the DON perform assessments on the residents involved. She said all the information from the investigation should be submitted to the state in the 5 day report. The Administrator said residents are placed at risk for continuation of abuse if allegations of abuse are not investigated or reported appropriately. In an interview on 02/10/22 at 01:00 PM, Resident #52 said he had no issues or incidents of abuse or neglect with LVN B. He said he was never treated aggressively by any staff and that the staff were nice and respectful. In an interview on 02/10/21 at 02:10 PM the HR Coordinator said that in January of 2022 CNA B asked to be removed from LVN B's hall. She said that CNA B informed her that she could no longer work with her and that LVN B slammed Resident #52 in bed and that LVN B was mean and rough with resident. The HR Coordinator said she reported this to the Social Worker, who then interviewed CNA B. In an interview on 02/10/22 at 02:28 PM, the Social Worker said that In January CNA B expressed that she observed LVN B picked up Resident #52 of the floor and threw him in bed. She said that she did not create an incident/accident/abuse reports and she spoke with CNA B over the phone and requested CNA B provide a written statement. The Social Worker said CNA B wrote a statement but she didn't sign it She said she notified Administrator and the DON about the allegation and spoke briefly with LVN B and Resident #52 about the incident, but neither of them remembered such an incident occurring. The Social Worker said that the Administrator is the facility's abuse coordinator and when abuse is suspected facility staff are required to intervene in the situation and report appropriately to facility management, the ombudsman, and the state agency while an investigation is completed. She said beyond the undated statement made by CNA B the facility did not perform further investigation into the incident because the allegation came in a month after it occurred. Record review of an unsigned witness statement dated 01/28/22 revealed, when I was working with LVN B on 100 hall, when I passed down the hall I seen Resident #52 on the floor and there was no one else to help but LVN B. CNA C asked LVN B to come quick because Resident #52 was on the floor. LVN B was upset and said Resident #52 does this all the time. LVN B moved the wheelchair and grabbed Resident #52 by the arm, picked him up and threw him down and started talking crazy to Resident #52, saying don't do it again, she was upset. Record review of Social Progress Notes dated 01/28/22 signed by the Social Worker revealed, she spoke with Resident #52 and he denied having a fall recently and he had not gotten up that day. Resident #52 was calm and displayed no signs of any emotional distress or anxiety. He stated that he had no current concerns and he denied that any staff helped him off the floor in a negative or harmful way and denied any falls. Record review of Social Progress Notes dated 01/20/22 signed by LVN B revealed, I do not know anything regarding the accusation and it never happened. I cannot independently transfer the patient in question by myself or without any help. Record review of the facility in-service record Abuse and Neglect dated 01/05/22 and conducted by the DON revealed, employee group(s) present- direct care team, RN/LVN, CNA and all staff. The abuse coordinator is the Administrator, if you witness or hear of any suspected or alleged abuse or neglect, report it immediately to the abuse coordinator. Your responsibility is to report it and the abuse coordinator to proceed. Record review of the facility in-service record Abuse and Neglect dated 01/14/22 and conducted by the DON revealed CNA C was in attendance. Record review of the facility's policy Abuse and Neglect- Clinical Protocol revised 04/2007 revealed, assessment and recognition 1. The nurse will assess the individual and document related finding. Assessment date will include a- injury assessment(bleeding, bruising deformity, swelling etc.) . d- vital signs, e- behavior over the last 24 hours. Treatment/Management- 1- The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2- the management and staff, with the support of the physicians (as needed), will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Monitoring and Follow up 1- The staff and physician will monitor individuals who have been abused at least until their medical condition, mood and function have stabilized, and periodically thereafter.

Based on interview and record review the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges for one of seven residents(Resident #1) reviewed for diagnostic services in that. - The facility did not timely report Resident #1's radiology findings of an acute [CONDITION(S)] to the ordering physician, resulting in a 2 day delay in treatment. This failure could place residents who required radiology services at risk for delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Included: Record review of Resident # 1's face sheet revealed the resident was a [AGE] year-old female, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's minimum data set (MDS) dated [DATE] revealed in part: resident wore corrective lenses, had intact cognition as indicated by a Brief Interview of Mental Status (BIMS) score of 13 out of 15, needed extensive assistance with all activities of daily living and was mobile with a wheelchair. Resident#1 was not steady, only able to stabilize with staff assistance when moving from a seating to standing position and transferring between bed and chair or wheelchair. Resident was frequently incontinent of both bladder and bowel, experienced pain occasionally, had 2 or more falls with no injury in the 7-day review period, and was on a mechanically altered diet. The resident received physical therapy. Record review of Resident #1's care plan revised on 06/30/21 revealed in part: Focus- resident is at moderate risk for falls related to weakness and history of falls. Intervention- re-orient resident on the use of call light and call for help when necessary, be sure resident's call light is within reach and encourage resident to use it for assistance, resident needs prompt response to all requests for assistance. Record review of Resident #1's Nursing Progress Notes dated 06/19/21 at 07:11 AM completed by LVN B revealed: writer was called into the resident's room where resident was observed on the floor next to her wheelchair. Resident #1 was assessed and with the help of the aides and was moved to her bed. The resident denied she was in pain and there were no indications of pain. The MD was notified, and he placed a standing order for an x-ray for any limb or joint Resident #1 complained of having pain going forward. In an interview conducted on 06/29/21 at 03:10 PM, LVN B said on 06/19/21 she was informed by an aide that Resident #1 was found on the floor. The resident was assessed and had no complaint of pain, so the MD put in a standing order for X-rays in case the resident complained about pain. On 06/22/21 the resident complained about pain and an X-ray was performed but no fracture was found. Record review of Resident #1's Nursing Progress Notes dated 06/22/21 at 01:00 PM completed by LVN A revealed: Resident #1 complained of pain to left hip and left knee, resident was assessed, pain scale 5 out of 10, left knee yellowish discoloration and tender to touch. Resident #1 was given Tylenol as needed for pain, and a x-ray of both hips and knees were ordered and completed. Record review of Resident #1's Radiology report dated 06/22/21 with a fax receipt time of 02:00 PM revealed: no suspicious fractures or dislocations were identified for Resident #1's left hip, right hip, left knee and right knee. Record review of Resident #1's Nursing Progress Notes dated 06/22/21 at 6:29 PM completed by LVN B revealed: Resident #1's x-ray results came in and the MD was notified. No new orders as of this time, resident complained of a little pain and was given an as needed dose of pain killer. Record review of Resident #1's Nursing Progress Notes dated 06/25/21 at 05:54 PM revealed: Resident complained of increased pain to the left hip this shift, greenish bruises noted suspected fall on 06/19/21. Medication Tylenol 650 mg given for pain, new order received to repeat left hip and left knee x-ray called into the radiology provider. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Radiology Report dated 06/26/21 with a fax receipt time of 11:00 AM revealed: Resident #1 had an acute (severe and sudden) severely displaced left [CONDITION(S)]. The X-ray was signed by the radiology provider's medical doctor on 06/26/21 at 10:57 AM. In an interview conducted on 06/30/21 at 11:15 AM, the DON said that on the morning of 06/28/21 the ADON checked the fax machine and saw X-ray results for Resident #1 came in over the weekend, on 06/26/21. The DON said RN A was the weekend supervisor and she was responsible for checking the fax for any incoming laboratory of radiology reports. The DON said nurse supervisors are responsible for making sure radiology reports are communicated to the residents physicians and to make sure appropriate action is taken. Record review of Resident # 1's Situation, Background, Assessment, Recommendations- tool to facilitate prompt and appropriate communication (SBAR) dated 06/28/21 completed by LVNA revealed: The change of condition started on 06/28/21, this condition, symptom or sign had not occurred before. The Pain evaluation indicated the pain was new with an intensity of 5 out of 10. The recommendation of primary clinician was an X -ray. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 10:30 AM, completed by LVN A revealed: X-ray result received showed acute fracture of the left hip. The MD (medical doctor) was notified and an order was written for the resident to be sent to the hospital. Patient stated she had pain on her left hip at 5 out of 10 on the pain scale. New order for Tylenol #3 (Acetaminophen-[MEDICATION(S)] #3), a pain medication, as needed received and an initial dose was given. Transportation notified for pick up. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 11:16 AM LVN A revealed: Resident received 1 tabled of Tylenol # 3 with note given for left hip pain. Record review of Resident #1's Pain assessment dated [DATE] at 11:18 AM revealed: The resident had vocal complaints of pain, received pain medication as needed and pain was on left hip on a pain scale of 5 out of 10. No answers were provided for the frequency of pain and the effect of pain on Resident #1's function. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 12:23 PM completed by LVN A revealed after receiving pain medication at 11:16 AM the residents follow-up pain scale was 1 out of 10. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 01:25 PM completed by LVN A revealed: patient picked up and transported to hospital via stretcher. Record review of Resident #1's Nursing Progress Notes dated 06/30/21 at 10:35 AM revealed: resident returned from the hospital with a fracture, she is very tired and not feeling like herself . Record review of Resident # 1's Medication Review Report dated 06/30/21 revealed: Prior to 06/28/21 Resident #1 had orders for Tylenol 325 mg, 2 tablets every four hours as needed for pain with start date 06/06/2017. Following identification of the fracture, on 06/28/21, Resident # 1 received new orders Tylenol #3, 1 tablet every 6 hours as needed for pain. Upon return from the hospital, on 06/30/21, Resident #1 received orders for Tylenol #3 on a fixed schedule every 6 hours for pain. Resident #1 had no other medications prescribed for pain management. In an interview conducted on 06/30/21 at 01:27 PM, Resident #1 said she was in a lot of pain for days, over the weekend, and she was receiving some pain medication to help her sleep before leaving for the hospital. Resident #1 said her pain level was a 10 out of 10 and she was screaming out in pain the day she was sent to the hospital. Resident # 1 said since the fracture and her return from the hospital it was a little harder for her to move around. She said she was now receiving medication that made her pain better, but she still had some pain when she moved around. In an interview on 06/30/21 at 01:37 PM, the ADON said on 06/19/21 the doctor put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An x-ray was performed on 06/22/21 but no fracture was found. The ADON said on 06/25/21Resident # 1 complained about pain again an x-ray was ordered. The ADON said on Monday, 06/28/21, she checked the fax machine and found Resident #1's x-ray results, faxed to the facility on [DATE], were still on the fax machine. She said the x-ray indicated Resident #1 had a left [CONDITION(S)]. The ADON said she immediately informed the DON and instructed LVN A to contact the doctor to alert him of Resident #1's x-ray results. The ADON said the weekend nurse supervisor, RN A was responsible for checking the fax for any incoming reports and making sure the doctor was informed of the findings. The ADON said if the x-ray results were seen on 06/26/21, Resident #1 would have been sent out to the hospital immediately but instead she was sent on 06/28/21, when the results were found. In an interview on 06/30/21 at 01:45 PM, LVN A said Resident #1 complained of pain on 06/21/21 and 06/22/21. She said on 6/22/21 the resident was not behaving like herself so an x-ray was ordered but no fracture was found. LVN A said over the next week she noticed the resident still complained of pain and was less mobile, so an x-ray was ordered on 06/25/21. LVN A said on 06/28/21 the x-ray results confirmed Resident #1 had a left [CONDITION(S)]. LVN A said the weekend supervisor, RN A, was responsible for receiving x-ray results faxed to the facility and informing the floor nurse who then notifies the MD. In an interview on 06/30/21 at 02:10 PM, the DON said the missed x-ray results over the weekend was due to changes the facility made to its provider in April. The DON said the previous provider called to alert nursing staff of any fractures or positive findings, so staff was directly informed of the results before sending a confirmatory fax. The DON said after talking to the new X-ray provider she found out the facility's current x-ray provider only sends a fax regardless of the x-ray results. She said the weekend staff was probably not aware of Resident #1's results because no one called to inform them. In an interview on 06/30/21 at 02:20 PM with the DON, a request was made for facility policies on radiology services and reports. The DON said there was no facility policy specifically addressing radiology services and reports. In an interview on 06/30/21 at 02:30 PM with the DON, a request was made for in-service records or policies addressing expectations for the communication of radiology reports. The DON said no such in-services or policies existed. In an interview on 06/30/21 at 02:40 PM, RN A said she was the weekend nurse supervisor from 06/26 through 06/27/21. She said she was not aware of any pending x-ray results for Resident #1 or any other residents, so she did not check the fax on her weekend shifts. RN A said normally if x-ray results showed a fracture, the x-ray company would call the facility to inform them of the results before faxing it. RN A said she did not receive a call from the x-ray company over the weekend. In an interview on 06/30/21 at 03:06 PM, X-ray A said an order came in for a routine x-ray for Resident #1 on 06/25/21 at 11:45 PM and since it was not a stat order the x-ray was completed on 06/26/21 at 09:00 AM. X-ray A said the results were read and faxed to the facility on [DATE] at 11:00 AM and 11:01 AM. She said the x-ray results are always faxed and never called in regardless of the findings. X-ray A said their company uses a verification system that placed a check mark by the transmission information in their system when a fax is received by a recipient. She said a verification checkmark was present on Resident #1's x-ray results transmitted on 06/26/21 at 11:00 AM and 11:01 AM. Record review of facility in-service titled Clinical Documentation-Alert dated 05/21/21 revealed: All x-ray /lab result documentation must be done in the electronic chart and 24-hour book. Do not drop off important data from previous shift. Record review of facility policy titled Change in a Resident's Condition or Status revised December 2016 revealed: 1- The nurse will notify the resident's attending physician or physician on call when there has been a (an) d. significant change in the resident's physical/emotional/mental condition. 2- A significant change in condition is a major decline or improvement in the resident's status that A. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions 5. Except in medical emergencies, notification will be made timely when a change occurs in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for quality of care in that. -The facility nursing staff failed to obtain radiology results for Resident #1 after she received a radiology test ordered by her physician, leaving the resident in pain and discomfort for 2 days before action was taken. This failure could affect residents with a change of condition at risk for a delay of care or treatment, pain and suffering. Findings Included: Record review of Resident # 1's face sheet revealed the resident was a [AGE] year-old female, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's minimum data set (MDS) dated [DATE] revealed in part: resident wore corrective lenses, had intact cognition as indicated by a Brief Interview of Mental Status (BIMS) score of 13 out of 15 , needed extensive assistance with all activities of daily living and was mobile with a wheelchair. Resident#1was not steady, only able to stabilize with staff assistance when moving from a seating to standing position and transferring between bed and chair or wheelchair. Resident was frequently incontinent of both bladder and bowel, experienced pain occasionally, had 2 or more falls with no injury in the 7-day review period, and was on a mechanically altered diet. The resident received physical therapy. Record review of Resident #1's care plan revised on 06/30/21 revealed in part: the resident was a moderate fall risk related to weakness and history of falls. The Interventions were to re-orient the resident on the use of call light, call for help when necessary, ensure resident's call light was in reach, encourage resident to use the call light for assistance, and staff to provide the resident with prompt response to all requests for assistance. Record review of Resident #1's Nursing Progress Notes dated 06/19/21 at 07:11 AM revealed: writer was called into the resident's room where resident was observed on the floor next to her wheelchair. Resident #1 was assessed and with the help of the aides and was moved to her bed. The resident denied she was in pain and there were no indications of pain. The MD was notified, and he placed a standing order for an x-ray for any limb or joint Resident #1 complained of having pain going forward. Record review of Resident #1's Nursing Progress Notes dated 06/22/21 at 01:00 PM completed by LVN A revealed: Resident #1 complained of pain to left hip and left knee, resident was assessed, pain scale 5 out of 10, left knee yellowish discoloration and tender to touch. Resident #1 was given Tylenol as needed for pain, x-ray of both hips and knees were ordered and done. Record review of Resident #1's Radiology report dated 06/22/21 with a fax receipt time of 02:00 PM revealed: no suspicious fractures or dislocations can be identified for Resident #1's left hip, right hip, left knee and right knee. Record review of Resident #1's Nursing Progress Notes dated 06/22/21 at 6:29 PM revealed: Resident #1's x-ray results came in and the MD was notified. No new orders as of this time, resident complained of a little pain and was given an as needed dose of pain killer. Record review of Resident #1's Nursing Progress Notes dated 06/25/21 at 05:54 PM revealed: resident complained of increased pain to the left hip this shift, greenish bruises noted suspected fall on 06/19/21. Medication Tylenol 650 mg given for pain, new order received to repeat left hip and left knee x-ray called into the radiology provider. Record review of Resident #1's Physicians Orders dated 06/25/21 revealed: a repeat X-rays of left hip, lower leg (tibia and fibula) and knee 2 views one time only for 1 day. Record review of Resident #1's Radiology Report dated 06/26/21 with a fax receipt time of 11:00 AM revealed: Resident #1 had an acute (severe and sudden) severely displaced left hip fracture. The X-ray was signed by the radiology provider's medical doctor on 06/26/21 at 10:57 AM. In an interview on 06/30/21 at 11:15 AM, the DON said that on the morning of 06/28/21 the ADON checked the fax machine and saw X-ray results for Resident #1 came in over the weekend, on 06/26/21. The DON said RN A was the weekend supervisor and she was responsible for checking the fax for any incoming laboratory or radiology reports. The DON said nurse supervisors are responsible for making sure radiology reports are communicated to the resident's physicians and to make sure appropriate action is taken. Record review of Resident # 1's Situation, Background, Assessment, Recommendations- tool to facilitate prompt and appropriate communication (SBAR) dated 06/28/21 revealed: Resident #1 had a change of condition that started on 06/28/21 and there was no symptom or sign that had occurred before the change of condition. The Pain evaluation indicated the pain was new with an intensity of 5 out of 10. The recommendation of primary clinician was an X -ray. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 10:30 AM revealed: x-ray result received showed acute fracture of the left hip. The MD (medical doctor) was notified and an order was written for the resident to be sent to the hospital. Patient stated she had pain on her left hip at 5 out of 10 on the pain scale. New order for Tylenol #3 (Acetaminophen-[MEDICATION(S)] #3), a pain medication, as needed received and an initial dose was given. Transportation notified for pick up. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 11:16 AM revealed: Resident received 1 tabled of Tylenol # 3 with note given for left hip pain. Record review of Resident #1's Pain assessment dated [DATE] at 11:18 AM revealed: The resident had vocal complaints of pain, received pain medication as needed and pain was on left hip on a pain scale of 5 out of 10. No answers were provided for the frequency of pain and the effect of pain on Resident #1's function. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 12:23 PM revealed after receiving pain medication at 11:16 AM the residents follow-up pain scale was 1 out of 10. Record review of Resident #1's Nursing Progress Notes dated 06/28/21 at 01:25 PM revealed: patient picked up and transported to hospital via stretcher. Record review of Resident #1's Nursing Progress Notes dated 06/30/21 at 10:35 AM revealed: resident returned from the hospital with a fracture, she was very tired and not feeling like herself . Record review of Resident # 1's Medication Review Report dated 06/30/21 revealed: prior to 06/28/21 Resident #1 had orders for Tylenol 325 mg, 2 tablets every four hours as needed for pain with start date 06/06/2017. Following identification of the fracture, on 06/28/21, Resident # 1 received new orders Tylenol #3, 1 tablet every 6 hours as needed for pain. Upon return from the hospital, on 06/30/21, Resident #1 received orders for Tylenol #3 on a fixed schedule every 6 hours for pain. Resident #1 had no other medications prescribed for pain management. In an interview on 06/29/21 at 03:10 PM, LVN B said on 06/19/21 she was informed by an unnamed aide that Resident #1 was found on the floor. The resident was assessed and had no complaint of pain, so the MD put in a standing order for X-rays in case the resident complained about pain. On 06/22/21 the resident complained about pain and an X-ray was performed but no fracture was found. In an interview conducted on 06/30/21 at 01:27 PM, Resident #1 said she was in a lot of pain for days, over the weekend, and she was receiving some pain medication to help her sleep before leaving for the hospital. Resident #1 said her pain level was a 10 out of 10 and she was screaming out in pain the day she was sent to the hospital. Resident # 1 said since the fracture and her return from the hospital it was a little harder for her to move around. She said she was now receiving medication that made her pain better, but she still had some pain when she moved around. In an interview on 06/30/21 at 01:37 PM, the ADON said on 06/19/21 the doctor put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An x-ray was performed on 06/22/21 but no fracture was found. The ADON said on 06/25/21 Resident # 1 complained about pain again an x-ray was ordered. The ADON said on Monday, 06/28/21, she checked the fax machine and found Resident #1's x-ray results were faxed to the facility on [DATE]. She said the x-ray indicated Resident #1 had a left hip fracture. The ADON said she immediately informed the DON and instructed LVN A to contact the doctor to alert him of Resident #1's x-ray results. The ADON said the weekend nurse supervisor, RN A was responsible for checking the fax for any incoming reports and making sure the doctor was informed of the findings. The ADON said if the x-ray results were seen on 06/26/21, Resident #1 would have been sent out to the hospital immediately but instead she was sent on 06/28/21, when the results were found. In an interview on 06/30/21 at 01:45 PM, LVN A said Resident #1 complained of pain on 06/21/21 and 06/22/21. She said on 6/22/21 the resident was not behaving like herself so an x-ray was ordered but no fracture was found. LVN A said over the next week she noticed the resident still complained of pain and was less mobile, so an x-ray was ordered on 06/25/21. On LVN A said on 06/28/21 the x-ray results confirmed Resident #1 had a left hip fracture. LVN A said the weekend supervisor, RN A, was responsible for receiving x-ray results faxed to the facility and informing the floor nurse who then notifies the MD. In an interview on 06/30/21 at 02:10 PM, the DON said the missed x-ray results over the weekend was due to changes the facility made to its provider in April. The DON said the previous provider called to alert nursing staff of any fractures or positive findings, so staff was directly informed of the results before sending a confirmatory fax. The DON said the facility's current x-ray provider only sends a fax regardless of the x-ray results. She said the weekend staff was probably not aware of Resident #1's results because no one called to inform them. In an interview on 06/30/21 at 02:20 PM with the DON, a request was made for facility policies on radiology services and reports. The DON said there was no facility policy specifically addressing radiology services and reports. In an interview on 06/30/21 at 02:30 PM with the DON, a request was made for in-service records or policies addressing expectations for the communication of radiology reports. The DON said no such in-services or policies existed. In an interview on 06/30/21 at 02:40 PM, RN A said she was the weekend nurse supervisor from 06/26 through 06/27/21. She said she was not aware of any pending x-ray results for Resident #1 or any other residents, so she did not check the fax on her weekend shifts. RN A said normally if x-ray results showed a fracture, the x-ray company would call the facility to inform them of the results before faxing it. RN A said she did not receive a call from the x-ray company over the weekend. In an interview on 06/30/21 at 03:06 PM, X-ray A said an order came in for a routine x-ray for Resident #1 on 06/25/21 at 11:45 PM and since it was not a stat order the x-ray was completed on 06/26/21 at 09:00 AM. X-ray A said the results were read and faxed to the facility on [DATE] at 11:00 AM and 11:01 AM. She said the x-ray results are always faxed and never called in regardless of the findings. X-ray A said their company used a verification system that placed a check mark by the transmission information in their system when a fax was received by a recipient. She said a verification checkmark was present on Resident #1's x-ray results transmitted on 06/26/21 at 11:00 AM and 11:01 AM. Record review of facility in-service titled Clinical Documentation-Alert dated 05/21/21 revealed: All x-ray /lab result documentation must be done in the electronic chart and 24-hour book. Do not drop off important data from previous shift. Record review of facility policy titled Change in a Resident's Condition or Status revised December 2016 revealed: 1- The nurse will notify the resident's attending physician or physician on call when there has been a (an) d. significant change in the resident's physical/emotional/mental condition. 2- A significant change in condition is a major decline or improvement in the resident's status that A. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions 5. Except in medical emergencies, notification will be made timely when a change occurs in the resident's medical/mental condition or status. Record review of facility policy titled Falls-Clinical Protocol revised April 2007 revealed: Monitoring and Follow-up- The staff, with physicians guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture have been ruled out. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall.

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 that: -Food was improperly sealed in the refrigerator. -Food was improperly sealed in the pantry. - Food in Pantry not properly labeled. These failures could affect residents eating food prepared in the kitchen, placing them at risk of foodborne illness. Findings include: Observations of the facility's kitchen on 11/09/2020 beginning at 10:00 a.m. revealed: Pantry -12 pack of hamburger buns with no opened date on package that had a large whole in the package there was about 6 buns remaining in the package. -Seasoning containers of garlic powder, lemon pepper, onion powder, paprika, and [MEDICATION NAME] leaves lids did not properly close to seal the containers. -Package of opened hamburger buns with three remaining buns in package no opened date on package. -Less than half a package of white bread no date on it. -2 packages of whole wheat bread opened no dates on packages. -A scoop sitting on top of a big white storage bin with corn meal in it not in a bag. Refrigerator -2 quart (qt) square plastic container with a label of p.b. (pinto beans) date 11/8/2020 lid not sealed on container. -Jelly in 3.5 liter (L) container lid not tightly secured on container. -3.5 L container with 1 qt remaining dated 11/6/2020 with c. flower (cauliflower) written on it lid not secured on container. -2 qt container with 1.5 liters remaining dated 11/6/2020 labeled m. sauce (marinera sauce) lid not tightly sealed. -2 qt container half full dated 11/7/2020 labeled tuna salad not sealed. In an interview on 11/9/2020 at 10:15 a.m., the Dietary Manager said the lids should snap and if they did not snap then they should wrap the container. Dietary Manager said they usually put a date on bags when they open the bread. The seasoning container lids just needed to be cleaned in order for them to close properly. All the kitchen staff was in charge of making sure things are store properly. Record review of the facilities policy labeled Food Receiving and Storage dated December 2008 revealed in part Food shall be received and stored in a manner that complies with safe food handling practices. All foods in the refrigerator or freezer will be covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 residents (Residents #52 and #79) reviewed for comprehensive care plans. -The facility failed to implement the care planned fall interventions for Resident #79. - The facility failed to create an activities care plan for Resident #52. These failures could place resident who experiences sat risk of not having their needs met and reduced quality of life. Findings include: Resident #52 Record review of Resident # 52's face sheet revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the Initial Minimum Data Set assessment ((MDS) dated [DATE] revealed Resident #52 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he had moderate cognitive impairment. He required extensive assistance of one person for transfers, dressing, and eating. He required total assistance of one person for toileting, personal hygiene, and bathing. Record review of Resident #52's care plan with an initiated date of 9/28/2020 revealed no care plan for activities. In an interview with the Activity Director on 11/11/2020 at 3:28 p.m. revealed she did the care plans based off a calendar provided to her by the MDS coordinator. She stated Resident #52 received 1 on 1 activities because he did not like to come out of his room and preferred to stay to himself when he was in the facility. In an interview with the MDS Coordinator and the PPS Coordinator on 11/11/2020 at 3:30 p.m. the MDS Coordinator said that MDS Coordinator gave the Activity Director a calendar listing residents needing quarterly or annual care plans. Newly admitted residents were not on this calendar. The PPS Coordinator stated that the initial activities care plan should have been completed after section F of the MDS was completed. In a second interview on 11/11/2020 at 3:32 p.m., the Activity Director said that Resident #52 was originally quarantined when he entered the facility and she could not go visit him. When she entered the quarantined halls she was not allowed back in the facility, so she must plan to do so at the end of her shift. Resident #79 Record review of the Admission Record for Resident #79, revealed a [AGE] year old female initially admitted on [DATE] and re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #79 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating she had moderate cognitive impairment. She required extensive assistance from 2 people for bed mobility and transfers. She required total assistance from one person assistance with toilet needs. She required extensive assistance from one person for dressing and personal hygiene. She was always incontinent of bladder and she had a [MEDICAL CONDITION]. The MDS read in part, .Section DJ: Health Conditions - J1800, indicated that she had no falls since admission/entry or reentry . Record review of Resident #79's online Comprehensive Care plan, viewed on 11/10/2020 read in part: Focus- Resident had an actual fall and is at risk for further falls related to (r/t) decreased mobility, poor cognitive function and poor safety awareness. -9/14/2018- actual fall, redness to left side of head -11/16/2019-actual fall, no visible injuries noted -07/25/2020 - actual fall - abrasion to right forearm, bruise the left wrist. -Date initiated: 08/22/2018, Revised on 08/10/2020 -Goal - will be free of injuries related to (r/t) falls through the review date. Date initiated 08/22/2018. Revised on 6/11/2019. Target date 09/29/2020. -Interventions read in part: 11/16/2019 - Continue with interventions already in place, floor mat next to bed. Date initiated 11/25/2019 . 09/14/2018 - Position bed against wall, low bed, floor mat, encourage resident to call for assistance using the call light. Date initiated 10/10/2018 . Record review of Resident #79's fall investigation worksheet dated 11/08/2020 read in part, . per the patient she was turning in bed and rolled out . Observation on 11/09/2020 at 10:40 a.m., Resident #79 was in her room in bed with a sitter. There was no floor mat next to her bed. The bed was not against a wall. Observation on 11/10/2020 at 1:45 p.m., Resident #79 was in her bed, no sitter by her side. There were no floor mats near her bed and bed was not up against the wall. In an interview on 11/10/2020 at 1:45 p.m. RN S said she did not know if Resident #79 was a fall risk and would have to check to see if she has had falls. The sitter for the roommate said Resident #79 fell on Sunday. The sitter said she knew this because the resident she was caring for, in bed B told her. In an interview on 11/10/2020 at 2:27 p.m., the DON stated if a resident is a fall risk we would use floor mats, put bed up against wall, keep bed low. When asked why was there not a floor mat next to Resident #79's bed and why was the bed not against the wall as stated in the care plan. She said the resident did not like to have the bed up against the wall. It also makes it difficult for staff to boost her up in bed when doing resident care. It is also makes it awkward for where the sitter sits. She said the care plan has not been updated. In an interview on 11/11/2020 at 08:50 a.m., LVN R said Resident #79 was not really a fall risk, I don't know what happened last Sunday. She said Resident #79 had a private duty sitter nearby and sitter was not present on weekends. In an interview on 11/11/20 at 02:30 p.m., the MDS Coordinator said she was responsible for the first care plan. She agreed that a resident fall triggered an assessment by the nurses. Then an investigation was done. When nurses reviewed resident records, they could read the care plan on their kiosk. She said her expectation was that the nurses then communicate the interventions to the CNAs. Record review of facility policy and procedure titled: Care plans, Comprehensive Person-Centered, 2001 MED-PASS, Inc. (Revised December 2016), revealed in part: Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Record review of facility policy and procedure titled: Falls and Fall Risk, Managing, 2001 MED-PASS, Inc. (Revised December 2017), revealed in part: Policy Statement - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .

Based on interview, and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment to attain or maintain the highest practicable physical and mental well-being for one of ten residents (CR #1) reviewed for services provided. CR # 1 who was admitted with the [DIAGNOSES REDACTED]. CR # 1 was transferred to the hospital on [DATE] with an critical blood sugar level. This failure affected 1 resident whose blood glucose was not monitored and placed 40 residents with diabetes at risk of complication which could lead to a decline in both physical abilities and psychosocial well-being. Findings included: Intake # 9 Record review of CR# 1 ' s face sheet revealed an 86 year old female admitted to the facility on 3/10/14. Her [DIAGNOSES REDACTED]. Record review of CR #1 ' s care plan dated 5/29/14 revealed the resident was a diabetic and at risk for frequent infections , pressure /venous /stasis ulcers, vision impairment, hyper/hypo- glycemia, [MEDICAL CONDITION] , cognitive /physical impairment. Goal was diabetic status will remain stable as evidenced by resident's blood sugar staying within normal limits over the next 90 days. Approaches included: give meds per order, monitor labs, report results to MD, and monitor blood glucose per MD orders . Record review of CR #1 ' s MDS dated [DATE] , revealed the resident was severely impaired for cognition with long and short term memory problems. She was dependent on staff for all ADLs and required extensive assistance for eating and listed diabetes mellitus as one of her active diagnoses. Record review of CR#1 ' s physician's orders [REDACTED]. Record review of CR # 1 ' s lab result dated 7/30/14 revealed the resident's Hemoglobin A1c result " pending " . Further review of the result revealed a hand written noted which read " MD notified " . Record review of CR#1 ' s physician order [REDACTED]. Record review of CR#1 ' s BMP lab result dated 8/20/14 revealed Glucose critical high values of Glucose 478 mg/dl. Record review of CR#1 ' s transfer form dated 8/20/14 revealed the resident was transferred to the hospital on [DATE] due to critical high lab values: sodium 179, chloride 135, BUN 102 and Glucose 478 mg/dl. Upon inquiry on 9/12/14, CR# 1 ' Hemoglobin A1c that were ordered on [DATE] results was printed out from the computer. Hemoglobin A1c result was 7.8% which meant a blood sugar of 174 mg/dl. The report was entered into the computer system on 7/31/14 but had not been printed by the facility until requested. Interview of on 9/12/14 at 2:10 P.M., ADON # 1 said he printed out the result from the computer today and CR# 1 ' s MD was not notified of the results prior. Interview on 9/12/14 at at 2:40 P.M., the DON after inquires with staff said CR# 1 had no orders for blood sugar checks, and was not on any medication for diabetes. Interview on 9/10/14 at 3:10 P.M., CR# 1 ' s family member said (CR # 1 ) was in the ICU, was unresponsive and did not know the family member was even there. She reported (CR# 1 ) now had gastrostomy tube, was on a ventilator due to [MEDICAL CONDITION] and the hospital was considering a [MEDICAL CONDITION]. She said (CR# 1) has been through so much and was still in ICU. Record review of CR# 1 ' s hospital record dated 8/21/14 revealed CR# 1 had chronic type II diabetes mellitus uncontrolled, glucose level of 469; plan revealed insulin sliding scale. No policy concerning diabetic monitoring was available. Facility census dated 9/9/14 was 104 with 40 residents had a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to provide sufficient fluids to maintain proper hydration and health to one of nine residents (CR#1) reviewed for hydration, who was dependent on staff for hydration and nutrition needs being met and who had been identified at a risk of dehydration. CR#1 who had documented weight loss, decrease in intake, and was totally dependent on staff for assistance was admitted to a local hospital with [DIAGNOSES REDACTED]. The failure affected one resident who developed kidney failure and was hospitalized and placed 87 residents who depended on staff for care at risk of dehydration and associated symptoms and complications including skin breakdown, urinary tract infections, kidney failure and a general health decline. Findings include: Intake # 9 Record review of CR# 1 ' s face sheet revealed an 86 year old female admitted to the facility on 3/10/14. Her [DIAGNOSES REDACTED]. Record review of CR# 1 ' s care plan dated 5/29/14 revealed CR #1 had impaired cognitive function /impaired thought process related to dementia. Approaches included: the resident needed total assistance with all decision making. Record review of CR #1's care plan dated 8/25/14 revealed the resident had unplanned /unexpected weight loss related to poor food intake. Care plan did not address CR# 1 ' s risk for dehydration. Record review of CR# 1 ' s Nurse notes dated 7/8/14 revealed CR# 1 had an 8 pound weight loss. Weight was recorded on 6/9/14 at 140 LBs with current weight at 132 Lbs. It was documented the weight loss was due to decrease in PO intake. The resident's resident MD , registered dietician and responsible party were notified related to weight change . Record review of CR# 1 physician's orders [REDACTED]. Hemoglobin A1C, TSH ([MEDICAL CONDITION] stimulating hormone), Lipid panel on Monday (7/28/2014) and every 3 months " . Record review of CR# 1 ' s lab values revealed they were dated on 7/30/2014. The resident's comprehensive metabolic panel lab result revealed abnormal values: sodium 150, BUN 29, Creatinine 1.4 and Glucose 147. Lab result had a hand written note " MD notified, no new orders received " . Record review of CR #1 ' s MDS dated [DATE] , revealed the resident was severely impaired for cognition with long and short term memory problems. She was dependent on staff for all ADLs and required extensive assistance for eating. Record review of CR# 1 ' s Nurse notes dated 8/13/14 revealed nutrition progress notes " aides reported pocketing food, weekly weight shows weight loss related insufficient PO intake, resident was at risk for undesirable weight loss ,impaired skin and dehydration , goal is weight maintenance with no significant weight change in 30, 90 and 180 days, continue plan of care, monitor weight , labs , intake and hydration " . Record review of CR#1 ' s Dietitian ' s report to the attending physician dated 8/13/14 revealed nutritional concerns: weight loss, pocketing food, liberalized diet to create home like environment. Recommendations included a speech therapy consult for pocketing. Above recommendation was approved by CR#1 ' s physician on 8/14/14. Record review on 9/9/14 of CR# 1 ' s record revealed no speech consults results following the recommendation 8/13/14. There was no evidence that the dietician was notified that CR# 1 consumed only 25% of served meals on 8/13/14, 8/15/14, 8/16/14, and 8/18/14 as outlined in the care plan. Further review of CR# 1 ' s record revealed increased risk for dehydration was not addressed following decreased PO intake and Dietician ' s consult and recommendations. Record review of CR# 1 ' s nutrition progress notes dated 8/20/14 revealed the resident's weekly weight showed continued weight loss related to insufficient PO intake secondary to suspected pocketing /swallowing difficulty. Speech consult ordered 8/13/14. Continue to monitor weekly weights to determine if increase in supplement is necessary for weight maintenance. CR# 1 was at risk for undesirable weight loss , impaired skin and dehydration secondary to advanced age and impaired mental status. Goal was weight maintenance with no significant weight change for 30, 90 and 180 days, continue plan of care, and monitor weight, labs, intake and hydration. Review of CR# 1 ' BMP lab result dated 8/20/14 revealed critical lab values for Sodium 179, Chloride 135, Glucose 478, BUN 102, and creatinine 4.0. Sodium, chloride, BUN and Glucose were listed as critically high values. Interview on 9/9/14 at 1:00 P.M., ADON #1 said CR# 1 had poor PO intake, and weight loss. She had critical lab values on 8/20/14 which resulted in the resident being transferred to the hospital. ADON #1 said the resident had unstable weight due to poor PO intake. He explained the dietician and physician were notified of the change. He stated the Dietician saw the resident twice. ADON #1 said CR# 1 was cognitively impaired and was dependent on staff for all ADLs including eating and drinking, CR# 1 did not request fluids and was unable to make needs known. Interview on 9/9/14 at 2:15 P.M., the DON said the facility ' s protocol was to do hydration rounds daily. She explained the aides did hydration rounds in the morning between breakfast and between lunch and dinner. The DON recalled CR# 1 was not eating by mouth and had significant weight loss. The DON said the resident was at risk of dehydration due to her impaired cognitive status and was dependent on staff for all care and decisions. She was unsure why the ordered labs were not done as ordered, and why the resident ' s increased risk for dehydration was not addressed when identified by dietician. Interview on 9/9/14 at 3:30 P.M., LVN # 1 said CR# 1 was not eating. LVN #1 said the resident continued to lose weight despite implemented recommendations by the dietician. Interview on 9/12/14 at 10:30 A.M., the Speech Therapist said she screened CR# 1 on 8/15/14 during lunch. CR# 1 was served pureed consistency. The Speech Therapist said she did not think the resident had any change from the last time she received speech therapy services (May 2014) for difficulty swallowing. CR# 1 was to continue pureed consistency with her meals. The Speech Therapist was unaware if the screen results were communicated to the dietician and when. She explained the department had a folder where some screen results were kept prior to filing in the resident ' s chart. The Speech Therapist said the resident was pocketing food and required constant cueing. Interview on 9/12/14 at 2:00 P.M., the DON and ADON # 1 did not know if the result of the speech screen was seen by the dietitian who saw CR#1 on 8/20/14. The DON said CR# 1 was seen by the dietician on 8/13 and 8/20 but had no explanation why the dietitian was not notified of CR # 1 ' s continued weight loss despite intervention. The DON and ADON # 1 agreed CR # 1 lost 12 Lbs. in about two twice and was last weighed on 8/18/14 and transferred to the hospital on [DATE]. ADON # 1 and the DON said the resident was sent to the hospital due to critical lab values. Record review of CR# 1 ' s hospital record dated 8/20/14 revealed " [AGE] year old female presents with altered mental status and unresponsiveness. Reportedly the patient has had poor PO intake for the last several days. Further review of record revealed the resident was critically ill with high probability of sudden significant deterioration of her condition as evidenced by altered mental status, [MEDICAL CONDITION], acute [MEDICAL CONDITION] , hypovolemia, dehydration, and leukocytosis " . Interview on 9/10/14 at 3:10 P.M., CR# 1 ' s family member said (CR # 1 ) was in the ICU was unresponsive and did not know the family member was even there. She reported (CR# 1 ) now had gastrostomy tube, was on a ventilator due to [MEDICAL CONDITION] and the hospital was considering a [MEDICAL CONDITION]. She said (CR# 1) has been through so much and was still in ICU. Facility ' s policy on Hydration dated April 2007 revealed " physician will manage significant fluid and electrolyte imbalances and associated risk, appropriately and in a timely manner. A- Timeliness depends on the severity nature and causes of the fluid and electrolyte imbalance. The staff and physician ' s input will identify individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance. Staff will report this information promptly to the attending physician." The facility ' s census listed 104 residents. The staff reported 87 residents were dependent on staff for ADLs.