Every finding on record at Ponchatoula Community Care Center

Based on observations, interviews, and record review, the facility failed to ensure medications were properly stored in 2 (Med Cart 2 and Med Cart 3) of 3 (Med Cart 1, Med Cart 2, and Med Cart 3) medication carts observed for medication storage. Findings: Review of the facility's policy titled, Storage of Medications, dated 11/2020 revealed in part, the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Review of the Lorazepam medication insert, which was located within the Lorazepam box, revealed in part, the following: How should I store Lorazepam? Store Lorazepam at a cold temperature. Refrigerate at 36 degrees Fahrenheit to 46 degrees Fahrenheit. Review of research information given to surveyor by facility's Pharmacy Consultant revealed in part, the following: Lorazepam storage: Refrigerate between 36 degrees Fahrenheit to 46 degrees Fahrenheit. Review of additional document given to surveyor by facility's Pharmacy Consultant titled Oral and Enteral Medications revealed in part, the following: Lorazepam Solution: Store in refrigerator. An observation was made on 08/12/2024 at 9:40 a.m. of Med Cart 2 with S5LPN. Observed 1 opened bottle of Lorazepam 2mg/mL for Resident #18, which was warm to touch, located in the narcotic lock box drawer of the medication cart. The Lorazepam bottle and box revealed a label which read Refrigerate located on the box and bottle. An interview was conducted on 08/12/2024 at 9:40 a.m. with S5LPN. S5LPN confirmed the label on Resident #18's bottle and box of Lorazepam read Refrigerate and should have been placed back into the refrigerator after each dose. S5LPN confirmed the bottle of Lorazepam was room temperature and opened. S5LPN reviewed the narcotic log book for Resident #18's Lorazepam and stated the last dose administered was on 08/11/2024. An observation was made on 08/12/2024 at 10:10 a.m. of Med Cart 3 with S6LPN. Observed 1 opened bottle of Lorazepam 2mg/mL for Resident #97, which was warm to touch, located in the narcotic lock box drawer of the medication cart. The Lorazepam bottle and box revealed a label which read Refrigerate located on the box and bottle. An interview was conducted on 08/12/2024 at 10:10 a.m. with S6LPN. S6LPN confirmed the label on Resident #97's bottle and box of Lorazepam read Refrigerate and should have been placed back into the refrigerator after each dose. S6LPN confirmed the bottle of Lorazepam was room temperature and opened. S6LPN reviewed the narcotic log book for Resident #97's Lorazepam and stated the last dose administered was on 08/12/2024. S6LPN stated she gave the last dose on 08/12/2024 at 9:32 a.m., and the bottle of Lorazepam was already located in Med Cart 3 prior to administering it. S6LPN stated the bottle of Lorazepam was left in Med Cart 3 for at least a week. An interview was conducted on 08/13/2024 at 12:05 p.m. with a local pharmacist. She stated liquid Lorazepam required refrigeration and would lose its potency if left in room temperature for extended periods of time. An interview was conducted on 08/13/2024 at 12:11 p.m. with the facility's pharmacist. She stated liquid Lorazepam required refrigeration and would lose its potency if left at room temperature for extended periods of time.

Based on observation and interviews, the facility failed to maintain an infection control program to ensure staff performed proper hygiene administering medication for 1 (#12) of 4 (#12, #38, #41, and #386) residents observed for medication administration. Findings: On 08/13/2024 at 7:35 a.m., an observation was made of S8MAC preparing medication for Resident #12. S8MAC dropped a pill onto the floor, picked up the pill, discarded the pill, and then continued to prepare additional medications without performing hand hygiene. On 08/13/2024 at 7:39 a.m., an interview was conducted with S8MAC. She confirmed she did not perform hand hygiene after picking up the pill off the floor and administering medication to Resident #12 and should have. On 08/13/2024 at 4:30 p.m., an interview was conducted with S3DON. She stated she expected staff to perform proper hand hygiene during medication administration. S3DON confirmed S8MAC should have performed hand hygiene after picking up the pill off the floor before continuing medication administration.

Based on observation, record reviews, and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 2 (#61 and #99) of 27 residents reviewed for abuse in the final sample. The facility failed to ensure: 1.Resident #99 was free from physical abuse by Resident #61. 2.Resident #61 was free from physical abuse by Resident #99. Findings: Review of the facility's Abuse Components Plan Elder Justice Act and Affordable Care Act policy dated 10/24/2022 revealed the following, in part: 1.5 Policy: Residents have the right to be free from abuse . 2.0 Definitions Abuse is defined as the willful infliction of injury Instances of abuse .cause physical harm, pain or mental anguish. Willful means the individual must have acted deliberately. 1. Resident #99 Review of the Clinical Record revealed Resident #99 was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Anxiety. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/04/2024 revealed Resident #99 had a BIMS (Brief Interview of Mental Status) score of 14, which indicated he was cognitively intact. Review of Resident #99's Incident Report revealed the following: Date: 08/07/2024 at 11:06 a.m. Resident Incident Description: Resident #99 reported the aggressor (Resident #61) purposefully rolled into him while he was getting coffee. At the time Resident #99 attempted to defend himself resulting in the altercation. On 08/12/2024 at 10:30 a.m., an interview was conducted with Resident #99. He stated there was an incident where Resident #61 purposefully ran into him with his electric wheelchair. He stated he felt threatened so he defended himself. 2. Resident #61 Review of the Clinical Record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses, which included Depression. Review of the Quarterly MDS with an ARD of 06/03/2024 revealed Resident #61 had a BIMS of 12, which indicated he was cognitively moderately intact. Review of Resident #61's Incident Report revealed the following: Date: 08/07/2024 at 11:06 a.m. Resident Incident Description: Resident #61 reported he ran into Resident #99 due to feeling the other resident told on him and got him in trouble with the Administrative staff. On 08/14/2024 at 3:50 p.m., an interview was conducted S10LPN. She stated she was working the day of the altercation between Resident #99 and Resident #61. She stated she was in another resident's room when she heard screaming. She stated when she walked out into the dining area she saw Resident #61 in his wheelchair with blood on his forehead and skin tear to his arm. She stated Resident #61 was alert, oriented and was aware of the situation. On 08/14/2024 at 4:04 p.m., an interview was conducted with S7WC. She stated she witnessed the incident that occurred between Resident #99 and Resident #61. She stated Resident #99 was sitting in his wheelchair when Resident #61 purposefully rammed his electric wheelchair into him. She stated after being hit, Resident #99 was half out of his wheelchair with one knee to the ground. She stated Resident #61 started to punch Resident #99 and Resident #99 began to defend himself and hit back. She stated Resident #61was noted to have cuts on his face and forearm. On 08/15/2024 at 8:50 a.m., an interview was conducted with S3DON. She stated on 08/07/2024 Resident #99 and Resident #61 were involved in an altercation. She stated Resident #61 purposefully rammed his electric wheelchair into Resident #99. She stated out of self-defense Resident #99 began punching Resident #61. She stated both resident's actions were purposeful. On 08/15/24 09:03 a.m., an interview was conducted with S1ADM. S1ADM stated he was informed there had been an altercation between Resident #61 and Resident #99. He stated after speaking to the residents, Resident #61 told him he was upset with Resident #99, so he rammed into him using his electric wheelchair. On 08/15/2024 at 10:00 a.m., an observation and interview was conducted with S1ADM. The video surveillance of the 08/07/2024 incident occurring between Residents #61 and #99 was reviewed. Resident #61 was observed entering into the dining area where Resident #99 was sitting in his wheelchair. Resident #61 was observed running his electric wheelchair into Resident #99. Resident #61 continued to push Resident #99 in his wheelchair. Resident #99 stood up from his wheelchair and hit Resident #61. At that time both residents began hitting each other. S1ADM confirmed the above observation of Resident #61 and Resident #99 was purposeful and considered abuse.

Based on record review and interview, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1(#83) of 27 sampled residents by failing to ensure Resident #83 was coded correctly for active diagnoses. Findings: Review of Resident #83's clinical record revealed admitted [DATE]. Further review revealed Resident #83 had a diagnosis of Cataracts with onset date of 06/06/2024. Review of Resident #83's Quarterly MDS with ARD of 07/08/2024 revealed Cataracts was not coded as an active diagnosis in Section I. Review of Resident #83's optometrist progress note dated 06/06/2024 revealed, in part: diagnosis of Cataracts of left eye. Review of Resident #83's physician's progress notes dated 07/05/2024 revealed diagnoses which included Cataracts. History of Present Illness section revealed, in part: Resident #83 reported visual loss in the left eye for the last 3 weeks and was seen by the optometrist on 06/06/2024 who diagnosed him with cataracts which will require surgery. On 08/14/2024 at 9:40 a.m., an interview was conducted with S9MDS. She stated the process was for MDS department to review progress notes and add diagnosis to resident's diagnoses. After reviewing, Resident #83's progress note from optometrist appointment dated 06/06/2024, S9MDS confirmed the diagnosis for cataracts should have been added to the quarterly MDS with ARD of 07/08/2024 as an active diagnosis and was not.

Based on interviews and record review, the facility failed to ensure services were provided by failing to follow physician orders for 1 (#18) of 26 residents investigated in the final sample. Findings: Review of the facility's policy titled Administering Oral Medications, dated 10/2010 revealed in part, the following: Steps in the procedure: 6. Check the label on the medication and confirm the medication name and dose with the MAR. 8. Check the medication dose. Re-check to confirm the proper dose. Review of Resident #18's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute on Chronic Diastolic Congestive Heart Failure and Chronic Respiratory Failure. Review of Resident #18's Physician's Orders revealed the following: Lorazepam Oral Concentrate 2 mg/mL. Give 0.25 mL by mouth every 4 hours as needed for agitation or shortness of breath, start date 08/06/2024. Review of Resident #18's MAR for August 2024 revealed the following: Lorazepam Oral Concentrate 2 mg/mL. 0.25 mL administered on 08/11/2024 at 2:06 p.m. by S4LPN. Review of the narcotic log for Resident #18 for August 2024 revealed the following: Medication: Lorazepam Name of Individual Administering: S4LPN Date: 08/11/2024 Time: 2:06 p.m. Amount on Hand: 21 mL Amount Administered: 0.5 mL Amount Remaining: 20.5 mL A phone interview was conducted on 08/13/2024 at 3:15 p.m. with S4LPN. She stated Resident #18 was having some shortness of breath on 08/11/2024 around 2:00 p.m. She stated she checked the narcotic log for the last administered time of Lorazepam for Resident #18. She stated Resident #18 had Lorazpam 0.5 mL ordered every 4 hours as needed. She stated she documented on the narcotic log and the MAR after she drew up the 0.5 mL of Lorazepam and administered it to Resident #18. An interview was conducted on 08/13/2024 at 4:00 p.m. with S3DON. She reviewed the narcotic log and MAR for Resident #18. She confirmed S4LPN did document a dose of 0.5 mL of Lorazepam given on 08/11/2024.

Based on interviews and record review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies for 1(#83) of 27 sampled residents. Findings: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, revealed, in part, the following: Program: Facility leadership, including the Administrator and Director of Nursing are responsible to ensure there is an on-going, sustainable QAPI program that addresses identified priorities while allowing for adequate resources, staff time, and training. Facilities must maintain the following documentation and evidence of its ongoing QAPI program: Documentation demonstrating development, implementation and evaluation of corrective actions or performance improvement activities. Implementation: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance c. Identifying and prioritizing quality deficiencies. e. Developing and implementing corrective action or performance improvement activities. f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Review of facility's Plan of Action/Continuous Quality Improvement, dated 07/22/2024, revealed, in part, the following: Problem Area Identified: Resident's care plans, and diagnoses list are not accurately completed. Corrective Actions: S2DON or designee will review 8 resident care plans and diagnoses a week to check accuracy. An in-service with the MDS staff was completed to ensure that residents care plans and diagnosis are completed and accurate. Review of the facility's Audits for Care plan Checklist, revealed no audit was conducted on Resident #83. Review of Resident #83's clinical record revealed admitted [DATE]. Further review revealed Resident #83 had a diagnosis of Cataracts with onset date of 06/06/2024. Review of Resident #83's Quarterly MDS with ARD of 07/08/2024 revealed Cataracts was not coded as an active diagnosis in Section I. An interview was conducted on 08/14/2024 at 9:40 a.m. with S9MDS. She stated the process was for MDS department to review progress notes and add diagnosis to resident's diagnoses. After reviewing, Resident #83's progress note from optometrist appointment dated 06/06/2024, S9MDS confirmed the diagnosis for cataracts should have been added to the quarterly MDS with ARD of 07/08/2024 as an active diagnosis and was not. An interview was conducted on 08/15/2024 at 2:40 p.m. with S3DON. S3DON reviewed Resident #83's clinical chart and confirmed he had a Cataract diagnosis dated 06/06/2024. She confirmed Resident #83's Quarterly MDS with an ARD of 07/08/2024 did not accurately reflect his current diagnosis of Cataracts. She stated there was an open QAPI for resident's care plans, and diagnoses list not accurately completed. She confirmed they had not addressed the issues of diagnoses on the MDS for Resident #83. An interview was conducted with S1ADM on 08/15/2024 at 1:20 p.m. He confirmed there was an open QAPI addressing MDS and Care Plans not reflecting active diagnosis. He confirmed they had not addressed the issues of diagnoses' on the MDS for Resident #83.

Based on observation, interviews, and record review, the facility failed to ensure nurse staffing data requirements were documented on daily postings. This deficient practice had the potential to affect any of the 129 residents residing in the facility. Findings: Review of the facility's policy dated 01/2023 and titled Posting Direct Care Daily Staffing Numbers revealed in part, the following: Policy Interpretation and Implementation: 2. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: a. The name of the facility. An observation was made on 08/12/2024 at 8:05 a.m. of the staffing data sheet dated 08/12/2024. Further review revealed no documentation of the facility name. An interview was conducted on 08/12/2024 at 8:45 a.m. with S2AA. She reviewed the staffing data sheet dated 08/12/2024. She stated she was not aware the staffing data sheet required the facility name. She confirmed the staffing data sheet did not have the facility name. An interview was conducted on 08/12/2024 at 9:00 a.m. with S1ADM. He reviewed the staffing data sheet dated 08/12/2024. He confirmed the staffing data sheet did not have the facility name.

Based on observations, interviews, and record review, the facility failed to ensure injuries of unknown source without serious bodily injury were reported within 24 hours to the State Survey Agency for 1 (#3) of 6 (#1, #2, #3, #R1, #R2 and #R3) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse Components Plan dated 10/24/2022, revealed the following, in part: Policy The facility administrator and their designee shall be responsible for the implementing of this policy. Definitions Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: 1) The source of the injury was not observed by any person; and 2) Or the source of the injury could not be explained by the resident; and 3) The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Reporting 1. All alleged violations involving injuries of unknown source will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. State Agency online tracking incident system(required); 2. An alleged violation involving injuries of unknown will be reported immediately, but no later than: b. Twenty-four (24) hours if the alleged violation does not involve abuse, AND has not resulted in serious bodily injury. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia and Long Term Use of Anticoagulants. Review of the Quarterly MDS with ARD of 05/25/2024 revealed Resident #3 had a BIMS of 5, which indicated the resident was severely cognitively impaired. Review of the facility's Incident log dated March 2024 through current revealed Resident #3 had an incident on 05/27/2024 related to bruising. Review of the facility's Incident report dated 05/27/2024, revealed in part: Incident Description: Bruising found on Resident #3 by S2DON Bruises Measured: Left Upper Outer Arm Lateral 8 cm x 4.4 cm Left Outer Forearm 6 cm x 9 cm Left Inner Forearm 10.1 cm x 6 cm Right Upper Outer Arm Lateral 3.5 cm x 2.8 cm Right Upper Outer Arm Medial 2.8 cm x 3.4 cm Right Elbow 4.7cm x 7 cm Right Outer Forearm 3 cm x 3.9 cm Right Outer Forearm Inferior 9 cm x 10.2 cm Right Outer Wrist 8.5 cm x 5.1 cm Review of the facility's state agency reported incidents for the past six months revealed no reports of the above incident. On 06/13/2024 at 9:25 a.m., an observation was made of Resident #3. An interview attempt was made with Resident #3, but due to cognitive impairment she was unable to answer questions regarding how she got the bruises. Resident #3 was noted to have one bruise to her left outer forearm and side of forearm. Resident #3's left upper arm was noted to have two sets of bruises. Resident #3's right arm was noted to have a small bruise to the outer wrist area, outer and side of forearm, and upper arm near outer arm crease, and one bruises to right elbow. On 06/13/2024 at 10:58 a.m., a telephone interview was conducted with S4LPN. She confirmed she was the oncoming nurse for the 6:00 a.m. to 6:00 p.m. shift on 05/27/2024 for Resident #3. She stated S5CNA reported to her on the morning of 05/27/2024 Resident #3 had bruises on both of her forearms. She stated she then reported the findings to S3ADON. On 06/13/2024 at 12:01 p.m., a telephone interview was conducted with S3ADON. She stated on the morning of 05/27/2024, S4LPN informed her of the bruises to Resident #3's bilateral upper extremities. She stated she assessed Resident #3 immediately and noted bruises to bilateral upper extremities and right elbow. She stated she immediately reported her assessment of Resident #3's bilateral upper arm bruising to S2DON and S1NFA. On 06/12/2024 at 3:11p.m., an interview was conducted with S2DON. She stated was responsible for completing the 05/27/2024 incident report for Resident #3. She stated after S3ADON notified her of the incident with Resident #3, she went directly to S1NFA. S2DON stated after bringing it to the S1NFA's attention, she started her investigation. She stated Resident #3 could not tell her how she received the bruises due to Dementia. She stated the bruises to Resident #3's bilateral upper extremities were consistent with hand placement during moving Resident #3. She stated they determined the bruising was not abuse related, and did not report it. On 06/12/2024 at 4:00 p.m., an interview was conducted with S1NFA. He stated he was responsible for reporting or injuries of unknown origin to the required agencies. He stated he could not recall the exact time on 05/27/2024 in which the bruises to Resident #3's bilateral upper extremities were brought to his attention. He stated as soon as he was informed by S2DON of Resident #3's bruising, he went to Resident #3's room to investigate. He stated he was made aware by S2DON of Resident #3 being on a blood thinner and antiplatelet medication. He stated there was no clear occurrence to have caused the bruises, and Resident #3 has a BIMS of 5 which makes her severely cognitively impaired. S1NFA stated based on the placement of the bruises, he determined it was caused by resident care. He confirmed after observing the bruising he did not report it to the state agency.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practice for 1 of 1(#117) resident reviewed for oxygen therapy. Findings: Review of the facility's policy titled, Oxygen Administration revealed the following, in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident #117's clinical record revealed Resident #117 was admitted on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease and Asthma. Review of Resident #117's MDS with an ARD of 09/06/2023 revealed a BIMS of 12, which indicated intact cognition. Review of Resident #117's Physician Orders revealed no order for oxygen therapy services in the electronic health record. Review of Resident #117's Medication Administration Record from July to current revealed no clinical documentation for oxygen therapy services were provided or documented accordingly to accurately reflect services provided. Review of Resident #117's Care plan revealed the following: Problem: I am currently receiving oxygen therapy as needed. Goal: I will have no signs and symptoms of poor oxygen absorption through the review date. Approaches: Oxygen Settings: Administer oxygen per MD orders, may remove for ADL. Review of Resident #117's Oxygen Saturation summary report from 06/01/2023-09/30/2023 revealed Oxygen services were provided on the following dates: 07/18/2023- Oxygen via Nasal Cannula 08/01/2023- Oxygen via Nasal Cannula 08/09/2023- Oxygen via Nasal Cannula 09/06/2023- Oxygen via Nasal Cannula 09/08/2023- Oxygen via Nasal Cannula 09/12/2023- Oxygen via Nasal Cannula 09/13/2023- Oxygen via Nasal Cannula On 09/19/2023 at 11:05 a.m., an interview was conducted with Resident #117. She stated she had been wearing oxygen on and off for all her life due to a history of Chronic Obstructive Pulmonary Disease. She stated since admission she wore 2 liters of oxygen as needed. An observation was made at that time of Resident #117 wearing oxygen via nasal cannula. On 09/19/2023 at 11:50 a.m., an interview was conducted with S6LPN. She stated Resident #117 was oxygen dependent since returning from the hospital on 09/11/2023. She confirmed the resident was currently wearing 2 liters of oxygen per nasal cannula. She confirmed there were no physician order for oxygen therapy services in the electronic health record. She confirmed a Physician's Order for oxygen services would be needed to initiate standing orders and should have been placed in the clinical record. On 09/19/2023 at 12:15 p.m., an interview was conducted with S2DON. She stated standing orders, continuous and prn orders for oxygen therapy services should be manually placed in the clinical record per physician order. She confirmed Resident #117 did not have an order for use of oxygen therapy services and an order should have been placed in the clinical record. On 09/20/2023 at 8:55 a.m., an interview was conducted with S7LPN. She confirmed when Resident #117 returned to the facility on [DATE], she was wearing 2 liters of oxygen via nasal cannula. She stated prior to Resident #117's hospital admission on 09/09/2023 the resident wore oxygen intermittently. She stated she did not place an order for oxygen due to the assumption the order was already placed in the electronic health record from past oxygen usage. She stated when a standing order was initiated, nursing staff was expected to manually enter the order into clinical record so it would show up on the MAR and Physician Orders. She confirmed she did not enter a standing order for oxygen therapy services. On 09/20/2023 at 11:07 a.m., an interview was conducted with S5NP. She stated nursing staff could initiate standing orders for oxygen use if needed. She stated nursing staff were expected to manually input orders into clinical record when initiating any standing order. She confirmed an order should have been placed in Resident #117 electronic health record to accurately reflect services being provided and was not.

Based on interviews and record review, the facility failed to ensure that a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#9 and #82) of 4 (#9, #17, #30, and #82) sampled residents reviewed for PASRR Level II. Findings: Resident #9 Review of the Clinical Record revealed Resident #9 was admitted to the facility on [DATE]. Further review revealed she was diagnosed with Severe Major Depressive Disorder with Psychotic Symptoms on 09/07/2021. On 09/20/2023 at 2:05 p.m., an interview was conducted with S4SW. She stated she was responsible for submitting Level II PASRR request to the OBH. She reviewed Resident #9's Level I PASRR dated 02/26/2019, then reviewed Resident #9's diagnoses. She stated due to Resident #9's diagnosis of Major Depressive Disorder with Psychotic Symptoms dated 09/07/2021, a Level II PASRR request was required. She stated she had not submitted Resident #9's PASRR Level II request to the OBH prior to the survey team's entrance. She confirmed the Level II PASRR request should have been submitted to the OBH when Resident #9 received the new mental health diagnosis. Resident #82 Review of the Clinical Record revealed Resident #82 was admitted to the facility on [DATE]. Further review revealed she was diagnosed with Bipolar Disorder on 04/16/2020 and Major Depressive Disorder on 03/12/2021. On 09/18/2023 at 2:50 p.m., an interview was conducted with S4SW. She reviewed Resident #82's Level I PASRR dated 02/04/2019, then reviewed Resident #82's diagnosis of Bipolar Disorder on 04/16/2020 and Major Depressive Disorder on 03/12/2021. She verified she had not submitted Resident #82's PASRR Level II request to the OBH prior to the survey team's entrance. She confirmed the Level II PASRR request should have been submitted to the OBH when Resident #82 received the new mental health diagnoses. On 09/19/2023 at 10:16 a.m., an interview was conducted with the OBH Program Manager. She stated in 2019, Resident #82 was reviewed for a Level II PASRR which was not required as she did not meet criteria for a serious mental illness. She stated a new diagnosis of Bipolar Disorder would require a Level II PASRR to be submitted. She stated the OBH received a Level II PASRR request at 2:41 a.m. on 09/19/2023 for Resident #82. She stated there had been no former Level II PASRR requests submitted for Resident #82 since 2019. She stated she received Resident #9's Level II PASRR request on 09/18/2023 at 9:09 p.m. She stated if any resident was diagnosed with a new mental health disorder, a Level II PASRR request should have been submitted to the OBH. On 09/18/2023 at 2:30 p.m., an interview was conducted with S1ADM. He stated he was aware there were multiple residents who needed Level II PASRR requests submitted to the OBH.

Based on record review and interviews, the facility failed to ensure a Change in Status Minimum Data Set (MDS) Assessment was completed within 14 days of a resident changing hospice companies for 1 (#85) of 4 (#6, #82, #85, and #94) sampled residents receiving hospice services. Findings: Review of Resident #85's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #85's Transfer Hospice Services form dated 02/23/2023 revealed Resident #85 was discharged from one hospice company and admitted to another hospice company per family request. Review of Resident #85's MDS revealed no Significant Change MDS was submitted after Resident #85 changed hospice companies on 02/23/2023. On 09/19/2023 at 12:25 p.m., an interview was conducted with Resident #85's hospice nurse. She stated Resident #85 received care from another hospice company, but the family was not happy with the care he received, so they changed to the current hospice company. She stated she did not know the exact date, but he started with the current hospice company at the beginning of this year. On 09/20/2023 at 9:57 a.m., an interview was conducted with the LPN Intake Coordinator for Resident #85's current hospice company. She confirmed Resident #85's admitted to the current hospice company was 02/23/2023. On 09/20/2023 at 12:00 p.m., an interview was conducted with S3CCC. She stated a Significant Change MDS should be completed when a resident was admitted to hospice and when a resident was discharged from hospice. S3CCC stated she did not complete a Significant Change MDS when a resident was transferred from one hospice agency to another, and she did not think it was required. S3CCC reviewed the Minimum Data Set Resident Assessment Instrument and verified a resident required a Significant Change MDS when a change in hospice companies took place. She reviewed Resident #85's Transfer Hospice Services form, then reviewed the MDS's submitted after his transfer of services on 02/23/2023. S3CCC confirmed Resident #85 did not have a Significant Change MDS submitted when he changed hospice companies on 02/23/2023 and should have. On 09/20/2023 at 12:22 p.m., an interview was conducted with S2DON. S2DON stated she was aware Resident #85 did not have a Significant Change MDS submitted when he transferred hospice companies in February 2023, and he should have.

Based on observations, interviews, and record reviews the facility failed to ensure staff performed proper hand hygiene during incontinence care for 2(#77, #102) of 2 (#77, #102) residents during observations of perineal care. Findings: Review of the facility's policy titled, Perineal Care, revealed the following, in part: Steps in the Procedure: 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. 4. Fold the bedspread or blanket toward the foot of the bed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 7. Put on gloves. 8. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. (2) Continue to wash the perineum moving from the inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. (4) Gently dry perineum. c. Ask the resident to turn on her side with her top leg slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. 9. Discard disposable items into designated containers 10. Remove gloves and discard into designated containers. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean the wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly. Resident #77 Review of Resident #77's clinical record revealed she was a female admitted to the facility on [DATE]. Review of the facility's infection log for September 2022 revealed Resident #77 had a [CONDITION(S)] with a culture resulting in E. coli on 9/01/2022. An observation was made on 10/25/2022 at 6:15 p.m. of S4CNA and S5CNA performing perineal and catheter care for Resident #77. S4CNA and S5CNA donned gloves then transferred Resident #77 using a Hoyer lift. Following the transfer, S4CNA used her same gloves to remove the resident's disposable brief and applied perineal cleanser to a clean wipe. S4CNA used the wipe to clean Resident #77's vagina, wiped the resident's catheter, and cleaned around the sacral wound dressing. S4CNA disposed of the wipe, but continued using the same gloves. S4CNA then picked up an ointment tube and applied the ointment to Resident #77's buttocks. Following perineal care, S4CNA used the same gloves and applied a clean brief, adjusted the bedding, repositioned pillows, handed the resident her bed remote and call light, then opened a drawer of the bedside table. S4CNA failed to change gloves or sanitize hands throughout the observation of perineal care. An interview was conducted on 10/25/2022 at 6:30 p.m. with S4CNA. S4CNA confirmed she did not change gloves or perform hand hygiene during the aforementioned observation. An interview was conducted on 10/25/2022 at 6:35 p.m. with S2DON. She was informed of the aforementioned observation. S2DON stated her expectations of CNA staff performing perineal/catheter care was to perform hand hygiene before applying clean gloves, to remove soiled gloves, perform hand hygiene after touching dirty/soiled items, and then apply new gloves before touching clean items. Resident #102 Review of the clinical record revealed Resident #102 was a female resident admitted to the facility on [DATE]. Review of the facility's infection log revealed Resident #102 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 10/26/2022 at 10:00 a.m. of S9CNA, S8LPN and S10CNA performing perineal care for Resident #102. S9CNA, S8LPN, and S10CNA performed hand hygiene and applied gloves. S8LPN and S9CNA turned the resident on her side while S8LPN proceeded to remove Resident #102's brief. S8LPN used wipes to remove feces. S8LPN removed her gloves as she communicated to S9CNA and S10CNA the resident was not finished with her bowel movement. S8LPN did not wash or sanitize her hands and proceeded to touch a clean brief, the resident's clean clothes, bed, pillow, wheelchair, and handed the brief to S9CNA. S9CNA proceeded to wipe the resident when she finished with her bowel movement. She touched the wipes container while her gloves were visibly soiled with feces. S10CNA retrieved the resident's buttocks cream and dispensed it into S9CNA dirty gloved hands. S9CNA applied the cream onto the resident's buttocks. S9CNA then removed her soiled dirty gloves and applied clean gloves. S9CNA did not perform hand hygiene between the glove changes. S9CNA then placed a clean brief on the resident, touched the bed and proceeded to get the resident dressed. S9CNA touched the Hoyer lift, Hoyer mat, put deodorant under the resident's right armpit, touched the wheelchair, bed, oxygen tank, and O2 tubing. She then pressed buttons on the Hoyer lift and touched the resident to get her placed into the wheelchair. S9CNA grabbed the resident's wheelchair handles and placed the resident in the wheelchair using the Hoyer lift. S9CNA failed to sanitize the Hoyer lift after use. S9CNA continued to assist Resident #102 with brushing her teeth by picking up a clean towel, turning the water faucet on, pick up a toothbrush and toothpaste then hand it to the resident. While the resident brushed her teeth, S9CNA collected the wipes, dirty gown, dirty linens and clothes and put them into the dirty laundry bag. Afterwards, S9CNA removed the dirty gloves and applied clean gloves without performing hand hygiene between. An interview was conducted on 10/26/2022 at 11:00 a.m. with S9CNA. She confirmed she perform hand hygiene after taking off soiled dirty gloves and reapplying clean gloves. She verified she should have performed hand hygiene after each glove removal, and should not have touched any items while hands were visible soiled. An interview was conducted on 10/26/2022 at 11:08 a.m. with S2DON. She confirmed gloves should have been changed after visible soiled, and hand hygiene should have been conducted after each glove change. An interview was conducted on 10/26/2022 at 11:12 a.m. with S1ADMIN. He confirmed the facility's policy titled, Perineal Care stated hands should be washed and/or sanitized after removal of gloves.

Based on observations of medication administration pass, records review, and interviews the facility failed to ensure medications were administered without error for 4 out of 26 opportunities for 2 (#83,#97) of 4 (#83,#55, #65,#97) residents resulting in a medication error rate of 15.38%. This failed practice had the potential to affect any of the 123 residents currently residing in the facility who may receive medications. The facility failed to ensure: 1. Residents #97 and #83 received the correct medication, 2. Resident #83 received the correct dose, and 3. Discontinued medications were not administered to Resident #83. Findings: A review of the facility's Oral Medication Administration policy revealed in part the following: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation: 1.) Verify that there is a physician's medication order for this procedure. Equipment and Supplies: 1.) Medication Administration Record. Steps in the Procedure: 3.) Place the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 5.) Select the drug from the unit dose drawer or stock supply. 6.) Check the label on the medication and confirm the medication name and dose with the Medication Administration Record. 8.) Check the medication dose. Re-check to confirm the proper dose. 9.) Prepare the correct dose of medication. On 10/21/2022 the following medication administration errors were observed: At 8:22 a.m. S8LPN administered to Resident #97: one Cetirizine HCL 10mg tablet by mouth. At 9:04 a.m. S8LPN administered to Resident #83: one [MEDICATION(S)] 5mg tablet by mouth; one [MEDICATION(S)] Sulfate 325mg (Elemental Fe 65mg) tablet by mouth; and one Calcium 600+D 400mg tablet by mouth. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Loratadine Tablet 10mg Give 1 tablet by mouth one time a day. (Order date 6/15/2022-Start date 6/16/2022). No order for Cetirizine HCL 10mg tablet. Review of Resident #97's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Loratadine Tablet 10mg. Give 1 tablet by mouth one time a day administered daily. (Start date 6/16/2022). No scheduled administration/order for Cetirizine HCL Tablet 10mg. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. No order for [MEDICATION(S)] 5mg tablet 2. [MEDICATION(S)] [MEDICATION(S)] Tablet 324 (38 Fe)mg. Give 1 tablet by mouth one time a day. (Order date 9/22/2022-Start date 9/23/2022). No order for [MEDICATION(S)] Sulfate 325mg (Elemental Fe 65mg) tablet. 3. Calcium 600+D Tablet 600-400 mg-unit (Calcium [MEDICATION(S)]-Vitamin D). Give 2 tablets by mouth two times a day. (Order date/Start date 5/30/2022). Review of Resident #83's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] DISCONTINUED-[MEDICATION(S)] Tablet 5 mg. Give 1 tablet by mouth one time a day administered daily September 1, 2022 through 10/21/2022. (Order date 2/8/2022-Discontinue date 9/22/2022) Review of Resident #83's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. No scheduled administration/order for [MEDICATION(S)] Tablet 5 mg. 2. [MEDICATION(S)] [MEDICATION(S)] Tablet 324 (38 Fe) mg. Give 1 tablet by mouth one time a day. (Start date 9/23/2022). 3. Calcium 600+D Tablet 600-400mg-unit (Calcium [MEDICATION(S)]-Vitamin D). Give 2 tablets by mouth two times a day. (Start date 5/30/2022). An interview was conducted on 10/21/2022 at 2:15 p.m. with S8LPN. She verified her 4 medication errors. She confirmed that she had given one Cetirizine HCL 10mg tablet by mouth instead of one Loratadine 10mg tablet by mouth as ordered for Resident #97. She confirmed that she had given one [MEDICATION(S)] 5mg tablet by mouth to Resident #83 and verified this medication was discontinued on 9/22/2022. She confirmed that she had given one [MEDICATION(S)] Sulfate 325mg (Elemental Fe 65mg) tablet by mouth instead of one [MEDICATION(S)] [MEDICATION(S)] 324mg (Elemental Fe 38mg) tablet by mouth as ordered for Resident #83. She confirmed that she had given one Calcium 600+D 400mg tablet by mouth instead of two tablets as ordered for Resident #83. An interview was conducted on 10/21/2022 at 2:27 p.m. with S3ADON. She was informed of each medication error made by S8LPN. After S3ADON reviewed the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed that S8LPN had given one Cetirizine HCL 10mg tablet by mouth instead of one Loratadine 10mg tablet by mouth as ordered for Resident #97. She confirmed that S8LPN had given one [MEDICATION(S)] 5mg tablet by mouth to Resident #83 and verified this medication was discontinued on 9/22/2022. She confirmed that S8LPN had given one [MEDICATION(S)] Sulfate 325mg (Elemental Fe 65mg) tablet by mouth instead of one [MEDICATION(S)] [MEDICATION(S)] 324mg (Elemental Fe 38mg) tablet by mouth as ordered for Resident #83. She confirmed that S8LPN had given one Calcium 600+D 400mg tablet by mouth instead of two tablets as ordered for Resident #83. An interview was conducted on 10/21/2022 at 2:38 p.m.with S2DON. She confirmed each medication error made by S8LPN. She confirmed that giving one Cetirizine HCL 10mg tablet by mouth instead of one Loratadine 10mg tablet by mouth as ordered for Resident #97 was a medication error. She confirmed that giving one [MEDICATION(S)] 5mg tablet by mouth to Resident #83 after the medication had been discontinued was a medication error. She confirmed that giving one [MEDICATION(S)] Sulfate 325mg (Elemental Fe 65mg) tablet by mouth instead of one [MEDICATION(S)] [MEDICATION(S)] 324mg (Elemental Fe 38mg) tablet by mouth as ordered for Resident #83 was a medication error. She confirmed that giving one Calcium 600+D 400mg tablet by mouth instead of two tablets as ordered for Resident #83 was a medication error.

Based on interviews and record review, the provider failed to maintain accurate records in accordance with professional standards for 1 (#83) of 22 residents reviewed. The provider failed to ensure nursing staff documented the resident's noncompliance with oxygen therapy accurately on the Medication Administration Record. Findings: Review of the clinical record for Resident #83 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS with an ARD of 05/31/2021 revealed the resident had a BIMS of 15 indicating the resident was cognitively intact. Review of the current Physicians Order's for Resident #83 revealed staff were to apply the [CONDITION(S)] at 14 cm with water with nasal pillows at bedtime and document compliance. Start date 05/26/2021. Review of a nursing note written by S6ADON dated 05/26/2021 at 4:18 p.m. revealed the [CONDITION(S)] machine was placed on the resident and the resident pulled it off stating she could not wear it because it gave her a headache. Review of the resident's MAR for May 2021 and June 2021 revealed the nursing staff documented the resident wore the [CONDITION(S)] at night during the following dates: 05/27/2021, 05/28/2021, 05/29/2021, 05/30/2021, 06/01/2021, 06/02/2021, 06/03/2021, 06/04/2021, 06/05/2021, 06/06/2021, 06/07/2021, 06/08/2021, 06/09/2021, 06/10/2021, 06/11/2021, 06/12/2021, 06/13/2021, 06/14/2021, 06/15/2021, 06/16/2021, 06/17/2021, 06/18/2021, 06/19/2021, 06/20/2021, 06/21/2021, 06/22/2021, 06/23/2021, 06/24/2021, 06/25/2021, 06/26/2021, 06/28/2021, 06/29/2021 Review of nursing progress notes dated 05/26/2021 - 06/30/2021 revealed there was no documentation of resident's compliance with wearing the [CONDITION(S)] machine at night. An interview was conducted with Resident #83 on 06/28/21 at 11:35 a.m. She stated she had a [CONDITION(S)] machine in her room and she was supposed to wear it at night, but she had never worn it. She stated staff tried to put the [CONDITION(S)] machine on her 06/27/2021, but she asked them to remove it because it was blowing in her ears and the mask was not tight enough. An interview was conducted with Resident #83 on 06/29/2021 at 11:18 a.m. She confirmed she did not wear the [CONDITION(S)] machine the night of 06/28/2021. An interview was conducted with Resident #83 on 06/30/2021 at 10:40 a.m. She confirmed she did not wear the [CONDITION(S)] machine the night of 06/29/2021. An interview was conducted with S9CNA on 06/29/2021 at 11:25 a.m. She confirmed she worked with the resident and she never saw the resident wearing the [CONDITION(S)] machine during any of her shifts when she reported to work at 6:00 a.m. An interview was conducted with S10CNA on 06/29/2021 at 11:47 a.m. She confirmed she worked with the resident and she never saw the resident wearing the [CONDITION(S)] machine during any of her shifts when she reported to work at 6:00 a.m. An interview was conducted with S7LPN on 06/29/2021 at 12:16 p.m. She stated on 06/28/2021 the resident confirmed she did not wear the [CONDITION(S)] machine at night because the machine was not working properly and the mask was not tight enough. A telephone interview was conducted with S8LPN on 06/29/2021 at 1:39 p.m. She confirmed she worked both the day shift and the night shift. She stated she started working with the resident a few months ago and the resident told her she did not use the [CONDITION(S)] machine because she did not know how to use it. She stated she then attempted to put the [CONDITION(S)] on the resident, but the resident refused to wear it because she complained the mask did not fit tightly and the nose piece was smothering her. She stated whenever she worked with the resident at night the resident always refused to wear the [CONDITION(S)]. She stated she offered it to the resident but she did not put it on her because she said no. She confirmed she was assigned to the resident during the night shift on 06/25/2021 and 06/26/2021. She confirmed the resident refused to wear the [CONDITION(S)] machine during both nights and did not wear it. An interview was conducted with S8LPN on 06/30/2021 at 9:45 a.m. She confirmed on 06/25/2021 and 06/26/2021 her documentation on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed her documentation did not accurately reflect the resident's compliance with wearing the [CONDITION(S)] on those days. An interview was conducted with S5DON on 06/30/2021 at 2:07 p.m. She verified the resident's orders required staff to document the resident's compliance with wearing the [CONDITION(S)] machine at night. She confirmed the documentation on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice was evidenced by the following: 1. Food stored in the reach-in cooler was not dated. 2. Perishable food items were refrigerated longer than recommended by the US FDA Refrigerator and Freezer Storage Guidance and not according to the facility's policy. Findings: Review of the US FDA Refrigerator and Freezer Storage Guidance recommended storage dates of no greater than 3-4 days for egg substitute products and meat-based soups. Review of the facility's policy titled Food Service Operational Standards For Purchasing, Cooking And Storage revealed, in part, the following: Policy: The facility stores, prepares, distributes and served food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Procedure: 8. Cooling and storing g. Label and store food with the date and time they were prepared to indicate when to discard. 9. Reheating c. Reheat only food that have been cooled and refrigerated for two days or less. On 06/27/2021 at 9:25 a.m., an initial tour of the kitchen was performed with S2CK. The following items stored in the reach-in cooler were dated greater than 3 days: a container of pureed eggs dated 06/23/2021, and a container of beef broth dated 06/07/2021. There was also a container of chicken broth that was not dated at all. S2CK stated normally food was not kept more than 3 days. She verified the food items noted should have been thrown away after 3 days. She verified the chicken broth was not dated. On 06/29/2021 at 12:40 p.m., an interview was conducted with S3CK. She stated she was temporarily in charge of the dietary department while the dietary manager was out sick. She was made aware of the food items found in the cooler during the initial tour of the kitchen. She stated cooked food items should not be stored in the cooler if they were not used within 24 hours of the preparation date.

Based on observations, interviews, and record review, the facility failed to ensure food temperatures were maintained at 135 degrees Fahrenheit or higher to prevent possible food borne illness. This deficient practice had the potential to affect all 30 residents that were served meals from the steam table on Hall 1. Findings: Review of the facility's policy titled Food Service Operational Standards For Purchasing, Cooking And Storage revealed, in part, the following: Policy: The facility stores, prepares, distributes and served food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Procedure: 7. Holding a. Holding equipment should keep hot foods at 140 degrees Fahrenheit or above and cold foods at 40 degrees Fahrenheit or below. On 06/27/2021 at 11:50 a.m., an observation of food temperature checks on the Hall 1 steam table was performed with S4DT. The following temperatures were noted to be out of range: mashed sweet potatoes 113 degrees Fahrenheit, and chopped chicken 78 degrees Fahrenheit. When asked what temperature the chopped meats should be held at on the steam table, she stated, At least 80 degrees. She did not reheat the food items before serving to residents. On 06/28/2021 at 11:38 a.m., an observation of food temperature checks on the Hall 1 steam table was performed with S4DT. The following temperatures were noted to be out of range: pureed red beans 131 degrees Fahrenheit, and pureed corn 128 degrees Fahrenheit. She did not reheat the food items before serving to residents. On 06/29/2021 at 12:40 p.m., an interview was conducted with S3CK. She stated she was temporarily in charge of the dietary department while the dietary manager was out sick. She was made aware of the temperature findings on Hall 1. She stated holding temperatures on the steam tables should be at least 150 degrees. She stated if the temperatures were not warm enough, dietary staff should bring the food back to the kitchen to reheat or use the microwaves on the units to reheat the foods. S3CK stated the temperature of the food should then be rechecked to make sure it was hot enough before serving it to the residents. On 06/29/2021 at 1:20 p.m., an interview was conducted with S1ADM. He verified 30 residents were served food from the steam tables on Hall 1.

Based on record reviews and interviews, the facility failed to ensure residents' drug regimens were free from unnecessary [CONDITION(S)] medications for 1 (#83) of 5 (#1, #5, #21, #70 and #83) residents reviewed for unnecessary medications. The facility failed to ensure PRN orders for [CONDITION(S)] drugs had a documented rationale and duration for the medication to be administered beyond 14 days. Findings: Review of the clinical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses that included, in part: Heart Failure, Anxiety Disorder, [CONDITION(S)], and Major Depressive Disorder. Review of the quarterly MDS with an ARD of 05/31/2021 revealed the resident had a BIMS of 15 indicating the resident was cognitively intact. Review of the Physician Orders for Resident #83 revealed the following: Start Date 03/31/2021 - Trazadone HCl 100 mg tablet - Give 100 mg by mouth every 24 hours as needed for [CONDITION(S)]. Take 100 mg PO at bedtime PRN. No stop date or duration was documented. Start Date 02/19/2021 - [MEDICATION(S)] Tablet 0.25 mg - Give 0.5 mg by mouth every 12 hours as needed for anxiety. No stop date or duration was documented. Review of the resident's MAR for May 2021 and June 2021 revealed [MEDICATION(S)] 0.5 mg and Trazadone 100 mg were listed on the MAR. No stop date or duration was documented for either medication. Review of the MAR for May 2021 revealed the resident received [MEDICATION(S)] 0.5 mg on the following dates and during the following times: 05/03/2021 at 7:36 p.m. 05/05/2021 at 7:46 p.m. 05/10/2021 at 2:48 p.m. 05/11/2021 at 11:10 p.m. 05/14/2021 at 10:36 a.m. 05/15/2021 at 11:17 a.m. 05/16/2021 at 7:26 p.m. 05/17/2021 at 6:49 p.m. 05/18/2021 at 8:21 a.m. and 8:09 p.m. 05/19/2021 at 8:53 p.m. 05/20/2021 at 12:49 p.m. 05/21/2021 at 1:58 a.m. and 8:01 p.m. 05/23/2021 at 9:20 a.m. and 7:45 p.m. 05/24/2021 at 8:59 p.m. 05/25/2021 at 9:07 a.m. and 9:41 p.m. 05/28/2021 at 7:32 a.m. and 8:30 p.m. 05/29/2021 at 8:55 p.m. 05/30/2021 at 6:46 p.m. Review of the MAR for June 2021 revealed the resident received [MEDICATION(S)] 0.5 mg on the following dates: 06/01/2021 at 8:14 p.m. 06/02/2021 at 8:42 a.m. 06/03/2021 at 8:36 a.m. and 10:51 p.m. 06/04/2021 at 9:01 p.m. 06/05/2021 at 8:29 p.m. 06/06/2021 at 12:22 p.m. 06/07/2021 at 7:39 a.m. and 7:51 p.m. 06/08/2021 at 8:25 a.m. 06/09/2021 at 8:05 p.m. 06/10/2021 at 8:15 p.m. 06/13/2021 at 8:14 p.m. 06/14/2021 at 8:27 a.m. and 8:15 p.m. 06/16/2021 at 7:16 a.m. 06/17/2021 at 12:58 a.m. 06/19/2021 at 8:15 p.m. 06/20/2021 at 7:55 p.m. 06/21/2021 at 8:35 a.m. and 11:13 p.m. 06/23/2021 at 12:00 p.m. 06/24/2021 at 7:31 a.m. 06/25/2021 at 7:58 p.m. 06/26/2021 at 8:58 p.m. 06/27/2021 at 9:03 p.m. 06/28/2021 at 8:37 p.m. 06/29/2021 at 8:17 p.m. Further review of the clinical record for Resident #83 revealed there was no documentation of a rationale written by the physician or duration of time for the prn [MEDICATION(S)] or the prn Trazadone to be administered to the resident beyond 14 days. There were no new orders for either medication beyond the 14 days after the start date. An interview was conducted on 06/30/2021 at 2:07 p.m. with S5DON. She reviewed Resident #83's medical record. She confirmed Resident #83 had an order for [MEDICATION(S)] 0.5 mg prn and Trazadone 100 mg prn. She confirmed there were no stop dates for either medication. She confirmed there was no documentation in the medical record indicating the duration or rationale for the continuation of either medication as a PRN order beyond 14 days.

Based on observation, interviews and policy review, the facility failed to implement appropriate use of PPE for residents placed on observation when admitted to the facility. The facility failed to ensure staff (S3CNA and S4LPN) wore proper PPE when providing direct care to a resident under quarantined observation for COVID-19. Findings: Review of facility's policy entitled, COVID-19 Guidelines for Infection Control and Prevention, revealed in part, the following: -New admissions and residents requiring outside services should be monitored closely for any signs and symptoms of infection. This should be in coordination with the Medical Director and/or NP recommendations and/or orders. -Proper PPE will be utilized when caring for these residents. This will be determined by the medical and administration staff of each facility. On 01/21/2021 at 11:41 a.m. an observation was made of S3CNA and S4LPN walking into Resident #R1's room to provide care. S3CNA and S4LPN were both observed only wearing gloves and face masks prior to entering the room. At 11:46 a.m., S3CNA and S4LPN were observed exiting Resident #R1's room with a mechanical lift. An observation was made of the front of Resident #R1's door with a sign that stated the following: UNDER QUARANTINE (new admission, re-admission, ER visits) require 14 days. Perform hand hygiene before entering and exiting room. Use FULL personal protective equipment (PPE) appropriately- Mask, face shield, gloves, gown, use dedicated or disposable equipment. Place biohazardous waste in biohazardous disposable bin. Keep door closed. Start date: 01/19/2021 Stop date: 02/02/2021, for questions contact the infection control nurse. On 01/21/2021 at 12:14 p.m., an interview was conducted with S4LPN. She confirmed Resident #R1 was in isolation because he was a new admission to the facility. She confirmed she entered Resident #R1's room at 11:41 a.m. to provide care. She verified she had on a mask, goggles, and gloves but was not wearing a gown. She confirmed she was not wearing a gown while providing care to Resident #R1 and should have been. On 01/21/2021 at 12:20 p.m., an interview was conducted with S3CNA. She verified when she transferred Resident #R1 to his bed, she was only wearing a mask and gloves. She confirmed she should have had on full PPE, which included a gown. On 01/21/2021 at 2:03 p.m., an interview was conducted with S2IC and S1DON. They both verified Resident #R1 was a new admission to the facility on [DATE]. They confirmed when a resident was a new admission to the facility, they were placed on quarantined isolation for 14 days. They stated staff should wear full PPE including; mask, face shield, gloves, and gown while caring for residents in isolation.

Based on record reviews and interviews, the facility failed to ensure alleged violations involving abuse were properly reported to the State Agency in accordance with the mandated reporting guidelines for 3 (#3, #5, #7) of 7 (#1, #2, #3, #5, #6, #7, #8) residents reviewed for abuse. Findings: Review of the State Agency document titled Guidance for Mandated Reporting for Allegations of Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Reportable Incidents with a revision dated of 10/04/2018 revealed the following, in part: IV. Reporting Requirements: NF must report to the State Agency any incidents and allegations of abuse, neglect, exploitation, misappropriation of resident property and/or injuries of unknown origin immediately, but no later than 2 hours after the allegation is made, if the event that caused the allegation involves abuse or results in bodily harm or injury. Review of the facility's policy and procedure on Abuse Reporting: Policy: All personnel must promptly report any incident or suspected incident of resident abuse or neglect including misappropriation of resident property or injuries of unknown origin. An investigation of such reports shall be immediately initiated by the Administrator. Policy Interpretation and Implementation: 14. Should the investigation reveal that abuse occurred; the Administrator will report the findings .to the appropriate State licensing agency within twenty-four (24) hours of the results of the investigation and corrective action taken. Resident #3 Review of Resident #3's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed she had a BIMS of 13 and was an extensive two person assist with bed mobility. Review of Nurse's Notes dated 07/05/2020 at 4:27 p.m., revealed, in part, the following: (Resident #3's) Daughter called back and stated the family watched the video and witnessed verbal/physical abuse and that she is going to call the administrator tomorrow. S8LPN Review of SIMS report with Incident ID : Entry Date: 07/06/2020 Entry Time: 1:20 p.m. Incident Occurred: 07/05/2020 Incident Occurred Time: 3:30 p.m. Incident Discovered: 07/05/2020 Incident Discovered Time: 5:00 p.m. Allegation Finding: Substantiated Accused: S11CNA Accused Allegation: Verbal Abuse Accused Allegation Finding: Substantiated Accused #2: S12CNA Accused #2 Allegation: Verbal Abuse Accused #2 Allegation Finding: Substantiated On 11/16/2020 at 11:51 a.m., an interview was conducted with Resident #3. She stated she remembered the incident back in July 2020. She stated two CNAs were being ugly to her while providing care. She stated when the CNAs adjusted her in the bed, one of the CNAs yanked her pillow quickly and harshly from behind her head. She stated she could not remember what the CNAs said but it made her feel intimidated and afraid. On 11/17/2020 at 10:09 a.m., an interview was conducted with Resident #3's daughter. She stated there was an visual/audio camera in her mother's room and she viewed the footage from the afternoon of 07/05/2020. She stated her mother had slid down in the bed. S11CNA and S12CNA entered the room stomping their feet. She stated S12CNA roughly jerked the pillow out from under her mother's head without warning. She stated S11CNA and S12CNA each grabbed a side of the pad and jerked her roughly up in the bed. She stated she heard her mother say, What are you doing? Ya'll treat me so badly sometimes. She stated S12CNA responded to her by saying, You treat us mean too. She stated when they pulled her blanket up, they threw it in her face. She stated the way the CNAs treated her mother was abusive. She stated she reported what she saw on the camera to the nurse that afternoon. On 11/19/2020 at 2:27 p.m., an interview was conducted with S8LPN. She stated she was working as Resident #3's nurse on 07/05/2020. She stated she received a phone call from Resident #3's daughter who was very upset. She stated the daughter said the CNAs were being rough and ugly to her mother and her mother was calling out for help. She confirmed her nurse's note read the daughter reported she witnessed verbal/physical abuse of Resident #3. She stated when she went to check on Resident #3 she was crying and visibly upset. She stated she immediately notified S3ADON of the allegations made by Resident #3's daughter. On 11/20/2020 at 9:13 a.m., an interview was conducted with S1ADM. He stated Resident #3's daughter notified the facility on 07/05/2020 of an allegation of abuse. He stated following their investigation the allegation was substantiated. He stated he had twenty-four (24) hours to initiate a SIMS report on allegations of abuse. He stated there was not a two (2) hour deadline to initiate a SIMS report. Resident #5 Review of Resident #5's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly MDS dated [DATE] revealed she had a BIMS of 4 which indicated severely impaired cognition. Review of note by S5SW revealed the following in part: On 11/11/2020 I was called outside to speak to Resident #5 and her daughter. Resident #5 told her daughter that a man was coming into her room, touching her inappropriately, making foul comments to her and sexual advances toward her. On 11/23/2020 at 9:53 a.m., an interview was conducted with S2DON. She stated when Resident #5 made an allegation of a male resident touching her inappropriately in a sexual manner on 11/11/2020, a SIMS report was not needed because they had 24 hours to investigate the situation. S2DON stated the facility had determined she had a UTI and they considered the allegation unsubstantiated. On 11/23/2020 at 11:01 a.m., an interview was conducted with S5SW. She stated on the morning of 11/11/2020 Resident #5's daughter asked to speak to her after a visit. She stated Resident #5's daughter reported her mother had stated a man was bothering her by making vulgar comments, had touched her inappropriately and told her he wanted to have sex with her. S5SW stated when she questioned Resident #5 she was angry this man had done these things. She stated this was serious because it was an allegation of sexual abuse. On 11/23/2020 at 11:42 a.m., an interview was conducted with S1ADM. He stated on 11/11/2020 Resident #5's daughter reported an allegation of the resident being inappropriately touched by a male resident to S5SW. He stated Resident #5's allegation of Resident #7 inappropriately touching her was concerning but did not need a SIMS report filed. He stated a SIMS report was not filed because they conducted an investigation within 24 hours and determined sexual assault had not occurred. Resident #7 Review of clinical record revealed Resident #7 was admitted to the facility on [DATE] with the following diagnoses, in part, Dementia, [MEDICAL CONDITION], and Cerebral Infarction. Review of Resident #7's MDS with an ARD of 11/11/2020 revealed Resident #7 had a BIMS of 11, which indicated he was moderately impaired. Review of the note completed by S5SW revealed the following in part: On 11/11/2020, I was called outside to speak with Resident #5 and her daughter. Resident #5 told her daughter that a man was coming into her room, touching her inappropriately, making foul comments to her, and sexual advances to her. S1ADM and I spoke with Resident #7 and he admitted Resident #5 went into his room to talk. S1ADM and I told Resident #7 to ask Resident #5 to leave the next time she went into his room. On 11/23/2020 at 2:05 p.m., an interview was conducted with S5SW and S1ADM. S5SW stated after the facility conducted an investigation, it was concluded, Resident #7 did not go into Resident #5's room. S5SW verified a SIMS report was not completed when an allegation of abuse was reported. S1ADM stated the facility concluded Resident #5's allegations were related to her medical condition and Resident #7 did not sexually abuse her. S1ADM confirmed neither he nor S5SW completed a SIMS report.

Bases on record reviews, policy reviews, and interviews, the facility failed to investigate, resolve, and conduct a follow-up on resident grievances for 1 (#R9) of 3 (#2, #4, #R9) residents reviewed for grievances. Findings: Review of facility's policy entitled, Grievance Policy, revealed in part: Procedure: 6. The facility will make prompt efforts to resolve grievances the resident may have. 8. All written grievance decisions will include the date the grievance was received, a summary statement of the resident's grievance, steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Review of Resident #R9's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] revealed Resident #R9 had a BIMS score of 13 which indicated Resident #R9 was cognitively intact. Review of Complaint/Grievance Report revealed the following, in part: Date of Incident: 10/26/2020 Date Reported: 10/27/2020 Resident: Resident #R9 Grievance: Resident #R9 stated CNA had nasty attitude towards her. There was no name-calling but she could just tell she just wasn't happy. Investigation: S5SW spoke with Resident #R9. Resident #R9 stated she did not have her call light so she was yelling from her room and banging on table. Resident #R9 stated when the CNA came in she just had an attitude. S5SW picked Resident #R9's call light up from floor and put it near her. Resolution: S5SW told Resident #R9 to make sure her call light is close. S5SW apologized to Resident #R9 for the rudeness of the CNA. Administrator's Signature: S1ADM On 11/23/2020 at 1:47 p.m., an interview was conducted with S5SW. S5SW stated she spoke with Resident #R9, and she completed the Compliant/Grievance Report on 10/26/2020. S5SW stated Resident #R9 could not recall who the CNA was. S5SW stated she did not speak with CNAs, and she did not conduct an investigation. On 11/23/2020 at 1:47 p.m., an interview was conducted with S1ADM. S1ADM stated there was no documentation of an investigation, training/counseling of CNAs or a follow up on Resident #R9's grievance. S1ADM confirmed Resident #R9's grievance was not addressed adequately.

Based on observations, interviews and record review, the facility failed to ensure that a resident who had been identified as being at high risk for falls received adequate supervision and interventions to prevent accidents for 1 (#76) of 3 (#39, #76, #83) sampled residents from a total of 27 sampled Stage 2 residents. The facility failed to: 1. Ensure that supervision/monitoring was increased for a resident with a history of falls on 09/14/17. 2. Identify and implement appropriate fall interventions following unwitnessed falls This failed practice resulted in an actual harm for Resident #76 on 09/14/17 when the resident fell in the bathroom at 19:15 (7:15 p.m. ) then had a second fall at 22:55 (10:55 p.m.) that resulted in the resident being transferred to the hospital where she was admitted and diagnosed with [REDACTED]. The facility did not increase supervision or implement interventions to prevent further accidents for the resident following the first fall on 09/14/17 at 7:15 p.m. The resident returned from the hospital on [DATE] and the facility failed to implement interventions for the resident to prevent future falls. Findings: Review of the clinical record for Resident #76 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's admission Minimum Data Set (MDS) for Resident #76 with an Assessment Reference Date (ARD) of 09/12/17 revealed the resident had a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. Further review of the MDS revealed: Transfers: limited assistance (highly involved in activity, staff provide guided maneuver of limbs) Walking in Room: supervision (oversight and encouragement) Toileting: supervision (oversight and encouragement) Review of the significant change assessment MDS with an ARD of 09/27/17 revealed: Transfers: extensive assistance (involved in activity, staff providing weight bearing support) Walking in Room: limited assistance (highly involved in activity, staff provide guided maneuver of limbs) Toileting: extensive assistance (involved in activity, staff providing weight bearing support) Review of Care Plan revealed the following: Focus: Risk for Falls characterized by history of falls/injury, multiple risk factors related to: impaired balance, cognition, History of Syncope and Collapse (Date initiated:9/12/17) Goals: No preventable injury from falls Interventions: Date initiated (09/12/17) --Call light within reach when in bed --Fall assessments quarterly and prn --Bed to be kept in lowest position --Reinforce need to call for assistance --Have commonly used articles within easy reach --Ensure environment is free of clutter Date initiated (09/15/17) --09/14/17 Fall x 2 - IDT (Interdisciplinary Team) met - will counsel staff on leaving resident in bathroom, counsel resident to continue to call for assist to bathroom, when she returns to the hospital. Further review of the Care Plan revealed no new revisions or modifications for safety interventions after the resident's first fall. Review of incident/accident records revealed the following: Incident Type: Unwitnessed fall Date: 09/14/17 Time: 19:15 (7:15 p.m.) Type of Injury: No injuries observed Nursing Description: Upon administering medications to the resident's roommate, the resident went into the bathroom without assist, and shut the door. Resident began to call out for help, the resident had her back against the door while sitting on the floor. Resident Description: The resident voiced that she felt dizzy. Predisposing Physiological Factors: Weakness/Fainted Other Info: Resident is able to ambulate without assist. Resident may need assistance x one as needed to help with going to the bathroom. Incident Type: Unwitnessed fall Date: 09/14/17 Time: 22:55 (10:55 p.m.) Type of Injury: No injuries observed Nursing Description: At 22:55 went to the resident room while CNA was obtaining vital signs for prior FFU (fall follow up). Resident stated she needed to go to the bathroom, while assisting the resident with walking to the bathroom, nurse voiced to the CNA to stay with the resident while she used the bathroom, and (nurse) proceeded out of the room. Once (nurse) made it to the nurse's station, called back to room by CNA that resident was on the floor in the bathroom. Resident attempted to sit down on the toilet and was sitting between the toilet/sink. Resident appears to be confused. Resident Description: Resident stated that she did not know what happened when going to the bathroom. When asked was she dizzy, she replied no. Other info: Resident appears to be confused at this time, Resident shows unsteady gait while ambulating. Review of the Physician Order dated 09/14/17 revealed an order to send to ER for treatment and evaluation. Review of the Hospital Radiology Results dated 09/15/17 at 9:42 a.m. revealed the following: X-ray Pelvis Findings: Acute fractures of the left superior and inferior pubic rami CT Scan Findings: Mildly displaced and comminuted fracture along the left superior pubic ramus and inferior pubic ramus. Non displaced fracture along the left sacral with extension to the left SI (sacroiliac) joint anteriorly. Small intramuscular hematoma in the left thigh abductor musculature as well as the left obturator internus. Small volume hemorrhage in the extraperitoneal pelvis, left pelvic sidewall. Review of an Interdisciplinary Team Progress note dated 09/15/17 revealed in part: Action: This resident was sent to ER for evaluation for complaints of hip pain. This patient was admitted with a [DIAGNOSES REDACTED]. with Dr. (Doctor) for further evaluation of cardiac issues. Will counsel staff on being in the bathroom with this resident and any other resident at high risk for falls for immediate hands on assist if needed. On 11/15/17 at 8:51AM an observation was made of Resident #76 self-propelling herself down the hall into her room. Upon entering the room, an observation was made of the resident's w/c parked next to her bed where she had gotten in the bed by herself. She had a bed side commode at the side of her bed. On 11/15/17 at 8:55 a.m. an interview was conducted with the resident. She stated she had been to exercise class. She was asked if the staff helped her and she stated if she needed them she called them. She was asked if she had had any falls since being in the facility. She stated she had fallen at home, but did not remember having any recent falls. Review of the facility policy entitled, Fall Prevention Policy revealed the following: Procedure: A score of 10 or higher on the Fall Assessment Form indicates the resident is at high risk for falls. On 11/15/2017 at 10:17 AM an interview was conducted with S1DON, while reviewing the resident's electronic medical record. She stated that the resident had an initial fall risk assessment completed on admission (09/06/17) with a score of 14, indicating high risk for falls. She stated upon the resident's return from the hospital risk assessments were performed which revealed the following risk scores: 09/20/17 score 17 09/27/17 score 14 10/16/17 score 14. She was asked what fall prevention interventions were implemented upon the resident's return from the hospital to ensure the resident's safety from falls. The DON stated the resident had been counseled to use the call light. On 11/15/17 at 8:00 p.m. an interview was conducted with S2LPN who stated she was working when the resident had 2 (two) falls. She stated that during shift report on 09/14/17 she was told that the resident was alert and continent and didn't need assistance to the bathroom. She stated that she was giving medications to the resident's roommate and resident #76 got up and went to the bathroom and closed the door. She stated that the resident yelled out and when she went to the bathroom door, the resident was sitting on the floor. S2LPN stated that the resident stated she felt dizzy when she fell . She stated that she does not recall any new specific intervention being implemented after the fall other than the regular vital signs checks. She stated that at the time of the 4-hour vital sign check, after the first fall, she went into the room to make sure the CNA was getting the vital signs. She stated that the CNA was taking the resident's vital signs. S2LPN stated that the resident said she needed to go to the bathroom, and she instructed the CNA to stay in the room with the resident and help her to the bathroom, and the CNA acknowledged she would stay and help the resident to the bathroom. S2LPN stated she then left the room. She stated that before she got back to the desk, the CNA called out and reported the resident was back on the floor. She stated that when she entered the bathroom she observed the resident on the floor. She stated that they put the resident back to bed at which time she noticed that the resident had a grimacing facial expression when her leg was moved. She stated she contacted the physician and received orders to send Resident #76 to the ER. She stated she called the hospital to follow up on the resident and was told the resident had closed pelvic fractures. S2LPN verified the resident should have had been assisted into the bathroom and supervised when she needed to go to the bathroom. On 11/16/17 at 10:30 AM a phone interview was conducted with S9CNA she stated that while getting vital signs on the resident she had to go to the backroom. She stated she helped transfer her into the wheelchair and rolled her to the bathroom door. S9CNA stated she got out of wheelchair and walked into the bathroom. She stated while she waited in the resident's room, the resident began yelling that she missed the toilet. On 11/15/17 at 11:15 a.m. an interview was conducted with S8PT. She stated that initially the resident's pain was moderate and that she needed help with lifting and movement of the left leg due to the fractures. She also stated the resident had weakness and an unsteady balance. She stated the resident had moderate pain for about 2 (two) weeks but the pain has since subsided, however she has slight left leg weakness. On 11/15/2017 at 10:25 a.m. an interview was conducted with S1DON. She stated that an IDT meeting was held on 09/15/17, the morning after the resident's second fall. She stated that on 09/14/17 at 22:55 (10:55 p.m.) the CNA assisted the resident to the bathroom but did not remain with or assist the resident while she was in the bathroom. She stated that when the resident attempted to sit she missed the toilet and fell to the floor. S1DON verified that her expectation was that the CNA should have accompanied the resident into the bathroom and remained with the resident since the resident had fallen earlier in the shift.