Every finding on record at Pruitthealth - Sunrise

Based on interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure an allegation of potential sexual abuse was thoroughly investigated for one of three residents (Resident (R)14) reviewed for abuse out of a total sample of 18. This failure had the potential to place residents at continued risk of abuse. Findings include: Review of the facility's policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 11/15/2024, revealed that documentation of the investigation should include, but not be limited to,.Date and time of alleged occurrence, patient's full name and room number, names of accused and any witnesses. Interview should be conducted with all individuals who have relevant information, utilizing open-ended questions. Signed written statements from any involved parties should be obtained. Statements should be gathered from the following individuals: the suspect; the person(s) making the accusation(s); the patients(s) involved; reliable patients who may have witnessed the incident; and any other persons who may have information. Review of R14's Face Sheet, found under the Profile Tab of the electronic medical record (EMR), revealed an admission date of 12/28/22 with diagnoses that included steatohepatitis, cirrhosis of the liver, chronic obstructive pulmonary disease, generalized anxiety disorder, type 2 diabetes, depression, and pressure ulcers. Review of R14's Quarterly Minimum Data Set (MDS), found under the MDS tab of the EMR and with an assessment reference date (ARD) of 3/5/2025, revealed R14 had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R14 was severely cognitively impaired. Review of the facility's Abuse Investigation Report, dated 12/4/2025 and provided by the facility, indicated that R14 alleged that Certified Nurse Aide (CNA)12 beat her in her private areas on 11/29/2024. Review of the facility's Abuse Investigation Report revealed that there were no skin audits performed on cognitively impaired residents and no interviews of alert and oriented residents immediately after the alleged abuse incident to determine who else may have witnessed the alleged abuse, been abused, or have information regarding the allegation. During an interview on 6/4/2025 at 9:00 am, Administrator 2 stated that there were no resident interviews or skin audits completed, and no documentation could be found. During an interview on 6/5/2025 at 9:44 am, Administrator 3 stated that there were no resident interviews with alert and oriented residents immediately after the alleged incident, except for R14's roommate, R10, and skin audits on cognitively impaired residents were not performed. During an interview on 6/5/25 2:20 pm, Administrator 1 stated that going forward, her expectation would be to ensure there was a timeline for notification of all parties, visual skin checks, trauma screens, resident interviews, and witness statements from staff. Administrator 1 stated the facility would provide abuse packets with checklists for investigation to all parties who are delegated to assist with an investigation, and the facility would train all nurses on the new process.

3. Review of R31's admission Record, located in the Profile tab of the EMR, revealed R31 was admitted to the facility on [DATE] with diagnoses including hemiplegia, chronic pain syndrome, peripheral vascular disease, kidney disease, cerebrovascular disease, occlusion of artery of the right femoral vein, major depressive disorder, hypertensive heart disease with heart failure, atherosclerotic heart disease, cellulitis, and cognitive communication deficit. Review of R31's Orders tab of the EMR revealed an order dated 8/22/2024 for hospice services. Review of R31's quarterly MDS, with an ARD of 3/2/2025, revealed R31 was under hospice care and had a Brief Interview for Mental Status summary score of 99, which indicated R31 did not complete the test, and cognitive skills for daily decision making were moderately impaired. Review of R31's hospice visit note, dated 1/28/2025, by the HSW indicated that R31 reported to the HSW that he wanted to kill himself. He also stated to HSW that he would do this by starving himself. R31 was receptive to contracting for safety with HSW, and the facility social workers were receptive to safety measures set forth. Review of R31's hospice documentation uploads to the facility EMR revealed that the visit on 1/28/2025 was uploaded to R31's EMR on 4/8/2025. In an interview on 6/4/2025 at 4:00 pm, the Hospice Registered Nurse (HRN) regarding R31's condition, HRN stated that earlier this year, R31 expressed depression and suicidal ideations, but was unsure of the date. HRN stated that R31 stated that he would stop eating and stop taking his medications. HRN reported this to the Hospice Social Worker (HSW) and the nurse on duty. During an interview on 6/5/2024 at 11:14 am, the DON stated that she found out today (6/5/2025) that R31 had verbalized suicidal ideations to the HRN on 1/28/2025. She stated that the hospice nurse did not report this concern to her. The DON stated that the hospice company uploads visit notes in batches that include many visits. The DON stated the visit occurred on 1/28/2025, and no staff member at the facility knew about it. The DON stated that she had met earlier in the morning with hospice staff to correct communication systems for visits, and they would be using a communication book on the unit in the future. She stated that R31 was being assessed by the facility's SSD and the physician today. During an interview on 6/5/2025 at 1:00 pm, HRN stated that she told a nurse, but she did not document the nurse's name and could not be sure who it was. During an interview on 6/5/2025 at 2:02 pm, the facility's Social Services Director (SSD) stated that no hospice nurse had spoken to her about R31 or other hospice residents. Based on staff interviews, record review, and review of the facility policy titled Coordination of Hospice Services, the facility failed to ensure an effective communication process between hospice and the facility for three of three residents (Resident (R) 5, R32, and R31) reviewed for hospice services out of a total sample of 18. This failure had the potential to place R5, R32, and R31 at risk for not receiving the necessary comfort care, services, and a diminished quality of life. Findings include: Review of the facility policy titled, Coordination of Hospice Services, revised 8/21/2024, revealed, It is the policy of [name of facility corporation] Hospice Interdisciplinary Group (IDG) to make certain that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers, and in all settings. 1. Review of R5's Resident Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, stage 3 unspecified. Review of R5's Orders, located under the Orders tab of the EMR, revealed an order dated 5/5/2025 for hospice services. Review of R5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/2025, revealed R5 was under hospice care. Review of R5's Care Plan, located under the Care Plan tab of the EMR, revealed interventions dated 5/5/2025 to Call hospice first about any changes in condition, emergency, questions about care, medication changes or transport and prior to any procedures. Interventions also included Meds as ordered, Monitor signs and symptoms of pain, Notify hospice as appropriate and as family agrees, for evaluation for hospice services, Notify MD of changes, and Provide comfort measures. Review of R5's Resident Documents tab of the EMR revealed: a. Two Communication Notes with attached dates of 5/20/2025 and 5/30/2025. These Communication Notes with attached dates of 5/20/2025 and 5/30/2025 contained pertinent clinical information such as R5 having moderate confusion, sadness, skin findings, swelling of lower extremities, oxygen saturation reading, respirations becoming labored, foley catheter condition, oxygen use, pain assessment, lung sounds, meal intake, level of ADL assistance. b. Communication Notes with visit dates from 5/06/2025 to 5/21/2025 that were authored by nurses, a social worker, a chaplain, and a volunteer, but no hospice aides. c. A Communication Note, dated 5/08/2025 and authored by a chaplain, noted that R5 reported shortness of breath and stomach pain on exertion. Review of R5's Progress Notes, located in the Progress Notes tab of the EMR, revealed no progress note on 5/8/2025 or 5/9/2025 related to receiving a report that R5 had shortness of breath or stomach pain. c. A Communication Note, dated 5/7/2025, which indicated a recommendation to switch R5's montelukast order to Zyrtec due to formulary restrictions and to discontinue Victoza because it was a medication that was not usually continued during hospice. Review of R5's Orders, located in the Orders tab of the EMR, revealed that montelukast was not discontinued until 5/17/2025, and Victoza was not discontinued until 5/20/2025. Review of R5's Progress Notes did not reveal a note related to the medication recommendation or the discontinuation of either medication. d. A Communication Note, dated 5/14/2025 and authored by the hospice physician, that revealed R5 was assessed with 3+ pitting edema, shortness of breath with conversation, and capillary refill time greater than 5 seconds. Review of R5's Progress Notes revealed no note on 5/14/2025 or 5/15/2025 related to the hospice physician notifying facility staff regarding 3+ pitting edema, shortness of breath, and capillary refill time. 2. Review of 32's Resident Face Sheet, located in the Profile tab of the EMR, revealed R32 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset. Review of R32's Orders tab of the EMR revealed an order dated 3/19/2024 for . hospice to evaluate and treat if indicated. Review of R32's five-day MDS, with an ARD of 3/14/2025, revealed R32 was under hospice care. Review of 32's Care Plan, located under the Care Plan tab of the EMR, revealed interventions dated 3/20/2024 for hospice services with interventions to Call hospice first about any changes in condition, emergency, questions about care, medication changes, or transport, and prior to any procedures. Interventions also included Meds as ordered, Monitor signs and symptoms of pain, Notify hospice as appropriate and as family agrees, for evaluation for hospice services, Notify MD of changes, and Provide comfort measures. Review of R32's Resident Documents tab of the EMR revealed a Communication Note with attached date of 5/30/2025 and a Hospice Communication Note with an attached date of 5/9/2025. The Hospice Communication Note with an attached date of 5/9/2025, contained notes, dated 1/9/2025 through 4/3/2025. They were authored by nurses, a social worker, a chaplain, and a volunteer, but no hospice aides. The notes contained pertinent clinical information such as mental status, pain level, pain medication changes, agitation with activities of daily living, and skin condition. Included was a Hospice Communication Note, dated 2/1/2025, that revealed R32 told the Hospice Nurse she was going to get the bus and was observed to be exit seeking. Review of R32's Progress Notes, located in the Progress Notes tab of the EMR, revealed no progress notes on or around 2/1/2024 related to R32's exit-seeking behavior. During an interview on 6/4/2025 at 11:55 am, Licensed Practical Nurse (LPN) 5 revealed that hospice staff documented their visits on an electronic tablet, and then facility staff signed the hospice tablet to confirm hospice staff visits. LPN 5 stated that the facility staff did not document a progress note in the facility EMR related to the hospice visit. LPN 5 stated that hospice did not leave any documentation at the facility related to their visits, and there were no hard copies in the nurse's station. LPN 5 stated that hospice notes were uploaded later to the EMR. During an interview on 6/3/2025 at 3:50 pm, the Director of Nursing (DON) stated that hospice visit notes were uploaded every two weeks and did not include visits from hospice aides. During an interview on 6/5/2025 at 5:30 pm, the DON stated the hospice nurse aide visits were not uploaded into the facility EMR. The DON stated the hospice agency had access to the facility's EMR and uploaded only the visit notes from the social worker, nurse, physician, and chaplain. The DON stated that the hospice agency told her they uploaded notes every two weeks. During an interview on 5/7/2025 at 7:50 pm, the DON stated the hospice visit notes should be immediately available to facility staff.

Based on observation, Staff interviews, and review of the facility policy titled, labeling and Dating, the facility failed to ensure that opened food items were labeled and dated with an expiration date. The facility also failed to ensure expired food items were discarded after expiration date. The deficient practice had the potential to affect 52 of 54 residents receiving an oral diet. Findings: Review of facility policy titled, labeling and Dating, revised date of [DATE] revealed under policy statement: It is the policy of (facility Name) for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Under Procedure: 1. Food and beverages items will have an identifying label as well as a received date and opened date, as applicable: for items prepared onsite, a use by date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, or foil, etc. Observation on [DATE] at 8:14 am of the dry foods pantry revealed La Banderita flour tortillas expiration date [DATE], two opened packages of Vanilla instant pudding and pie filling with no open date or expiration date, Casa Solana yellow rice was stored in a blue plastic bag inside a cardboard box (not original packaging) with no open date or received date, Par excellence parboiled rice was stored in a blue plastic bag inside a cardboard box (not original packaging) with no open or received date. Continued observation of the facility freezer located in the main kitchen revealed Cinnamon rolls in a cardboard box with no open date or expiration date, Whole kernel corn in an opened bag with no received date or expiration date, cooked chopped chicken in and opened bag with no open date or expiration date, a bag of pork chops with no received date or expiration date. Interview on [DATE] at 8:14 am with Dietary Manager (DM) confirmed all food items were not properly labeled and dated. During interview DM stated that she did not know why the food items were in the freezer without being dated or labeled, and that they should have been sealed with dates on them. Further interview also revealed that all food items should have the date they were received, and the expiration date put on them when they are delivered. Interview on [DATE] at 11:05 am with the Registered Dietician revealed that she conducts in-services to the dietary staff on labeling and dating of foods. The staff should be labeling the food items with a received date and a use by date as the items come in for delivery. Further interview also revealed that the DM orders food for the facility weekly, and the dietary staff should be rotating the food items so that no foods are expired.

Based on staff interviews, and record review, the facility failed to implement a comprehensive person-centered care plan for one of 13 Residents (R) R6 that included measurable timeframes to meet the needs that were identified in the comprehensive assessment completed for R6. The deficient practice had the potential to prevent R6 from receiving the necessary staff assistance to meet the resident's level of required care needs. Findings include: Record review for R6 revealed resident was admitted to the facility with diagnoses of chronic kidney disease, stage 3, Alzheimer's disease, dysphagia, oral phase, schizophrenia unspecified, generalized anxiety disorder, functional quadriplegia, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C (Cognitive Pattern) C0500 Brief Interview of Mental Status (BIMS) score of 14 indicating resident was cognitively intact. Section GG (Functional Abilities and Goal) G0130 Self-care I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, resident requires substantial/maximal assistance- helper does more than half the effort. Review of R6 Care Plan dated 11/16/2020 revealed under problem resident has self-care deficit d/t impaired mobility, goal resident will maintain current level of function through next review date. Interventions: (approach start date 2/8/2024) encourage resident to allow staff to brush hair when ADL care is given, for refusal, re-attempt at later time. Include resident's preference in scheduling of care. Observation on 2/6/2024 at 12:12 pm revealed R6 was lying in bed hair was tangled and uncombed. Interview on 2/7/2024 at 2:48 pm with R6 revealed that her hair had not been combed today as of yet. Resident hair was observed to be tangled and knotted during interview. Interview on 2/8/2024 at 12:19 pm with the Director of Health Services (DHS) revealed the nurses are supposed to document any refusal of care by residents in the progress notes. If the residents continue to refuse care the nurse should notify the resident's family or responsible party of the refusal of care. During the interview the DHS confirmed R6 hair was tangled and uncombed and verified that there were no refusal of care documented in the residents progress notes.

Based on observations, staff interviews, and record review, the facility failed to ensure Activity of Daily living (ADLs) were completed for one of two residents (R) R6. Specifically, the facility failed to ensure the R6 hair was combed and prevented from being tangled. Findings include: Record review for R6 revealed resident was admitted to the facility with diagnoses of chronic kidney disease, stage 3, Alzheimer's disease, dysphagia, oral phase, schizophrenia unspecified, generalized anxiety disorder, functional quadriplegia, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C (Cognitive Pattern) C0500 Brief Interview of Mental Status (BIMS) score of 14 indicating resident was cognitively intact. Section GG (Functional Abilities and Goal) G0130 Self-care I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, resident requires substantial/maximal assistance- helper does more than half the effort. Review of R6 Care Plan dated 2/8/2024 revealed under problem resident has self-care deficit d/t impaired mobility, goal resident will maintain current level of function through next review date. Interventions: encourage resident to allow staff to brush hair when ADL care is given, for refusal, re-attempt at later time. Include resident's preference in scheduling of care. Observation on 2/6/2024 at 12:12 pm revealed R6 was lying in bed hair was tangled and uncombed. Interview on 2/6/2024 at 12:12 pm with Facility Hair stylist revealed that the facility staff asked her to look at R6 hair due to the knotting and tangling in the residents hair. Further interview also revealed that the knotting and tangling of the hair is caused by the hair not being combed regularly. Interview on 2/7/2024 at 2:48 pm with R6 revealed that her hair had not been combed today as of yet. Resident hair was observed to be tangled and knotted during interview. Interview on 2/8/2024 at 9:01 am with Licensed Practical Nurse (LPN) FF revealed that the Certified Nursing Assistants (CNA) should be combing the residents hair as part of their ADLs, and that he would expect that to be done during that time. Interview on 2/8/2024 at 12:19 pm with the Director of Health Services (DHS) revealed the nurses are supposed to document any refusal of care by residents in the progress notes. If the residents continue to refuse care the nurse should notify the resident's family or responsible party of the refusal of care. During the interview the DHS confirmed R6 hair was tangled and uncombed and verified that there were no refusal of care documented in the residents progress notes.

Based on staff and resident interviews, pharmacy staff interviews, record review, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to ensure that vital medications were obtained and administered from the pharmacy in a timely manner resulting in missing medications for one of 25 sampled Residents (R) (R350) reviewed. Findings include: Review of the facility's policy titled, Medication Administration: General Guidelines dated 4/10/2019 under the section titled, Procedure: revealed 13 . If more than two consecutive doses of a vital medication is withheld, or refused, the physician is notified. Interview on 2/6/2024 at 10:02 am with R350 stated she had not had her medications since admission on yesterday 2/5/2024 and was very concerned about missing her medications. Record review of R350's Electronic Medication Administration Record (EMAR) revealed missed medications for the following dates on 2/5/2024 and 2/6/2024: Gabapentin Capsule 300 milligram (mg) administer one capsule at bedtime (due at 9:00 pm); medication was missed on 2/5/2024 at 9:00 pm. Isosorbide tablet extended release 24 hour; 30 mg one tablet once a day (due at 9:00 am); medication was missed on 2/6/2024) at 9:00 am. Metoprolol 50 mg one tablet by mouth twice a day (due at 9:00 am and 9:00 pm); medications was missed on 2/5/2024 at 9:00 pm and 2/6/2024 at 9:00 am. Mirtazapine 15 mg two tablets by mouth at bedtime (due at 9:00 pm); medication was missed on 2/5/2024) at 9:00 pm. Omeprazole delayed release 10 mg one capsule by mouth once a day (due at 9:00 am); medication was missed on 2/6/2024 at 9:00 am. Polyethylene glycol 3350 [OTC] (over the counter) powder; 17 grams (gm) by mouth once a day (due at 9:00 am); medication was missed on 2/6/2024 at 9:00 am. Quetiapine 25mg one tablet by mouth at bedtime (due at 9:00 pm); medication was missed on 2/5/2024 at 9:00 pm. Senna [OTC] 8.6 mg one tablet by mouth twice a day (due at 9:00 am and 9:00 pm); medication was missed on 2/5/2024 at 9:00 pm. Tamsulosin 0.4 mg one capsule by mouth at bedtime (due at 9:00 pm); medication was missed on 2/5/2024 at 9:00 pm. Record review of the R350's EMR revealed that there was no documentation that the physician had been notified of the missing medication doses, nor a reason why medications were missed. Interview on 2/7/2024 at 9:22 am with Licensed Practical Nurse (LPN) JJ revealed that if a new resident arrived on a Sunday or if medications could not be filled by the pharmacy, the medications would be pulled from emergency meds (E-box) at the facility. LPN JJ stated, If medications were not available, or if it's after the main pharmacy hours then the back up pharmacy would be called, and the nurse would pick up the medications. She further revealed that the pharmacy delivered medications nightly except on Sundays. She also revealed that new residents should always receive their medication because orders are usually received prior to admission. Surveyor reviewed medications with nurse that were currently available on hand for R350, and the following medications were noted: 1. Omeprazole 10 mg Expiration. 2/25 2. Metoprolol 50 mg Expiration. 2/25 3. Isosorbide 30 mg ER Expiration.2/25 The individual pill pack was intact and labeled with the resident's information. Interview on 2/7/2024 at 1:49 pm with LPN FF revealed that new admission orders are faxed to the facility then the Assistant Director of Nursing (ADON) or Director of Nursing (DON) would put the orders in for the new residents. LPN FF stated nurses are responsible for checking the orders for any discrepancies. He also revealed that the cut off for new orders sent to pharmacy was usually at 5:00 pm and meds are typically delivered by 7:00 pm the same day with no specific time for admission. He stated if a medication was not available, the facility would utilize the backup pharmacy to order and obtain medications and that it should be charted in the EMR, and the physician should be notified. Interview on 2/8/2024 at 10:00 am with DON revealed that she or the ADON would put in new orders received for newly admitted residents into the system. She revealed that a variety of medications are kept in the E-box (medications on hand if not readily available from pharmacy) at the facility. DON stated new orders are usually emailed to the facility for review and entry prior to the resident arriving to the facility. The DON was asked about R350 missing doses of medication, she revealed that there was a discrepancy with her allergies stating that there was a broad allergy alert to muscle relaxers, she confirmed that resident did not have an order for muscle relaxers and had other vital medications ordered that should have been given. She also stated that if the resident misses any medications the physician should be notified, and it should be documented. The DON was asked to present the facility's policy for medication administration and any supporting documentation for the medication administration done by staff during this time. Interview on 2/8/2024 11:20 am with the DON who presented a copy of R350's EMAR which revealed that resident had not received medications on the dates of 2/5/2024 (9:00 pm) medications and 2/6/2024 (9:00 am) medications. When asked regarding these missed doses of medication the DON admitted that there was a deficient practice regarding the resident not receiving medications. A telephone interview conducted on 2/8/2024 at 12:58 pm with the Assistant Manager at the main pharmacy revealed that there was a discrepancy regarding the resident's allergies and that the medication fill was delayed because of the pending verification. He stated that there was an attempt to contact the ordering facility on 2/5/2024 to clarify the allergy and had no answer or call back until 2/6/2024 and at that time, the allergy was verified. He further revealed that the reason for the delay was that the pharmacy tech at the main pharmacy was waiting on clarification and due to the verification delay the other medications were not filled. He stated the other medications could have been filled, being that they were not related to the allergy in question. During this time, he admitted that was an error on the pharmacy and stated the pharmacy tech did not quite understand the policy. He further revealed that the facility should have medications on hand in an E-box or could call for medication needs from the backup pharmacies which are used for emergencies and after hour needs. He stated, R350's medication orders and allergies were clarified on the morning of 2/6/2024 and medications were filled and sent out for delivery. He stated according to the pharmacy records, the medications were dispensed on the evening of 2/7/2024 and delivered to the facility and were signed as received at 3:00 am.

Based on observations and interviews the facility failed to maintain a clean comfortable environment for facility residents. Specifically, the facility failed to ensure privacy curtains for rooms; 126, 119, 129, 130, and 127 on the North Hall were clean and properly affixed to the curtain ceiling tract. Findings include: Observation on 4/12/22 at 9:24 a.m. room 126 bed A North Hall privacy curtain has brown stain midway curtain by the hem right side. Observation on 4/12/22 at 9:25 a.m. room 119 bed B North Hall privacy curtain was observed to have brown stains on the front and back of curtain that were visible from hallway door. Observation on 4/12/22 at 9:33 a.m. room 129 bed A North Hall was observed to have a large brown stain on the curtain starting 3/4 of the way down privacy curtain to the bottom hem line with chunks of debris observed in the middle of the stain. Observation on 4/12/22 at 9:44 a.m. room 130 bed C North Hall the privacy curtain was observed to have brown stains throughout the curtain. The curtain between bed A and bed B was observed to be off tract with brown stains on the curtain as well. Observation on 4/12/22 at 9:50 a.m. room 127 bed A North Hall privacy curtain was observed to have brown stains to the outer hem line on both sides. On 4/13/22 at 8:07 a.m. environmental rounds were conducted with the Administrator, Maintenance Director, and the Housekeeping Supervisor which confirmed all observations of stained curtains in rooms 119,126,127,129, and 130. Interview with the Maintenance Director on 4/13/22 at 8:10 a.m. revealed that compliance rounds are conducted three times a week and each department head is assigned different rooms. While conducting compliance rounds there is a check off list that each staff member has that list certain items to look for when checking the rooms which includes privacy curtains for any stains or repairs that are needed and the overall upkeep of the room. Continued interview also revealed the Maintenance Director was responsible for room 129, 130, and room 127. During the interview it was also disclosed that the privacy curtains were not checked when compliance rounds were conducted on Monday. Further interview also revealed that Housekeeping and Maintenance are responsible for ensuring that all the privacy curtains are clean and in good repair. Interview with House Keeping Supervisor on 4/13/22 at 8:15 a.m. revealed that each room is deep cleaned monthly and the schedule for deep cleanings are populated by the building engines program. The deep cleaning process for each room consists of cleaning everything in the residents' room including checking the privacy curtains to ensure that they are clean and in good repair. Interview with Housekeeper AA on 4/13/22 at 8:50 a.m. revealed that deep cleanings are completed monthly for each room. The process for deep cleaning the rooms is that the rooms are dusted, the bedrails and mattresses are cleaned with disinfectant cleaner, privacy curtains are also checked for any stains or repairs during deep clean process. If there are any curtains that need to be replaced the maintenance director is notified and the curtain is taken down and washed in the laundry room and replaced. Further interview also revealed that staff members did not notice the stains on the curtains in the rooms that were cleaned on 4/12/22 during routine cleaning which included rooms 119,126,127,129, and 130. Interview with Administrator on 4/13/22 at 9:15 a.m. revealed that there are compliance rounds that are conducted by the department heads daily which include checking the privacy curtains for stains and repairs. After the rounds are completed the compliance rounds form is taken to morning meeting and any repairs or concerns are discussed at that time. Once there are issues identified the correction should be completed within 12 hours of being identified. Continued interview also revealed that it was the expectation of the Administrator to resolve all issues identified immediately.

Based on record review, family interview and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for one of 23 sampled residents (R#7). Specifically, the MDS dated [DATE] section I (Active Diagnoses) omitted diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Interview on 4/12/22 at 10:58 a.m. with Family of R#7 revealed there were concerns with resident having repeated UTIs. Further interview also revealed that resident was currently on antibiotics for a [CONDITION(S)]. Review of the medical record for R#7 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE] section C cognitive patterns C0500 revealed Brief Interview of Mental Status (BIMS) score of 7 indicating resident was severe cognitive impairment. Section I (Active Diagnoses) I2300. Urinary tract infection ([CONDITION(S)]) Last 30 days there was no indication of the residents [CONDITION(S)] status being addressed during the assessment period. Continued review of the medical record for R#7 revealed the resident was on antibiotics for [CONDITION(S)] on 12/12/2021 through 12/25/2021 ([MEDICATION(S)] 500mg), 1/17/2022 through 1/24/2022 ([MEDICATION(S)] 500mg), 3/31/2022 through 4/10/2022 ([MEDICATION(S)] 500 mg). On 4/13/22 at 1:28 p.m. Interview with Director of Health Services (DHS) who was also responsible for infection control, revealed that she is responsible for tracking and trending infections in the facility. The DHS was unable to verbalize any interventions or concerns related to R#7's recurrent UTIs. Interview on 4/13/22 at 2:51 p.m. with Licensed Practical Nurse (LPN) BB revealed R#7 has had several [CONDITION(S)]'s over the past three months. Further interview also revealed that the resident prefers to drink [NAME] and teas and very little water. Further interview also revealed that resident is not currently on any supplements for UTIs such as cranberry tablets or cranberry juice which was available in facility stock medications for use if needed. Interview also revealed that residents' family members sometimes bring in flavor packages to mix with residents' water to encourage him to drink more water and increase his fluid intake. Interview on 4/13/22 at 4:20 p.m.with the MDS Coordinator confirmed that the Annual assessment that was completed on 1/11/2022 had no indication noted in section I2300 of R#7 having [CONDITION(S)] in the past thirty days, the MDS Coordinator indicated that this section of the MDS is initiated based on the McGeer Criteria in which R#7 did not meet at time of assessment. Staff member was unable to verbalize what criteria according to McGeer R#7 failed to meet for indication of section I2300 of MDS to be initiated. Review of revised McGeer Criteria for infections surveillance checklist revealed under syndrome; Urinary tract infections in resident without an indwelling catheter 1. Must have at least one of the following signs or symptoms: New or increase dysuria or burning, pain, swelling, or tenderness of testes, epididymis, or prostate, no more than two species of organisms in a voided urine sample, any organisms collected by an in-and-out catheter urine sample. After review of R#7 medical record it was revealed that resident did meet the criteria for Mcgeer by presenting signs and symptoms required.

Based on record review, staff interview, and review of facility policy titled Care Plans the facility failed to develop care plans to address dementia care and [CONDITION(S)] drug use for one of 23 sampled (R#1). Findings Include: Review of the medical record for R#1 revealed resident was admitted to facility on 9/21/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)], persistent mood disorders, Dementia in other diseases classified elsewhere without behavioral disturbance, Cachexia, weakness, Anorexia, Alzheimer's disease, history of falling, and altered mental status. Medications included [MEDICATION(S)] sodium 100 mg, [MEDICATION(S)] ([MEDICATION(S)]) 50 mg, and [MEDICATION(S)] 20 mg. Review of Medical Data Set (MDS) quarterly assessment dated [DATE] Section C (Cognitive Patterns) C0500 revealed Brief Interview of Mental Status (BIMS) score of 99 indicating resident had severe cognitive impairment. Continued review of the residents record also disclosed that there was no indication of implementation of a care plan that addressed residents' dementia or [CONDITION(S)] drug use. Interview on 4/14/22 at 8:15 a.m. with the MDS Coordinator confirmed R#1 did not have an active care plan for dementia nor did she have a care plan that addressed the residents' [CONDITION(S)] drug use. Further interview also revealed that there should have been a care plan initiated that addressed R#1's status during the most recent quarterly assessment completed on 3/29/2022. Interview on 4/14/22 at 8:41 a.m. with the Director of Health Services (DHS) revealed that R#1 did not have a dementia care plan or [CONDITION(S)] care plan in place and confirmed that a care plan should have been initiated to address residents' current health status. Further interview also revealed that it is her expectation that residents are care planned correctly to meet their care needs. Review of facility Care Plan Policy revised date 10/05/ 2017, Revealed under Comprehensive Plan of care 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. Continued review of the policy also revealed under number 4. The care plan will contain 4 components: Problem, Goal, Approaches and Role or Accountability. The plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners.

Based on record review, staff interview, and review of facility policy titled Care Plans the facility failed to ensure care plans were revised and person-centered for two of 23 sampled residents (R#1 and R#7. Findings include: 1. Review of the medical record for R#1 revealed the resident was admitted to facility on 9/21/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)], persistent mood disorders, Dementia in other diseases classified elsewhere without behavioral disturbance, Cachexia, weakness, Anorexia, Alzheimer's disease, history of falling, and altered mental status. Medications included [MEDICATION(S)] sodium 100 mg, [MEDICATION(S)] ([MEDICATION(S)]) 50 mg, and [MEDICATION(S)] 20 mg. Review of Medical Data Set (MDS) quarterly assessment dated [DATE] Section C (Cognitive Patterns) C0500 revealed Brief Interview of Mental Status (BIMS) score of 99 indicating resident was severely cognitivly impaired. Continued review of residents record also revealed that there was no indication of revision of the care plan for R#1 being discharged from hospice services. Interview on 4/14/22 at 8:15 a.m. with the MDS Coordinator revealed R#1 was discharged from hospice services on 4/3/2022. The MDS Coordinator confirmed the resident's hospice care plan should have been updated to reflect the change in the residents' status. 2. Review of the medical record for R#7 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual assessment dated [DATE] section C cognitive patterns C0500 revealed BIMS score of 7 indicating resident was severe cognitive impairment, Section I (Active Diagnoses) I2300. Urinary tract infection ([CONDITION(S)]) Last 30 days there was no indication of resident [CONDITION(S)] status being addressed during the assessment period. Continued review of R#7 medical record revealed resident was on antibiotics for [CONDITION(S)] on 12/12/21 - 12/25/21 ([MEDICATION(S)] 500mg), 1/17/2022 through 1/24/2022 ([MEDICATION(S)] 500mg), 3/31/2022 through 4/10/2022 ([MEDICATION(S)] 500 mg). Interview on 4/14/22 at 8:41 a.m. with the Director of Health Services (DHS) revealed the care plans for R#1 and R#7 should have been revised or updated to reflect the residents current health status. Further interview also revealed that it was her expectation that residents are care planned correctly and in a timely manner for their care needs. Review of facility Care Plan Policy revised date 10/05/2017, Revealed under care plan Review and Update; 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed with in seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. Updates to the care plan should be made with any changes in condition at the time the change in condition occurred.

Based on record review, staff interviews and family interviews the facility failed to ensure that one of 23 (R#7) was free from recurring Urinary Tract Infections ([CONDITION(S)]). Findings Include: On 4/12/22 at 10:58 a.m. Interview with R#7 family member revealed there were concerns with resident having repeated UTIs. Further interview also revealed that resident was currently on antibiotics for [CONDITION(S)]. Review of R#7 medical record revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7 indicating resident was severely cognitively impaired. Section I (Active Diagnoses) I2300. Urinary tract infection ([CONDITION(S)]) Last 30 days there was no indication of resident [CONDITION(S)] status being addressed during the assessment period. Continued review of R#7 medical record revealed resident was on antibiotics for [CONDITION(S)] on 12/12/21 - 12/25/21 ([MEDICATION(S)] 500mg), 1/17/2022 through 1/24/2022 ([MEDICATION(S)] 500mg), 3/31/2022 through 4/10/2022 ([MEDICATION(S)] 500 mg). On 4/13/22 at 1:28 p.m. Interview with Director of Health Services (DHS) who was also responsible for infection control, revealed that she is responsible for tracking and trending infections in the facility. The [CONDITION(S)] infections are reviewed monthly for trends. If a resident is noted to have chronic UTIs' they are referred to urologist for follow up, cranberry juice is implemented on their meal trays, or increase and encourage fluids. Further interview also revealed that sometimes residents are ordered a prophylactic antibiotic to help with recurrent UTIs by the physician if it is appropriate for that resident. Continued interview also revealed that there were only two residents in the facility that are currently considered as having chronic [CONDITION(S)] and R#7 was not one of the two. Further interview also revealed that a resident that has had an [CONDITION(S)] monthly or at least every other month would be considered to have chronic UTIs and one of the interventions previously noted would be implemented. Interview on 4/13/22 at 3:38 p.m. with the facility Medical Director revealed there were not any specific protocols that have been implemented for the facility related to prevention of UTIs. Further interview also revealed that some residents that have frequent UTIs can be placed on prophylactics', but it would depend on the overall health of the resident in question. The Medical Director revealed that he was unaware that UTIs were an issue for R#7 but would be open to taking a closer look into residents medical record to include labs to determine what interventions would be more appropriate for resident status. There was no indication that facility staff had made physician aware of residents' recurrent status with UTIs.

Based on record review and staff interview the facility failed to ensure that one of 23 residents (R#41 medical records were accurate and complete. Specifically, the facility failed to maintain documentation that indicated R#41 events surrounding the residents death and recapitulation of resident stay at facility. Findings include: Record review for R#41 revealed resident was admitted to facility on [DATE] and expired on [DATE]. Residents admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued medical record review revealed a Admission assessment dated [DATE] revealed Brief Interview of Mental Status (BIMS) score of 11 indicating resident was moderately cognitively impaired. Interview on [DATE] at 8:30 a.m. with Director of health Services (DHS) revealed there was no documentation of the events of R#41 when he expired in the facility. Further interview also revealed that the charge nurse for the resident that expires is responsible for ensuring the events surrounding the residents' death are documented. The family and physician should be notified as well as the family or residents funeral home of choice. Continued interview revealed R#41 was pronounced by DHS at the facility on [DATE] at 10:40 a.m. The DHS stated the resident had a heart attack. However, there was not any documentation that indicated how resident was found nor were there any other events surrounding residents' death documented. Further interview also confirmed that there was not any evidence of documentation of a summary of care for R#41.

Based on resident interviews, staff interviews, and the facility policy titled, Resident Bill of Rights - GA, the facility failed to provide respect and dignity for three of five Residents (R#1, R#3, R#4) reviewed for dignity concerns. Findings include: Record review of the Resident Bill of Rights - GA 9. Each resident shall have the right to be free from mental, verbal, sexual and physical abuse, neglect and exploitation. 10. Each resident has the right to be free from actual or threatened physical or chemical restraints and the right to be free from isolation, corporal or unusual punishment including interference with the daily function of living, such as eating or sleeping. 1. Review of the Face Sheet revealed R#1 was admitted to the facility with the following Diagnoses: [REDACTED]. The Annual Minimum Data Set (MDS) revealed a Brief Interview Mental Status (BIMS) score of 15 indicating that R#1 is cognitively intact. Review of a Grievance/Complaint Form: Healthcare Centers dated 4/14/19 revealed R#1 that wanted a record for her incidents with RN HH. During an interview on 4/30/19 at 1:39 p.m. with Certified Nurse's Aide (CNA) BB revealed Registered Nurse (RN) HH talks to staff rudely. For example, if I tell her that a resident said that he wanted to fall on the floor, RN HH would reply - Let him fall. Another example, CNA BB stated that she reported to RN HH that a resident was choking, and RN HH replied, that she's not the only nurse. During an interview on 4/30/19 at 1:54 p.m. CNA DD revealed that RN HH talks to everyone any kind of way for example RN HH made R#1 cry about her weight. During an interview on 4/30/19 at 1:58 p.m. with R#1 revealed that RN HH has talked to her rudely and that the Director of Nursing (DON) and the Assistant Director of Nurse (ADON) had a meeting with RN HH to address RN HH's behavior and the DON removed RN HH from working with R#1. R#1 continued to say that RN HH made her upset on three different occasions. The first incident was when R#1 asked RN HH to call her doctor related to her urinary tract infection [MEDICAL CONDITION] medicine. R#1 stated that she wanted to be sure that the antibiotics was the right antibiotics for her UTI. R#1 stated that RN HH jumped up from her chair and went into the office and that the DON and ADON came to her to say that RN HH's behavior was wrong. The second incident occurred when R#1 stated that she requested her pain medications and was told by RN HH that she would give the pain mediation when RN HH gave it to her. R#1 explained that the pain medication was scheduled at 9:30 a.m. and it was 10:30 a.m. when she asked for it. The third incident occurred when R#1 stated that she asked two CNAs to warm up her pizza. RN HH sent the two CNAs back to her room with the comment, to ask R#1 how much she weighs. R#1 revealed that when the third incident occurred she came out of her room and found RN HH at the nursing station talking about her weight. R#1 stated she became upset and starting fussing with RN HH and telling her that all she wanted was to have her pizza warmed. R#1 stated that she filed a grievance after state last visit because she wanted a record of these incidents. R#1 did not file a formal grievance; however, she told the staff of the occurrence and this incident was witnessed. During an interview on 4/30/19 at 4:50 p.m. CNA GG revealed that she was aware of the pizza incident and revealed that R#1 had pizza in her room and wanted it warmed up. RN HH conveyed R#1's weight information at the nursing station standing near the treatment cart. R#1 came out of her room and to find out why her pizza could not be warmed. RN HH and R#1 got into a verbal argument about the pizza and her weight. During a clarification interview on 4/30/19 at 5:15 p.m. with CNA EE revealed that R#1 had asked her to warm up her pizza. And that she (CNA EE) was instructed by RN HH not to warm up the pizza. RN HH told her to tell R#1 that she had gained weight. During an interview on 5/1/19 at 2:20 p.m. RN HH revealed that the pizza incident with R#1, that R#1 did request her pizza to be warmed, and when she saw the CNA with the pizza, RN HH asked whose pizza. Stated that CNA EE told her it was for R#1. RN HH instructed CNA EE to tell R#1 her how much she weighed. RN HH stated that R#1 came out of her room wanting to know why she couldn't get her pizza warmed. RN HH stated that she told R#1 how much she weighed. During an interview on 5/1/19 at 3:31 p.m. with the ADON revealed that RN HH came to her about issues with staff and had multiple complaints about staff, but that RN HH had not revealed that she has had any residents issues The ADON stated that she has gone to RN HH about residents' concerns regarding RN HH, but that the ADON stated she was not aware of two of the five resident concerns with RN HH. During an interview on 5/1/19 at 4:04 p.m. with the DON revealed RN HH came to her to say that R#1 and another resident had a problem with her. And that R#2 and R#4 at one time had a problem with RN HH. 2. Review of the Face Sheet revealed R#3 was admitted to the facility with the following Diagnoses: [REDACTED]. The Quarterly MDS revealed R#3 BIMS score is 15, indicating she is cognitively intact. Review of the physician's orders [REDACTED]. Review of an invoice dated 2/22/19 revealed the call lights were being services for issues. And R#3 room call light is listed as a problem call light. And was noted to be disconnected at nurse's desk and room. During an interview on 5/1/19 at 9:36 a.m. R#3 revealed that she a problem with RN HH. R#3 stated that she had her call light on for a while. RN HH came into her room and threatened to jerk her call light out the wall. R#3 stated that she told RN HH that she would call the police and her family if she took her call light. R#3 stated she told everyone that came into her room about the call light. After that RN HH, would come into the room to assist her roommate and would not speak to her. And would not put her cream on her face ([MEDICATION NAME] cream). R#3 stated that she then sent word by CNA AA for another nurse, RN KK, to come to her room to put her cream on her face. Instead, RN HH came into the room asking her what was the emergency. And telling her, that she has all day to put cream on her face. And when RN HH did put the cream on her face, she was fussing at her, telling her again that she has all day apply the cream to her face. R#3 said that she is sometimes afraid of RN HH because she does not know how she is going to act. R#3 stated that she is unable to use her hands or get out of bed. During an interview on 5/1/19 at 10:02 a.m. with CNA AA revealed that R#3 did ask her to get RN KK to come and put cream on her face. When she was asking for RN KK, she was told by RN HH that RN KK was in a care plan meeting and RN HH inquired about what R#3 needed. CNA AA stated that when she told RN HH that R#3 wanted the face cream. RN HH got the cream out of the cart and was walking toward R#3's room saying that she had all day to get this cream. During an interview on 5/1/19 at 10:42 a.m. RN KK revealed that RN HH had did not put R#3 cream on face one day and that R#3 had told her that RN HH would not speak to her and when she does she is short with her. 3. Review of the Face Sheet revealed R#4 was admitted to the facility with the following Diagnoses: [REDACTED]. The Quarterly MDS revealed a BIMS score of 15 indicating that he is cognitively intact. And his care plan revealed R#4 wants nurse to show all his medications and name them before he will take them. Review of the Medication Record (MAR) dated 11/1/18 through 11/30/18 revealed R#4 scheduled medications were [MEDICATION NAME] 10/325 milligrams (mg) at 2 p.m. and [MEDICATION NAME] 600 mg tablet at 3 p.m. During an interview on 5/1/19 at 9:28 a.m. with R#4 revealed that he asked RN HH for his medication once and he observed RN HH ask one of the CNA's to give him his medication. R#4 said that he went to the Administrator (female) and told her what happened. And she said that she would take care of it. R#4 stated that he is not afraid of RN HH, but that RN HH displays an attitude of being better than us (residents). During an interview on 5/1/19 at 2:20 p.m. with RN HH revealed that she had parked the medication cart in front of the nursing station, and already had R#4's medication in a soufflé cup inside the top drawer. RN HH said she went to answer the telephone and that R#4 kept asking for his medicine and that RN HH had asked CNA LL to give the cup of medicine to R#4. During an interview on 5/1/19 at 3:27 p.m. CNA LL revealed that she was passing by nursing station and RN HH told her to look in the top drawer of the medication cart and take the cup of medicines and give it to R#4. CNA LL said that she had asked RN HH was it okay and was ensured by her that it was okay because she was standing there. RN HH got off the phone and took the R#4 the medications. During an interview on 5/1/19 at 4:04 p.m. with the DON revealed that R#4 had called his daughter about the CNA giving him his medication and at that time HH and CNA LL both had denied the incident.

Based on observations, policy review and interviews the facility failed to label and date items in the dry good storage area and to failed to discard items that were expired. All foods should be stored in accordance with professional standards for food service safety thereby decreasing the possibility of food-borne illnesses for the residents. The facility census was 57 residents. Findings include: Review of the facility policy entitled, Labeling, Dating and Storage, revised [DATE] which stated, .to follow the proper procedures for labeling, dating and storage to ensure proper food safety. Under the Procedures section, number one (1), Food and/or beverage items will be properly labeled with the name of the item and the use by date. Number two (2), states, Food will be stored in their original containers and clearly labeled with the name of the item and the use by date. Observations of the dry good storage area on [DATE] at 11:35 a.m, revealed the following concerns: 1. Two (2) 32 ounce (oz) containers of Rubbed Sage with the use by date of [DATE] 2. One (1) 32 oz. container of Red Food Dye that expired on [DATE]. This container was open with approximately one-third (,[DATE]) of the contents used. 3. One (1) 32 oz. container of Green Food Dye that expired on [DATE]. This container was open with approximately one-third (,[DATE]) of the contents used. 4. One (1) large container of Dill Weed that expired on [DATE]. 5. One-half (,[DATE]) of a large baggie of uncooked noodles that had an expiration date of [DATE]. This food item was not stored in the original box. 6. One (1) package of Strawberry Gelatin Dessert that had been opened and the top was folded down. It was not stored in the original box and had no label or date on it. 7. One (1) gallon container of Kikkoman Teriyaki Marinate sauce with only a small amount left in the bottom of the container. The container had directions on it that stated the container should be refrigerated after opening. The expiration date of this container was [DATE]. During an interview with the Dietary Manger (DM) on [DATE] at 7:55 a.m. she stated that it was the responsibility of the kitchen aides to check the items in the dry good storage for expirations dates. The DM stated that it was ultimately her responsibility to ensure those tasks were completed. During an interview with the Administrator on [DATE] at 8:10 a.m., revealed she expected the kitchen staff and the DM to ensure that stock in the dry goods storage area were rotated and checked on a regular basis. She stated it was ultimately the responsibility of the DM to ensure this task was completed.

Base on observation, record review, and interview, the facility failed to ensure that one Resident(R) #48 was assured full visual privacy. The facility census was 57 residents. Findings include: Review of the medical record revealed the following diagnosis ,small bowel, obstruction Diabetes Mellitus, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], Dementia, Generalized Anxiety Disorder Review of R#48's Quarterly Minimum Data Set ((MDS) dated [DATE] Section C revealed a Brief Interview Mental Status Score (BIMS) of 6 (six) and a score of 6 out of 15 indicates moderate cognitive impaired. Section G -toileting -extensive assistance- two person assist; Bathing -total dependent-one person assist, personal hygiene extensive assistance/1 person assist; dressing -extensive assistance-one person assist; bed mobility -extensive assistance -two person assist; transfer -extensive assistance -one person assist; mobility device -wheelchair; Range of Motion(ROM) -one side impairment for upper and lower extremity Observations on 11/27/18 at 8:45 a.m., 11:00 a.m , 3:00 p.m. , and 11/28/18 at 8:01 a.m. revealed privacy curtains failed to close comletely areound the entire bed to provide full visual privacy. Reviewed Care Plan dated 6/11/18 and last revised 11/8/18 titled Self Care deficit requiring limited to total assist with ADL 's/transfer/bed mobility d/t [MEDICAL CONDITION] , impaired mobility and impaired cognitive function with interventions Provide Privacy while delivering ADL care Reviewed Care Plan dated 6/11/18 and last revised 11/8/18 titled At risk for B & B incontinence d/t impaired cognitive status , possible side effects of medications and impaired mobility with interventions maintain privacy while performing incontinent care Interview on 11/28/18 at 9:17 a.m. with Roommate Bed B reported that if staff is assisting resident , and curtain is pulled , staff tells her to wait because the resident may be seen. During walk through with Administrator and Housekeeper Supervisor on 11/29/18 8:31 a.m , validated that a privacy curtain was missing and the curtain did not provide full privacy. Interview on 11/29/18 at 11:05 a.m, Certified Nursing Assistant (CNA) EE. reported that resident takes a shower but has a habit of undressing herself without staff asst, often she has came in the room found resident undressed and will have to dress her. She will have to make sure resident in bed B, does not come out from her area to see resident exposed due to the shortag privacy curtains. Interview on 11/29./18 at 11:07 am., CNA FF stated that R#48 displays behaviors of always disrobing from the bottom down and that she has witnessed this behaviors. She further stated that she was aware that curtains did not provide full visual privacy and always try to change resident in the bathroom.

Based on observations, record review, policy review of Oxygen Administration, resident and staff interviews, the facility failed to follow the Physician order [REDACTED].#4) related to the Oxygen (O2) concentrator settings at 2/LPM (Liters Per Minute). The sample size was 29 residents. Findings include: During an observation on 11/26/18 at 1:08 p.m. the O2 concentrator tubing was not dated and the liters per minute was observed to be set at 4/LPM. During an observation on 11/27/18 at 2:15 p.m. the O2 concentrator tubing was not dated; the O2 concentrator was set on 4/LPM. During an interview on 11/27/18 at 2:15 p.m. with R#4 she stated she can turn the O2 level up or down when she needs to. A record review of the monthly physician's orders [REDACTED]. During an observation on 11/28/18 at 10:25 a.m. the O2 concentrator tubing for the nasal cannula (NC) was lying on the foot of the mattress. The tubing is not dated and the LPM were set on four. A record review of the care plan dated 5/30/18 revealed R#4 is at risk for potential respiratory complications as evidenced by (AEB) shortness of breath on exertion, lying flat and at rest. It further reads she requires the use of O2. Her goals are to use O2 during activity or rest. The interventions are to assess respiratory function (i.e. Aspiration, infection, obstruction, atelectasis) as needed. To notify the physician of any respiratory complications. Medication (s) ordered. O2 flow rate as ordered. Humidifier/tubing changed per HCC policy. During an observation on 11/29/18 at 10:15 a.m. the O2 concentrator was observed to be set at 4LPM and running, the resident was not in the room. During an interview on 11/29/18 at 10:16 a.m. the assistant director of nursing (ADON) revealed the O2 tubing does not have a dating policy, she confirmed the O2 is at 4/LPM, she also confirmed a review of the Medication Administration Record [REDACTED]. During an interview on 11/29/18 at 10:18 a.m. with LPN AA she confirmed the O2 information is not written on the MAR. During an interview on 11/29/18 at 10:45 a.m. the ADON confirmed that R#4's Physicians orders for O2 were 2/LPM via nasal cannula. A record review of the Oxygen Administration policy dated 2014 revealed that Oxygen will be administered by licensed personnel only when ordered by a physician. The physician order [REDACTED].

Based on observations, record review, interviews, and review of the facility policy titled Oxygen Administration, the facility failed to date oxygen tubing and ensure that a clean nasal cannula was used for two residents (R) (#4 and #58) out of 29 sampled residents. Findings include: Review of medical record for R#58 revealed a [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set ((MDS) dated [DATE] Section O revealed a coding for oxygen use. Observation on 11/27/18 at 10:01 a.m. and 2:30 p.m.revealed Resident(R) #58 was lying in bed with oxygen in use and oxygen tubing not dated. Observation on 11/28/18 at 8:05 a.m., 1:30 p.m. and 3:37 p.m. , and 11/29/18 at 10:43 p.m. , revealed the 02 tubing for R#58 was not dated with water in the concentrators. Further review of Physician order for [REDACTED]. Review of MAR (Medication Administration Record) dated 11/8/18 revealed that the there was not evidence of documentation of oxygen for this resident. During an interview and review of R#58's MAR indicated [REDACTED]?, Who is responsible for changing the tubing out and how often? How do you know when it was changed out? She stated that O2 tubing should be changed out weekly on every Wednesday and nursing staff usually check and date O2 tubing.She later stated after consulting with the Director Of Nursing (DON) that any resident who has a prn order for O2, dating the O2 tube is not required. Interview on 11/29/18 at 11:10 a.m., Director of Nursing (DON) verifed that R#58 's oxygen tubing was not dated. She further stated that the facility policy is that all prn O2 is noted. When asked about how does her staff monitor and determine if the humidification is out of date if the nursing staff is not dating the O2 tubing after each use for prn oxygen use?She admitted that no way to determine if the humification is out of date. DON also stated that if staff is suppose to change the bottle prior to adding more water as a solution to the problem. She later stated that the facility will need to review their system (in regard to dating O2 tube) and put something in place. Review of the facility titled Oxygen Administration revealed the following listed below: (2). O2 humidifier bottles should be used on all patients receiving higher than 2 Liters/minuet of oxygen flow. (3). Humidifier bottles should be filled to fill line with distilled or sterile water upon initation of oxygen therapy or when water level drops below fill line marking. (4). Change all oxygen tubing when there is visible soiling with respiratory secretions and mucous. In addition , an oxygen water trap can be utilized for patients receiving high oxygen liter flow (5). liters/minute) or with patients who nurses note have a large amount of condensation in the oxygen tubing. (10). clean exterior of concentrators weekly and between each patient use with bactericidal surface cleaner 2. During an observation on 11/26/18 at 1:08 p.m. for R#4 the O2 concentrator tubing was not dated and the liters per minute were observed at 4/LPM. During an observation on 11/27/18 at 2:15 p.m. again for R#4 the O2 concentrator tubing was not dated; the O2 concentrator was set on 4/LPM. During an interview on 11/27/18 at 2:15 p.m. with R#4 she stated she can turn the O2 level up or down when she needs to. A record review of the monthly physician's orders dated (MONTH) (YEAR) for R#4 revealed for shortness of breath (SOB) O2 at 2L/min via nasal cannula and notify physician. During an observation on 11/28/18 at 10:25 a.m. the O2 concentrator tubing for R#4 revealed the nasal cannula (NC) was lying on the foot of the mattress. The tubing is not dated and the LPM were set on 4. A record review of the care plan dated 5/30/18 revealed R#4 is at risk for potential respiratory complications as evidenced by (AEB) shortness of breath on exertion, lying flat and at rest. It further reads she requires the use of O2. Her goals are to use O2 during activity or rest. The interventions are to assess respiratory function (i.e. Aspiration, infection, obstruction, atelectasis) as needed. To notify the physician of any respiratory complications. Medication (s) ordered. O2 flow rate as ordered. Humidifier/tubing changed per HCC policy. During an interview on 11/29/18 at 10:16 a.m. for R#4 the assistant director of nursing (ADON) revealed the O2 tubing does not have a dating policy, she confirmed the O2 is at 4/LPM, she also confirmed a review of the Medication Administration Record [REDACTED]. During an interview on 11/29/18 at 10:18 a.m. for R#4, LPN AA confirmed the O2 information was not written on the MAR.

Based on observation, record review, staff interviews the facility failed to ensure the medication error rate was less than five percent (5%). There was two errors with 32 opportunities for two of the four residents (R) (R#16 and R#45) by two of three nurses observed for a medication error rate of 6.25%. Findings include: 1. During an observation on 11/28/18 at 8:05 a.m., with the Licensed Practical Nurse (LPN) BB revealed that during medication administration for R#16 for his morning medications, the medications included [MEDICATION NAME] propionate ([MEDICATION NAME]) 50mcg (microgram) one (1) spray to each nostril daily. LPN BB did not ask R#16 to blow his nose prior to medication administration. Review of the manufacturers recommendations for administration of [MEDICATION NAME] include blowing the nose prior to administration to clear the nostrils. 2. During an observation on 11/29/18 at 7:59 a.m., with LPN AA during medication administrion, she was observed administering R#45 his morning medications. The medications included Dorzolamide solution 2% OP (ophthalmic) two (2) drops to the left eye twice. A review of the written instructions on the medication bottle for Dorzolamide solution 2% OP for R#16 included to wait at least five (5) minutes between drops. During an interview on 11/29/18 at 8:20 a.m. LPN AA confirmed she did not wait 5 minutes between the two (2) drops to the left eye as ordered for the medication Dorzolamide solution 2% OP. During an interview on 11/29/18 at 9:34 a.m. the Director of Nursing (DON) revealed both LPN's AA and LPN BB should have known better based on the education opportunities provided. She further revealed that LPN AA completed training on 2/5/18, 5/2/18, 7/3/18, and 11/2/18 with the pharmacy consultant and LPN BB completed an in-service education/staff development program on 7/18/18 for medication administration. During an interview on 11/29/18 at 9:38 a.m. with the Administrator, she also confirmed the DON's statement that both nurses should have known better and both nurses have had training.

Based on observation, interviews, and record review of the Daily Nursing Hours for Healthcare Centers (DNHHC) form, the facility failed to ensure that there was sufficient staffing on two out of two halls, (North Hall and South Hall). Two residents were impacted out of a total census 53. Findings include: Review of the DNHHC forms for the months of June 2017, July 2017, and October 2017 reveals one licensed nurse was present in the facility 34 nights out of a sampled 92 nights. This was during the night shift of 11:00 p.m. until 7:00 a.m. This single nurse was required to cover two out of two halls. The dates of single nurse coverage were 6/2/17, 6/21/17, 6/24/17, 6/25/17, 6/26/17, 6/27/17, 7/1/17, 7/2/17, 7/3/17, 7/4/17, 7/8/17, 7/9/17, 7/10/17, 7/11/17, 7/13/17, 7/16/17, 7/18/17, 7/19/17, 7/21/17, 7/22/17, 7/26/17, 7/27/17, 7/28/17, 7/30/17, 7/31/17, 10/1/17, 10/2/17, 10/8/17, 10/9/17, 10/11/17, 10/12/17, 10/16/17, 10/22/17, and 10/25/17. 11/22/17 11:15 a.m. Interview with LPN EE. She is an Licensed Practical Nurse (LPN) who has worked in the facility for 5 years. She works days. There is not enough staff here. Certified Nursing Assistants (CNA)s call out on days two or three days a week. Usually they can only get one CNA to come and take their place. It is difficult to provide routine Activities of Daily Living (ADLs) on those days. Often 2 or even 3 CNAs call out. The LPNs pretty much come to work every day. 11/22/17 11:20 a.m. Interview with LPN FF. She has worked here for 6 months, mostly at night. She has been an LPN for three years. She was called in to work day shift today. She said there is not enough staff here. There are lots of call outs, nearly every night. During October 2017, she worked an entire week at night by herself. She did not think she could safely cover both halls. She worried that during a crisis on both halls at the same time she could not attend both residents. One nurse for 53 residents is too many. Often there is only one CNA at night. 11/22/17 11:25 Interview with CNA GG. There is not enough staff here. There are supposed to be 5 CNAs during days but often they work with only 4. Call outs are a daily happening, but sometimes they can get a replacement. When they are short it takes longer for residents to get their morning care, sometimes past lunchtime. 11/22/17 11:35 a.m. Interview with R #2. There is not enough staff here. Sometimes there are five or even four CNAs on days, three on evenings and two or even just one at nights. Sometimes there is only one nurse at night. It takes a long time to get call light answered at night, sometimes as long as two hours. 11/22/17 11:35 a.m. Interview with CNA HH. Two or three days a week there are less than five CNAs. Sometimes they can get a replacement, sometimes not. She doesn't always get timely help when they are short. 11/22/17 12:00 p.m. Interview with Acting Director of Health Services (ADHS). She works as a regional consultant. The present DHS is in the hospital and will take some time to recover. It has been some time since they have had a permanent Director of Nursing (DON). She was not sure how long, but it has been more than several weeks. Staffing has been one of her biggest challenges. They have staffing shortages five to ten times per month. Two LPNs, one on each hall, is adequate staffing for each shift. There should be four to five CNAs on day shift and two to three at night. Registered Nurses (RN)s typically do other duties such as DON or Assistant Director of Nursing (ADON), so 16 nursing hours each day are RNs assigned to those tasks. They do have a couple of RNs doing direct resident care. 11/22/2017 12:00 PM. Interview with CNA II, When asked how she would request time off if she felt the need to decompress, she stated she would contact whomever was handling the scheduling. She further stated when staff reach a saturation point stress-wise they quite often call out sick, which in turn puts additional strain on the rest of the team. She knew of one resident whom had not had a bath in two weeks due to short staffing. 11/22/17 12:15 p.m. Interview with R#22. He said there is not enough staff here. There is a long wait at night and if there is only one aide they cannot get him up if he wants to, just reposition him.

Based on record review, staff interview, and the facility Care Plans Policy statement the facility failed to develop an individualized care plan related to wound development for one (1) Resident #60 (R#60) from a census sample of 53 residents. Findings include: R#60 was admitted with the [DIAGNOSES REDACTED]. R#60 is currently under the services of Hospice. A treatment record dated 9/22/17 for R#60 reveals a 4 centimeters (cm) X 4 cm unstageable left heel pressure ulcer. The monthly follow up physicians visit dated 9/26/17 at 1:41 p.m. reveals that the physician will consult with the family about R#60 visiting the wound care clinic and that R#60 is receiving wound care. The Body Audit Form dated 9/27/17 reveals red/broken areas on the feet/heels, left foot pressure ulcer noted, unstageable, resident with heel protector, heel lift and dressing to left heel. Review of R#60's care plan reviewed and updated on 10/6/17 revealed that there is no individualized care plan for the left heel wound and/or the treatments that R#60 is receiving. On 10/17/17, 10/26/17 and 11/2/17 hospice notes reveal left heel wound care for resident R#60. During an interview with the MDS Coordinator on 11/21/17 at 10:13 a.m. revealed that R#60 did not have a care plan for the left heel wound or the treatment regime ordered by the physician to treat the wound. She revealed it should have been care planned, and that during the care plan meeting on 10/10/2017 at 1:15 p.m. she did not have the Treatment Nurse in the meeting with her. During an interview with the Care Plan Consultant on 11/21/17 at 11:27 a.m. she revealed R#60 did not have a care plan for the left heel nor the treatment regime ordered by the physician to treat the left heel wound.