Every finding on record at Seven Oaks Nursing & Rehabilitation

Based on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 2 (Resident #1, Resident #2) residents reviewed for medical records. Resident #1's and Resident #2's EMR did not contain complete and accurate documentation that reflected the physician was notified of an AMA discharge and agreed to discharge the residents with their remaining medications for Resident #1 on 07/27/26 at 9:39 a.m., and for Resident #2 on 07/26/2026 at 8:51 p.m. This failure could place residents at risk for records not accurately documenting physician notification, authorization to release the resident with remaining medications and inaccurate records.The findings included: Record review of Resident #1's face sheet, dated 08/11/2026, revealed a [AGE] year-old female, admitted on [DATE] and discharged on 07/27/2026, with diagnoses which included metabolic encephalopathy (altered brain function resulting from system problems), diabetes mellitus type II (a chronic condition characterized by insulin resistance and high blood sugar levels), anemia (a condition characterized by a deficiency of healthy red blood cells leading to insufficient oxygen delivery to the body's tissues), hepatomegaly (enlarged liver), and hyperlipidemia (elevated cholesterol levels). Record review of Resident #1's Comprehensive MDS Assessment, dated 07/26/2026, revealed no hearing or communication deficits, resident understood what was said to her, was understood by others and had a BIMS score of 15 which indicated intact cognition. Resident #1 required the use of a walker for mobility, set-up assistance in eating, supervision with ostomy (an artificial opening in the skin that occurs after surgery) care, bed mobility and lower body dressing, moderate assistance in upper body dressing, transfers, and maximum assistance in bathing. Record review of Resident #1's baseline care plan, dated 07/23/2026, revealed plans for discharge were unknown at the time of admission. Record review of Resident #1's Discharge summary, dated [DATE], revealed the resident was discharged home with medications and she discharged AMA. Record review of Resident #1's nursing progress notes, dated 07/27/26, did not reveal documentation the charge nurse contacted the attending physician and made him aware of the unplanned discharge. Record review of Resident #1's physician's orders, dated 07/01/2026-07/31/2026, did not reveal an order that indicated the physician was notified of the AMA discharge and authorized resident to discharge with medications. An interview was attempted with Resident #1 and his responsible party on 08/12/26 at 9:12 a.m., surveyor was unable to leave a message. Record review of Resident #2's face sheet, dated 08/11/2026, revealed a [AGE] year-old male, admitted [DATE] and discharged [DATE], with diagnoses which included CHF (a chronic condition that affects the heart's ability to pump blood), diabetes mellitus Type II (a chronic condition characterized by insulin resistance and high blood sugar levels), dementia (a group of symptoms that cause a loss of memory, thinking skills, and the ability to do daily tasks), BPH (a condition in which the prostate gland grows larger than normal), Hyperlipidemia (elevated cholesterol levels), and CKD (a condition characterized by gradual loss of kidney function). Record review of Resident #2's Discharge MDS Assessment, dated 07/26/2026, revealed he was unable to complete the BIMS assessment, and the staff assessment revealed short-term memory deficit and moderately impaired cognitive skills for daily decision making. Resident #2 was independent in eating, required supervision in gait, dressing, toileting and required the use of a wheelchair for mobility. Record review of Resident #2's discharge care plan, dated 06/09/2026, revealed discharge from the facility was not feasible. Record review of Resident #2's Discharge summary, dated [DATE], revealed resident was discharged home with medications and that he discharged AMA. Record review of Resident #2's nursing progress notes, dated 07/26/2026, did not reveal the charge nurse contacted the attending physician and made him aware of the unplanned discharge. Record review of Resident #2's physician's orders, dated 07/01/2026-07/31/2026, did not reveal an order that indicated the physician was notified of the AMA discharge and authorized resident to discharge with medications. An interview with Resident #2 or her responsible party was not conducted prior to the end of the survey. During an interview on 08/12/2026 at 10:30 a.m., LVN A stated to her knowledge, all discharges should have documentation reflecting the physician was notified and approved for the resident to discharge with medications. LVN A stated she believed the physician was aware of both of these unplanned discharges, and that she failed to ensure documentation reflected the AMA discharge with medications. During an interview on 08/12/26 at 11:08 a.m., RN B stated the physician should be notified of all discharges and if he gave an order to permit the resident to discharge with medications, it should be documented in the medical record. During an interview on 08/12/2026 at 11:18 a.m. RN C stated AMA discharges did not require all the documentation as with a scheduled discharge or emergency transfer, but that it should be documented in the medical record that the physician was aware and gave approval for the resident to discharge with medications. During an interview on 08/12/2026 at 1:45 p.m., the DON stated the discharge documentation for all discharges, including AMA discharges, should reflect that the physician was notified. The DON stated when residents were discharged with their medications, she expected the nursing staff to indicate either in a progress note or with a telephone order that the physician approved the discharge with medications. The DON stated she was ultimately responsible for ensuring documentation is complete and accurate. During an interview on 08/12/2026 at 2:00 p.m., the Administrator stated that the DON was responsible for ensuring the physician was notified of all discharges, including AMA discharges, and he expected the nursing staff to document accurately. The Administrator stated that she would monitor that documentation was completed at the morning meeting following the discharge. Requested policy on documentation on 08/12/2026 at 1:45 p.m. and was informed by the DON that the facility does not have one. Record review of the facility policy titled Discharge or Transfer revised 02/12/2025 does not reflect guidance for the AMA process. On 08/12/2026 at 1:45 p.m., the DON revealed the facility does not have a policy or guidance for AMA discharges.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility did not keep the following equipment and surfaces clean and free of debris in the kitchen in that: 1. The stove back splash wall was not clean2. Burners on the stove were caked with food items3. Ovens were dirty4. Deep fryer had crumbs and dried food items5. Fans in the walk-in cooler had dust / debris6. Air vents with visible build-up7. Wash rags stored beneath hand-washing sinkThe facility did not properly store prepared food items in the walk-in cooler in that:1. Two prepared bowls of pears on a tray in the walk-in cooler were left uncoveredThe facility did not properly store frozen food items in the stand-alone freezer in that:1. An open and undated food storage bag was observed in the stand-alone freezer These failures could place residents who ate food from the kitchen at risk of food-borne illness. Findings included: During an observation on 04/24/2026 at 9:10 a.m., the following was observed on initial tour: Food and grease debris build-up was observed on the stove back splash wallFood and grease were built-up on the left and right front stove burnersFood built-up on left and right ovensFood and grease were built-up on the deep fryer, and both cages of the deep fryer had built-up foodTwo fans in the walk-in cooler had visible dust A ceiling air conditioner vent located in the kitchen had visible dirt and grease build-up9 wet wash rags were stored in an open milk-crate located beneath the hand-washing sinkTwo prepared bowls of pears were uncovered in the walk-in coolerAn undated open bag with 3 corn dogs was in the stand-alone freezer During an interview on 04/24/2026 at 9:10 a.m. during initial kitchen rounds, the DFN stated she had worked at this facility approximately 1 1/2 years and had recently lost two full-time staff members. The DFN acknowledged that the food and grease build-up on the stove back-splash was not acceptable, indicated multiple days of build-up, that build-up could result in cross-contamination and that she expected her staff to clean the backsplash are area after each use. The DFN acknowledged that the build-up around the stove burners was not acceptable and stated that she expected the staff to clean the stove after each use to avoid excessive build-up. The DFN acknowledged that the build-up could block the pilot light and prevent the burners from lighting or possibly cause the build-up to catch fire. The DFN acknowledged that both of the stoves were dirty, could not recall the last time they were deep cleaned and stated that the dirty ovens could result in debris catching fire. The DFN acknowledged that the deep fryer was not cleaned from use the night before when the staff had prepared potato tots. The DFN stated that she expected the fryer to be cleaned after use, that the oil was changed weekly on Fridays and could result in food cross contamination. The DFN stated that she had not observed the dust debris on both of the conditioning unit fans in the walk-in cooler and stated that the maintenance director was responsible for the cleaning of the fans. The DFN did not know when the last time the fans were cleaned and could result in dust debris falling onto prepared food items in the cooler. The DFN acknowledged that the ceiling vent was caked with build-up, that she had not noticed the build-up and could result in unhealthy air circulation and debris items could fall on the food preparation areas. The DFN acknowledged that the wet rags were openly stored in an unsanitary manner, that she expected the staff to take the rags to the laundry at the end of each shift and that this amount of rags indicated the staff did not remove the rags after supper last night. The DFN acknowledged that there were two uncovered bowls of pears on a tray in the walk-in cooler, stated she expected all prepared food items to be covered appropriately and that debris from the fans could fall into the bowls. The DFN threw the pears away. The DFN acknowledged the open and undated bag in the stand-alone freezer with three corndogs, stated she expected the staff to ensure all food containers were properly sealed and dated and that poorly stored food items causes freezer burn and effects the taste of food. The DFN threw away the corndogs. During an interview on 04/24/2026 at 11:55 a.m., the Maintenance Director stated that he utilized a computerized work order system that prompts him when cleanings or maintenance checks were due. The Maintenance Director stated that the walk-in cooler fans were triggered to be cleaned on 03/01/2026, that he completed the task on 03/11/2026 and he has not had time to complete the triggered task for the month of April. The Maintenance Director acknowledged that this could result in increased strain on the conditioning unit and that dust debris could flow freely in the walk-in cooler and land on prepared food items. The Maintenance Director stated that he could not recall the last time he removed and cleaned the ceiling vents in the kitchen. The Maintenance Director acknowledged that soiled air flow vents could result in increased strain on the air conditioning unit and possibly allow debris items to fall on the food preparation areas. During an interview on 04/24/2026 at 2:45 p.m., the DFN provided a cleaning schedule for daily and weekly tasks and acknowledged that she has had difficulty maintaining and monitoring that the tasks were completed per schedule due to the recent loss of two full-time employees and subsequent training of newly hired kitchen staff. The DFN acknowledged that uncleanliness of daily use equipment and improper food storage places residents at risk for food-borne illnesses. During an interview on 04/24/2026 at 2:45 p.m., the Administrator stated that recent challenges in the kitchen have made it difficult to ensure the cleaning schedules were followed appropriately and consequently, she was working with Human Resources and the DNF to hire new staff. The Administrator stated she had interviewed a number of candidates for the kitchen staff however had difficulty finding a candidate that could pass the drug test. The Administrator stated that she rounds every morning in the kitchen and that she will now assist the DFN in managing the kitchen more effectively to avoid any potential food borne illnesses and injury to the residents regarding the unclean condition of the stove, oven, air filters and walk-in cooler fans. The Administrator stated that improperly stored and labeled food items could result in cross-contamination and food-borne illnesses. A request for the policy for equipment cleaning and maintenance, and food storage were requested on 04/24/2026 at 10:00 a.m. from the DFN and not provided prior to survey exit. Record review of the Texas Administrative Code, Title 28, Chapter 554, Subchapter L, Rule 554.1111, reviewed 03/11/2024, Food Safety Requirements (b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements. Record review of the Texas Department of State Health Services, Division for Regulatory Service, Environmental and Consumer Safety Section, 228.114, Frequency of Cleaning, dated October 11, 2015, revealed, (a) Equipment food=contact surfaces and utensils. (4) Surfaces of equipment contacting time/temperature control for safety food may be cleaned less frequently than every four hours if: (F) the cleaning schedule is approved based on consideration of: (i) the characteristics of the equipment and its use; (ii) the type of food involved; and (iii) the amount of food residue accumulation; and (b) Cooking and baking equipment.(1) The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. (3) .food equipment food-contact surfaces shall be cleaned throughout the day at least every four hours.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen in that: Two of four stove burners were non-functioning. This failure could place residents at risk of consuming contaminated food from a poor sanitation environmentThe findings were: Observation on 04/24/2026 at 9:10 a.m., revealed that two of four stove burners were corroded with soot and food debris and were non-functioning when DFN attempted to turn them on. The pilot lights were non-functioning and no gas odor was present. During an interview on 04/24/2026 at 9:15 a.m., the DFN stated that the two back burners do not always work and staff need to contact the Maintenance Director to re-light the pilot light. The DFN acknowledged that the burners were soiled and food debris was visible. The DFN stated that not having all of the burners working did not interfere too much with cooking. During an interview on 04/24/2026 at 10:55 a.m., the Maintenance Director stated that he was aware that the stove had some carbon build-up on the pilot lights which clogged the flutes and stated that the last time he lit the pilot lights was approximately one month ago. The Maintenance Director stated he usually cleaned them about every 4-5 months, and the kitchen staff should clean them daily to avoid build-up. The Maintenance Director stated he cleaned the pilot lights about 5 months ago but was unable to provide a work log indicating the cleaning. The Maintenance Director acknowledged that carbon build-up and clogged flutes would result in the burners not lighting and potentially create a fire hazard. During an interview on 04/24/2026 at 2;45 p.m., the Administrator stated she recalled the Maintenance Director reported having to light the pilot lights on the stove about one month ago but was not aware of a long-standing concern that two of the stove burners were non-functioning due to the pilot light corrosion. The Administrator acknowledged that the work order system needs to be reviewed and updated to ensure all scheduling needs for equipment and general maintenance in kitchen are routinely triggered to ensure corrective maintenance is received. Record review of the facility's policy, Physical environment Safe/functional/sanitary/comfortable environment, dated 11/28/2017, revealed, Preventive maintenance will be completed routinely and according to protocol by the [Maintenance Supervisor] or qualified staff. The facility shall provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observations, interviews, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 3 of 22 residents (Resident #29, Resident #15, and Resident #3) reviewed for food preferences and the accommodation of resident's meal choices.1.The facility did not honor Resident #29's preference for milk with her supper meals. 2.The facility failed to honor Resident #15's preferences for a bacon and toast for breakfast.3.The facility failed to provide condiments (jelly and butter) and bread for Resident #3 on 07/20/25. These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: 1.Record review of Resident #29’s face sheet dated 07/23/25 indicated she was an [AGE] year-old female who had admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease causing too much sugar in the blood stream), high blood pressure, depressive disorder, and congestive heart failure (condition in which the heart does not pump well). Record review of Resident #29’s annual MDS dated [DATE] indicated she made herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated Resident #29 required set-up or clean up assistance with eating. Record review of Resident #29’s care plan dated 07/24/23 indicated she was at risk for malnutrition with interventions in place to monitor and document meal intake, offer diet as ordered by the physician, and to update food preferences as needed. Record review of Resident #29’s dietary profile dated 08/09/24 completed by the previous dietary manager indicated Resident #29 was independent with eating, and had no food likes, dislikes, or preferences noted. Record review of Resident #29’s meal cards dated 07/23/25 indicated she was to receive 8 ounces of milk at breakfast, 8 ounces of iced tea for lunch, and 8 ounces of beverage of choice at supper. During the resident council meeting on 07/22/25 at 3:32 PM Resident #29 stated that she wanted milk during her supper meals and the facility continued to bring her tea with her supper tray. During an interview on 07/23/25 at 2:50 PM CNA E said the kitchen normally sent out the milk on Resident #29’s trays at supper time. She said she did not know who, but the kitchen sent trays out on the weekend of 07/19/25 and 07/20/25 and did not send any milk because the facility was out of milk. CNA E said she did get her milk on 07/22/25 because she took her tray to her room. During an interview on 07/23/25 at 4:00 PM the Director of Food and Nutrition said the dietary department were responsible for sending drinks out to residents at meals on the hall. She said the kitchen has not run out of milk and she was unsure why Resident #29 did not get her milk. The Director of Food and Nutrition said all residents had the right to have what they would like to drink at meals. During an interview on 07/23/25 at 4:10 PM the DON said Resident #29 should have milk if they want milk. She said it was the resident’s rights violated if she does not get milk as she requested at supper. During an interview on 07/23/25 at 5:30 PM the Administrator said she was never aware of the kitchen being out of milk and that Resident #29 had the right to have milk if she wanted it at any meal. 2.Record review of Resident #15's face sheet, dated 07/23/25, indicated she was a [AGE] year-old female, who re-admitted to the facility on [DATE]. Her diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), stroke, and depression (a serious mood disorder that affects how you think, feel, and behave). Record review of Resident #15's quarterly MDS assessment, dated 06/16/25, indicated she had a BIMS score of 14, which indicated she was cognitively intact. She was able to make herself understood and she was able to understand others. She required set up for her activities of daily living and independent with eating. Record review of Resident #15's Order Summary Report, dated 07/23/25, indicated she had an order for: *Regular diet Regular texture, Regular consistency, offer sandwich or house supplement if less than 50% of meal was eaten. Wants Bacon and oatmeal only for breakfast with a start date of 02/24/23. Record review of Resident #15's care plan, last revised 01/29/25, indicated a focus of Resident #13 had a potential risk for malnutrition. Interventions were to serve diet as ordered and update preference as needed. Record review of Resident #15’s dietary profile dated 07/15/25 completed by the Director of Food and Nutrition indicated Resident #15 liked oatmeal, bacon, and bread at breakfast only. It stated she disliked sausage and eggs. During an observation and interview on 07/22/25 at 8:30 a.m., Resident #15 was sitting in her recliner, eating her breakfast. She said she liked bacon and toast but had sausage and a biscuit. She said she had told the staff (unknown) about her wanting bacon and toast but was still receiving sausage and biscuit. Her tray card said likes toast and bacon for breakfast. During the resident council meeting on 07/22/25 at 3:32 PM Resident #15 stated that she wanted bacon and toast but was receiving sausage and biscuit for breakfast. 3. Record review of Resident #3's face sheet, dated 07/23/25, indicated she was a [AGE] year-old female, who re-admitted to the facility on [DATE]. Her diagnoses included anxiety (feeling of unease, worry, or fear), Bipolar (mental illness that causes unusual shifts in mood), and Depression (a common and serious mood disorder that can affect how a person feels, thinks, and handles daily activities). Record review of Resident #3's quarterly MDS assessment, dated 06/05/25, indicated she had a BIMS score of 14, which indicated she was cognitively intact. She was able to make herself understood and was able to understand others. She was completely independent with eating. Record review of Resident #3's Order Summary Report, dated 07/23/25, indicated she had an order for: *Regular diet with a start date of 02/06/24. Record review of Resident #3's care plan, last revised on 03/31/22, indicated a focus of Resident #3 had a potential risk for Malnutrition. Interventions were for staff to provide and serve diet as ordered and update food preference as needed. During an interview on 07/21/25 at 11:32 a.m., Resident #3 said at times they do not have bread, butter, or Jelly. She said she did not have any bread, butter, or jelly this morning for breakfast. She said yesterday (07/20/25) they had a potatoes for supper with no butter or cheese. She said staff told her they were out of butter and cheese. During an interview on 07/21/25 at 12:14 p.m., CNA D said they did not have butter this morning, and they do not have any at lunch today (07/21/25). She said the Director of Food and Nutrition said it would be on the truck today (07/21/25). During an interview on 07/21/25 at 12:15 p.m., RN A said she asked about butter and was told they did not have any butter, and today (07/21/25) for lunch they had to substitute the strawberry dessert for green pudding because they did not have strawberries. She said the kitchen does occasionally run out of different things but mostly it would be delivered with the next truck delivery. During an interview on 07/21/23 at 2:52 p.m., the Director of Food and Nutrition said she was responsible to order food. She said she was aware they were low on butter, bread, and jelly but thought she had enough until the truck came in today (07/21/25). She said they were out of butter, bread and jelly for breakfast. She said she served croissants for breakfast. She said they had cheese in the kitchen and was not aware why the residents did not have cheese for their potatoes. She said she did tell anyone like the Administrator or the Dietitian she was out of condiments or bread. She said she should have told someone so she could have gone to the store and picked up what she needed until the truck came in. She said the supply truck ran today (07/21/25) but still did not bring any bread, she said she was going to see what she needed to do to get the bread. She said it was important to have food required for the health of the residents. During a confidential group interview with 9 residents on 07/22/25 starting at 3:00 p.m., the resident group said the facility had been running out of condiments and food. Resident #3 mentioned about the butter, cheese, jelly and bread and other residents agreed that they do not always have condiments on their trays. During an interview on 07/22/2025 at 4:09 p.m., The Dietitian said she had not had any concerns about condiments or foods. She said she expected the Director of Food and Nutrition to have the food the residents needed to meet the food preferences and nutrition. She said it was important to provide and serve nutritious food to prevent weight loss. She said if the Director of Food and Nutrition was having any problems with ordering food, she expected the Director of Food and Nutrition to reach out to her or the cooperate dietitian. During an interview on 07/23/25 at 5:16 p.m., the DON said all residents should have choices of the food being served. She said she was the nurse in the dining room checking tray cards when she asked about butter, jelly and bread and the dietary staff told her they were out and waiting on their food truck today (07/21/25). She said she expected the food the resident wanted or required to be in the facility. She said if a resident requested bacon, toast, jelly, bread, or butter they should be receive it. She said failure to provide the resident with food they like or condiments that might make their food more tasteful could cause the resident not to eat and potentially loss weight. During an interview on 07/23/25 at 5:23 p.m., the Administrator said she expected the residents to receive the foods they wanted. She said the Director of Food and Nutrition was responsible for ensuring she was ordering enough food and condiments. She said the dietary staff was responsible for placing the condiments on the tray. She said if bacon was on a resident’s tray card, then she expected that resident to receive bacon. She said she was not aware they were out of butter, jelly, bread, or milk. She said it was important to have what the resident needs as well as what they prefer for their overall health and nutrition. She said if a resident does not like the food they get or does not get the condiments for the food it could cause them not to eat and lose weight. Record review of the facility policy titled, Resident Rights,” revised 11/28/16, indicated, “The resident has a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. …. The resident has a right to be treated with respect and dignity, including: #3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.”

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 4 residents (Resident #8 and Resident #9) reviewed for PASRR. 1. The facility failed to complete the PASRR level 1 screening for Resident #8 who had a diagnosis of Bipolar with depression and psychotic disorder (where the individual is experiencing a depressive episode that is both severe and includes psychotic symptoms) on admission on [DATE]. 2. The facility failed to ensure Resident #9 had a new PASRR level 1 screening completed when she had a new diagnosis of schizoaffective disorder (a chronic brain disorder that significantly impacts a person's thoughts, feelings, and behavior) dated 04/05/22. These failures could place residents at risk of not receiving the needed PASRR services to meet their individual needs and could result in a decreased quality of life. Findings included: 1.Record review of Resident #8's face sheet, dated 07/23/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Bipolar (a mental illness that causes unusual shifts in mood), Depression (a serious mental illness characterized by persistent feelings of sadness, loss of interest in activities, and difficulty functioning in daily life) and anxiety (excessive and persistent fear or worry that interferes with daily life). Record review of Resident #8's care plan, revised 01/29/25, indicated Resident #8 had diagnoses which included depression, anxiety as evidence of self-picking and bipolar. The intervention were to give medication as order, monitor for increased sadness, irritable, anger, confusion, lack of energy and inform the physician for any adverse effects and behavioral symptom. Record review of Resident #8's annual MDS assessment, dated 07/02/25, indicated Resident #8 understood others and was understood by others. Her BIMS score was a 15, which indicated her cognition was intact. Resident #8 was independent in her ADLs except required supervision with bathing. Resident #8 had diagnoses which included depression, anxiety and bipolar. Record review of a PL1 for Resident #8, dated 8/30/22, did not indicated she had any evidence or indication of MI, ID, or DD. Record review of Resident #8's admission face sheet, dated 07/23/25, indicated she was admitted to the facility on [DATE] with mental illness diagnoses of bipolar and major depression. During an interview on 07/23/2025 at 11:30 a.m., the PASRR Coordinator said she saw in her system where a PL1 was submitted on 09/1/22 for Resident #8. She said the form was marked No for mental illness but should have been marked Yes for mental illness by the admitting facility filling out the PL1 form. She said since the PL1 form was marked incorrectly it would not have notified the Local Intellectual and Developmental Disabilities Authority to come do a PASRR Evaluation. During an interview on 07/23/2025 at 12:26 p.m., the MDS nurse, she said the previous MDS nurses were responsible for ensuring the PL1 they received from the prior facility was correct, and if it was not, they should have done a query and explained she had a diagnosis of Bipolar. She said it was important to make sure the PL1 was done correctly so the resident could be evaluated by LIDDA and if they qualified, they could receive services. She said since employment she was responsible for the PL1 being entered correct into their electronic system. 2. Record review of Resident #9's face sheet, dated 07/23/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included Schizophrenia (a chronic brain disorder that disrupts how a person thinks, feels, and behaves), Depression (a serious mental illness characterized by persistent feelings of sadness, loss of interest in activities, and difficulty functioning in daily life) and anxiety (excessive and persistent fear or worry that interferes with daily life). Record review of Resident #9's comprehensive care plan, revised on 05/02/24, indicated Resident #9 had a mood problem related to a psychotic disorder with delusions, anxiety and a diagnosis of major depressive disorder. Record review of Resident #9's quarterly MDS assessment, dated 07/18/25, indicated Resident #9 usually understood and was usually understood by others. Resident #9's BIMS score was 03, which indicated her cognition was severely impaired. Resident #9 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers and eating. Record review of a PL1 for Resident #9, dated 6/11/21, indicated she was not positive for MI, ID, or DD. Record review of Resident #9's PE for, dated 6/21/21, indicated she was not positive for MI, ID, or DD. Record review of Resident #9's nurses note, dated 04/05/22, indicated a new diagnosis of psychotic disorder with delusions was added. Record review of Resident #9's electronic medical records did not indicate a new PASRR level 1 screening was done, after the new diagnosis of schizoaffective disorder was added on 04/05/22. During an interview on 07/22/2025 at 4:32 p.m., the MDS nurse said she started in October of 2024. She said she was not aware why another PE was not done on 4/05/22 when the diagnosis of Schizoaffective was added for Resident #9. She said another PL1 should have been completed when they received the new diagnosis and therefore it would have been sent to LIDDA to complete a PE. During an interview on 07/23/25 at 5:16 p.m., the DON she said the MDS nurse was responsible to ensure the PL1 was filled out correctly and sent to LIDDA, if needed. She said if residents identified with a qualifying diagnosis were not accurately assessed for PASRR, it could affect the resident receiving services. During an interview on 07/23/25 at 5:23 p.m., the Administrator said the MDS nurse was responsible for making sure residents with qualified or new qualifying diagnoses got a new PASRR completed. She said the risk could be missed services under PASRR and she expected all residents were appropriately assessed for PASRR prior to and during admission at the facility. During an interview on 07/23/25 at 6:12 p.m., the Regional Compliance Nurse said they did not have a facility policy for PASRR and used the guidelines from the RAI manual. Record review of the RAI manual section A1500: Preadmission Screening and Resident Review (PASRR): All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions (please contact your local State Medicaid Agency for details regarding PASRR requirements and exemptions). Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. A resident with MI or ID/DD must have a Resident Review (RR) conducted when there is a significant change in the resident's physical or mental condition. Therefore, when an SCSA is completed for a resident with MI or ID/DD, the nursing home is required to notify the State mental health authority, intellectual disability or developmental disability authority (depending on which operates in their State) in order to notify them of the resident's change in status. Section 1919(e)(7)(B)(iii) of the Social Security Act requires the notification or referral for a significant change.1 Each State Medicaid Agency might have specific processes and guidelines for referral, and which types of significant changes should be referred. Therefore, facilities should become acquainted with their own State requirements.Preadmission Screening and Resident Review:Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities:Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). Provide all applicants the services they need in those settings.PASRR is an important tool for states to use in rebalancing services. under the Americans with Disabilities Act. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care.In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 breakfast meals reviewed for dietary services. The facility failed to serve an appetizing bowl of oatmeal. The oatmeal served was thick, porous texture that resembled cornbread during the breakfast meal on 07/22/25. This failure could place residents at risk of weight loss, altered nutritional status, and a diminished quality of life.Findings include:During an interview and observation on 07/22/25 at 8:26 a.m., the state surveyor asked Resident #12 how his breakfast was, Resident #12 stated, you're able to cut the oatmeal with his knife. The state surveyor observed a bowl of oatmeal that was thick, porous texture that resembled cornbread. During an observation on 07/22/25 at 8:30 a.m., revealed Resident #13 was sitting in her recliner, eating her breakfast. She stated the oatmeal did not look like oatmeal; it looked hard, so she did not even touch it. During an interview on 07/22/25 at 8:32 a.m., the Director of Food and Nutrition stated the oatmeal did look to thick. The Director of Food and Nutrition stated she should have split the oatmeal in two pans instead of one when she prepared it and add either milk or boiling water. The Director of Food and Nutrition stated she should have not let the oatmeal leave the kitchen, but she was thinking about compliance on mealtimes. The Director of Food and Nutrition stated it was important that food was palatable to prevent weight loss. During an interview on 07/23/25 at 3:40 p.m., the Regional Compliance Nurse stated there was no policy and procedures regarding food palatability. During an interview on 07/23/25 at 3:57 p.m., the DON stated oatmeal should not be thick or clumpy but a smooth texture. The DON stated the Director of Food and Nutrition should have fixed more oatmeal before servicing. The DON stated it was important to ensure food was palatable for health and enjoyment.During an interview on 07/23/25 at 4:40 p.m., the Traveling Certified Dietary Manager stated oatmeal should be served smooth not lumpy or too thick. The Traveling Certified Dietary Manager stated the oatmeal should not have been served. The Traveling Certified Dietary Manager stated it was important to ensure food was palatable for nutritional value. During an interview on 07/23/25 at 5:21 p.m., the Administrator stated she expected oatmeal to be served not to thick or runny. The Administrator stated the oatmeal should not have been served but corrected by making a new batch. The Administrator stated she monitored food palatable by random spot checks and ensured the recipe was followed. The Administrator stated it was important to ensure food was palatable to prevent choking weight loss.

Based on observation, interview, and record review, the facility failed to ensure each resident received food prepared in a form to meet their individual needs for 4 of 4 residents (Residents #13, #27, #28, and #12) reviewed for the lunch menu on 07/21/25. The facility failed to ensure Residents #13, #27, #28, and #12 was served the correct portion of food on 07/23/25. These failures could place residents at risk of inadequate nutrition. Findings included: 1.Record review of Resident #13's face sheet, dated 07/23/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), diabetes ( a chronic illness where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), and depression (a serious mood disorder that affects how you think, feel, and behave). Record review of Resident #13's quarterly MDS assessment, dated 04/17/25, indicated she had a BIMS score of 09, which indicated moderately cognitive impairment. She was usually able to make herself understood and she was sometimes able to understand others. She required set up for her activities of daily living including eating She required a mechanically altered diet (require change in texture of food). Resident #13 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #13's Order Summary Report, dated 07/23/25, indicated she had an order for:*Mechanical Soft texture, Regular consistency with a start date of 09/19/24. Record review of Resident #13's care plan, last revised 05/23/25, indicated a focus of Resident #13 had a mechanical ground meat diet other than Regular and was at risk for unplanned weight loss or gain. Interventions were to serve diet as ordered. Record Review of Resident #13's Food Tray Ticket for Lunch 07/21/25 indicated .Mechanical Soft texture, Regular consistency Diet .Entree .Pasta Manicotti Cheese w/MarinaraStarch garlic breadVegetable .Zucchini.Dessert .strawberry bread pudding 2. Record review of Resident #27's face sheet, dated 07/23/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dysphagia (difficulty swallowing), stroke and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life., Record review of Resident #27's quarterly MDS assessment, dated 05/16/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was able to make himself understood and she was usually able to understand others. She required set up for eating. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Resident #27 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #27's Order Summary Report, dated 07/23/25, indicated she had an order for:*Regular diet Mechanical Soft texture, Regular with a start date of 01/05/23. Record review of Resident #27's care plan, last revised on 02/07/25, indicated a focus of Resident #27 had a potential nutritional problem in which she required a mechanical soft diet. Interventions were for staff to provide and serve diet as ordered. Record Review of Resident #27's Food Tray Ticket for Lunch 07/21/25 indicated .Mechanical Soft texture, Regular consistency Diet .Entree .Pasta Manicotti Cheese w/MarinaraStarch Garlic breadVegetable .Zucchini.Dessert .strawberry bread pudding 3.Record review of Resident #28's face sheet dated 07/23/25 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnosis non-pressure chronic ulcer of the buttocks, major depressive disorder, high blood pressure, and anxiety. Record review of Resident #28's other payment MDS dated [DATE] indicated he made himself understood. The MDS also indicated he had a BIMS score of 14 which meant he was cognitively intact. The MDS also indicated Resident #28 required setup and supervision for eating. Resident #28 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #28's comprehensive care plan dated 03/01/21 and last updated 05/26/25 indicated he was at risk for malnutrition. The care plan interventions included: monitor/document meal intake, offer diet as ordered by the physician and update food preferences as needed. Record review of Resident #28's Order Summary Report, dated 07/23/25 indicated he had an order for:*Regular diet mechanical soft texture, regular consistency, add extra salt to meals, large protein portions with meals with a start date of 03/28/24. Record Review of Resident #28's Food Tray Ticket for Lunch 07/21/25 indicated .Mechanical Soft texture, Regular consistency Diet .large protein portions .Entree .Pasta Manicotti Cheese w/MarinaraStarch Garlic breadVegetable .Zucchini.Dessert .strawberry bread pudding 4.Record review of Resident #12's face sheet, dated 07/23/25, indicated he was a [AGE] year-old male, and readmitted to the facility on [DATE] with a diagnosis which included absence of right leg below knee. Record review of Resident #12's quarterly MDS assessment, dated 06/18/25, indicated Resident #12 made himself understood, and understood others. Resident #12's BIMS score was 14, which reflected his cognition was intact. Resident #12 required setup or clean-up assistance with eating. Record review of Resident #12's comprehensive care plan initiated 09/05/21, reflected Resident #12 was at risk for malnutrition. The care plan interventions included: monitor/document meal intake, offer diet as ordered by the physician and update food preferences as needed. Record review of Resident #12's Order Summary Report, dated 07/23/25, indicated he had an order for:* Regular texture, regular consistency, double meat/protein portions all meals with a start date of 03/12/24. Record Review of Resident #12's Food Tray Ticket for Lunch 07/21/25 indicated .regular texture, regular consistency, double meat/protein portions all meals .Entree .Pasta Manicotti Cheese w/Marinara, large meat portion onlyStarch Garlic breadVegetable .Zucchini.Dessert .strawberry bread pudding During a dining observation and interview on 07/21/25 at 12:45 p.m., RN A was checking the meal trays for the hall cart. RN A removed the cover to Resident #13, #27, #28, and #12 and placed the covers back and moved onto the next resident. Residents #13, #28 and #12 tray had 1 cheese manicotti with marinara and about 1/4 cup of Zucchini. Resident #13 should have received 2 servings of Manicotti and 1/2 Zucchini; Resident #27 and Resident #28 should have received 4 servings of Manicotti and 1/2 cup Zucchini. Resident #27 had 1.5 Manicotti and should have received 2 servings of Manicotti and 1/2 cup of Zucchini. After the state surveyor intervention RN A sent the meal trays back to the dietary staff to correct the discrepancy. During an interview on 07/21/23 at 2:52 p.m., the Director of Food and Nutrition said when she placed the order for Manicotti, and Zucchini they had 39 residents and today (07/21/25) they had 43 residents. She said because the census had changed, she felt that was why she did not have enough food for the lunch menu. She said each resident should have had at least 2 Manicotti and 1/2 cup of Zucchini. She said Dietary Manager B fixed the trays that were served incorrectly. She said she assumed she served less than what should have been given because they were running low on food. She said the residents should have received the correct serving size for overall nutrition. During an interview and observation on 07/21/2025 at 3:06 p.m., Dietary Manager B said she arrived at the facility to help the Director of food and Nutrition, because she had a call off in the kitchen. She said while helping get lunch prepped and prepared, she noticed the lack of Zucchini and asked the Director of Food and Nutrition to open a can of green beans. She said the Director of Food and Nutrition prepared the dining room and 2 hall carts before she took over on the food serving line. She said while on the serving line 5-6 trays were returned related to only 1 Manicotti or not enough Zucchini. She said she remade the trays but was not responsible for the mistakes of the original trays. She said all residents should have been served at least 2 Manicotti and 1/2 cup or 4ounces of Zucchini. She said the trays she remade only had 1 or 1.5 servings of Manicotti and about 1/4 cup of Zucchini. She said the Director of Food and Nutrition had the right size scoops in the food but was only given a small amount on the plates. She said she could only assume it was because she did not have enough Manicotti or Zucchini to serve all the residents. The state surveyor observed 6 hamburger patties been made because they did not have enough Manicotti for each resident. During an interview on 07/22/2025 at 4:09 p.m., The Dietitian said she had not had any concerns about condiments or foods. She said she expected the Director of Food and Nutrition to have the food the residents needed to meet the food preferences and nutrition. She said it was important to provide and serve nutritious food to prevent weight loss. She said if the Director of Food and Nutrition was having any problems with ordering food, she expected her to reach out to her or the cooperate dietitian. During an interview on 07/23/25 at 5:16 AM, the DON she expected the kitchen to serve the correct diet per the dietary manual. She said if a regular diet should have had 2 Manicotti, then she expected them to have 2. If the order called for large or double portion, then she expected the kitchen to serve it also. She said it was important for the resident's nutrition. During an interview on 07/23/25 at 5:23 p.m., the Administrator said she expected all residents to be served the correct amount. She said the Director of Food and Nutrition Manager oversaw the kitchen and expected her to know the correct size to serve each resident. She said the risk could be weight loss. Record review of the Facility's recipe for portion size for Pasta Manicotti Cheese w/Marinara on 07/21/25 at lunch indicated: .Pasta Manicotti Cheese w/Marinara Serve 2: Manicotti chopped with cheese, to equal 3 ounces. Record review of the Facility's recipes for portion size of Zucchini on 07/21/25 at lunch indicated:.Zucchini.Serve 1/2 cup each. Record review of the facility's policy titled, Resident Menus, form the Dietary Services Policy & Procedure Manual dated 2012, indicated, We will strive to assure the resident's nutritional needs are provided based on the Recommended Dietary Allowance (RDA). The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production. Procedure: 1. Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutritional Board, National Research Council, adjusted to the age, activity, and environment of the group involved . #5. The menus will be prepared as written using standardized recipes. The Dietary Service Manager and cooks are trained and responsible for the preparation and service of therapeutic diets as prescribed.

Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 2 of 15 residents (Residents #12 and #28) reviewed for therapeutic diets. 1. The facility did not ensure Resident #12 was given double protein portion as ordered by the physician. 2. The facility did not ensure Resident #28 was given large protein portions as ordered by the physician on 07/21/25 during the lunch service. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings Included: 1. Record review of Resident #12’s face sheet, dated 07/23/25, reflected Resident #12 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included absence of right leg below knee. Record review of Resident #12’s quarterly MDS assessment, dated 06/18/25, reflected Resident #12 made himself understood, and understood others. Resident #12’s BIMS score was 14, which reflected his cognition was intact. Resident #12 required setup or clean-up assistance with eating. Resident #12 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #12’s comprehensive care plan initiated 09/05/21, reflected Resident #12 was at risk for malnutrition. The care plan interventions included: monitor/document meal intake, offer diet as ordered by the physician and update food preferences as needed. Record review of Resident #12’s physician order summary report, dated 07/23/25, reflected regular texture, regular consistency, double meat/protein portions all meals with a start date 03/12/24. Record review of Resident #12’s lunch meal ticket dated 07/21/25, reflected entrée: large meat portion only. The entrée was 2 cheese manicottis with marinara. During a dining observation and interview on 07/21/25 at 12:45 p.m., RN A was checking the meal trays for the hall cart. RN removed the cover to Resident 12’s tray and stated, “that not enough.” RN placed the cover back and moved onto the next resident. Resident #12 received ½ serving of the entrée which was 1 cheese manicotti with marinara. After the state surveyor intervention RN stated Resident#12 was supposed to receive double portions. During an interview on 07/21/25 at 1:15 p.m., Resident #12 stated he had never received double meat with his meals until today (07/21/25). Resident #12 stated he was unaware that he was supposed to received double meat. 2.Record review of Resident #28’s face sheet dated 07/23/25 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of non-pressure chronic ulcer of the buttocks, major depressive disorder, high blood pressure, and anxiety. Record review of Resident #28’s other payment MDS dated [DATE] indicated he made himself understood. The MDS also indicated he had a BIMS score of 14 which meant he was cognitively intact. The MDS also indicated Resident #28 required setup and supervision for eating. Resident #28 did not have a 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #28’s comprehensive care plan dated 03/01/21 and last updated 05/26/25 indicated he was at risk for malnutrition. The care plan interventions included: monitor/document meal intake, offer diet as ordered by the physician and update food preferences as needed. Record review of Resident #28’s physician order summary report dated 07/23/25 indicated he had an order for a regular diet mechanical soft texture, regular consistency, add extra salt to meals, large protein portions with meals with a start date 03/28/24. During a dining observation and interview on 07/21/25 at 1:00 PM, RN A was checking the meal trays for the hall carts while surveyor was observing the trays. RN A removed the cover to Resident 28’s tray and stated, “that not enough.” RN A asked the kitchen staff to provide another portion of the cheese manicotti with marinara after surveyor intervention because his lunch card indicated large protein portion. The kitchen staff handed her another portion of the cheese manicotti with [NAME] on a separate covered plate. During an observation and interview on 07/21/2025 at 1:05 PM Resident #28 was in bed eating his lunch. Resident #28 said he was enjoying his lunch and having all that food”. Resident #28 said he did not normally receive that much food on his tray. During an interview on 07/21/25 at 2:50 p.m., Dietary Manager B stated she was from a sister facility and came over to assist the facility dietary manager because she was by herself. Dietary Manager B stated the Director of Food and Nutrition had fixed Resident #12’s tray prior to her correcting the discrepancy. Dietary Manager B stated Resident #12 should have received 4 cheese manicottis with marinara instead of 1. Dietary Manager B stated it was important to ensure residents received the correct diet order for proper nutrients and prevent further weight loss. During an interview on 07/21/25 at 3:06 p.m., the Director of Food and Nutrition stated she was the dietary manager for the facility and was aware of Resident #12 receiving double meat/protein portions. The Director of Food and Nutrition stated she did not have his lunch meal ticket while preparing his tray which she was supposed to. The Director of Food and Nutrition stated he should have received 4 cheese manicottis with marinara. The Director of Food and Nutrition stated the reason she believed he was receiving double meat/protein because he did not like vegetables so receiving double protein would help with his calorie intake. The Director of Food and Nutrition it was important to ensure residents received the correct diet order to prevent weight loss. During a telephone interview on 07/22/25 at 3:49 p.m., the Dietitian stated Resident #12 received double meat/protein related to a non-pressure wound to his RLE that currently had resolved and she expected Resident #28 to receive double protein portions as well due to a previous weight loss. The Dietitian stated she expected double servings of protein and large portions of protein which would have been 4 cheese manicottis with marinara. The Dietician stated it was important for the diet order to be followed until she come to assess the residents to see if the order needed to be change. During an interview on 07/23/25 at 9:46 a.m., the Medical Director stated he expected the diet orders to be followed. The Medical Director stated it was important for Resident #12 to received double meat/protein to help with wound healing and to build muscle and he expected Resident #28 to receive double protein portions to ensure no further weight loss. During an interview on 07/23/25 at 3:57 p.m., the DON stated she expected the diet order to be followed. The DON stated the Director of Food and Nutrition was responsible for responsible for monitoring diet orders. The Administrator stated it was important to ensure Resident #12 and Resident #28 received double meat/protein to prevent weight loss. During an interview on 07/23/25 at 5:21 p.m., the Administrator stated she expected the diet order to be followed. The Administrator stated the Director of Food and Nutrition was responsible for monitoring diet orders. The Administrator stated she oversees the kitchen by random spot checks several times a week and has not had any issues with staff not following the diet orders. The Administrator stated it was important to ensure Resident #12 and Resident #28 received double meat/protein for nutrition. Record review of the facility policy “Large Portions Diet undated indicated: We will add extra calories and protein to the regular diet as appropriate. Large portions may be used to promote weight gain if the resident has a good appetite or to satisfy the resident with a large appetite. Extra food items are added to the regular diet throughout the day. This diet provides the recommended Dietary Allowances for all nutrients. This diet provides over 2800 calories, 120 grams of protein per day. Procedure: Serve the Regular (or consistency modified) diet per the menu with additional foods as indicated… Lunch and Dinner Soups, salad, bread, starch, vegetable, fruit, condiments, beverages and desserts per regular menu portions Double servings of entrée/protein portions…”

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 ice machine reviewed for kitchen sanitation. The facility failed to ensure the ice machine, stored in the kitchen area, was free from a pink like substances on it and black like substance in the scoop container on 07/21/25. This failure could place residents at risk for foodborne illness. Findings included: During an observation on 07/21/25 at 9:07 a.m., revealed the ice scoop located in the main area of the kitchen had a pink like film on it. The ice container that held the ice scoop had some black and brown film inside of it. During an observation and interview on 07/21/25 at 9:10 a.m., the Director of Food and Nutrition came out of the kitchen and observed the ice scoop had some pink like substance on the ice scoop and the ice scoop holder had some black and brown film in the bottom of it. She said the kitchen staff were responsible for cleaning the ice scoop and holder. She said she was not sure about the cleaning schedule but said they clean the ice scoop daily and the ice scoop holder monthly. The Director of Food and Nutrition immediately took the ice scoop and the ice scoop holder and washed it. The Director of Food and Nutrition said the ice scoop holder was gross and since both were dirty it could lead to infection control issues. During an interview on 07/23/25 at 5:17 p.m., the DON said the kitchen staff were responsible for cleaning the ice scoop and ice scoop container. She said she was not aware of the cleaning schedule but knew they should be clean to prevent residents' from becoming sick. During an interview on 07/23/25 at 5:23 p.m., the Administrator said she did not expect for the ice scoop or the ice container to be dirty. She said the dietary staff was responsible to ensure the ice scoop and ice scoop container was clean. She said failure to keep clean could cause infection control issues and illness. Record review of the facilities policy titled, Equipment Sanitation, from the Dietary Services Policy & Procedure Manual dated 2012, indicated, We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure:f All equipment and utensils shall be sanitized by one of the following methods:g. Immersion for at least one-half minute in clean, hot water at a temperature of at least 180 degrees F.h. Immersion for a period of at least one minute in a sanitizing solution containing: At least 50 ppm of available chlorine at temperature not less that 75 degrees F. At least 12.5 ppm of available iodine in a solution having a pH higher than 5.0 and a temperature of not less than 75 degrees F. Any other approved chemical-sanitizing agent containing at least 150-400 ppm of quaternary ammonia at a temperature of approximately 70 degrees F. Record review of the facilities policy titled, Equipment Sanitation, from the Dietary Services Policy & Procedure Manual dated 2012 and revised 4/25, indicated, We will ensure that all employees practice infection control in the Food and Nutrition Services Department, and maintain sanitary food preparation. Procedure: #1. Personal cleanliness is required in sanitary food preparation. Employees should follow general sanitation guidelines from the Center of Disease Control (CDC) and the state food code when working in the Food and Nutrition Department. #5. Equipment Sanitation: a. All kitchenware and food contact used in the preparation and/or serving of food are cleaned and sanitized before use and cleaned after each meal preparation. Sanitizing agents are used for cleaning all surfaces.

Based on interview and record review the facility failed to ensure the resident had the right to and the facility made prompts efforts to resolve grievances the resident may have for 1 of 2 residents (Resident #3) reviewed for grievances. The facility failed to ensure a grievance was filed and Resident #3 was appropriately apprised of progress toward resolution when Resident #3's green pants were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolvedFindings include:Record review of Resident #3's face sheet, dated 07/23/25, reflected Resident #3 was a [AGE] year-old female readmitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #3's quarterly MDS assessment, dated 06/05/25, reflected Resident #3 made herself understood, and understood others. Resident #3's BIMS score was 14, which reflected her cognition was intact. Resident #3 was independent with upper body dressing and required set up or clean-up assistance with lower body dressing. Record review of Resident #3's comprehensive care plan, revised on 05/08/22, reflected Resident #3 had an ADL Self Care Performance Deficit. The care plan interventions included: provide supervision with dressing as needed. Record review of the grievance file, dated 06/01/25-07/01/25, did not indicate a grievance was completed for Resident #3's missing clothing in the last 2 months.During a group meeting on 07/22/25 at 3:00 p.m., Resident #3 stated she reported to the Housekeeping Supervisor she was missing a pair of green pants, white capri pants and a bright colored blouse. Resident #3 was unable to give the exact date she had reported the missing items. Resident #3 stated her items had been missing for several weeks and she had not heard if the items were found or would be replaced. Resident #3 voiced being frustrated with not knowing if her clothing would be replaced. During a telephone interview on 07/22/25 at 3:42 p.m., the Housekeeping Supervisor stated Resident #3 did report to him on 07/14/25 about her missing green pants but never mentioned the white capris or blouse. The Housekeeping Supervisor stated, Unfortunately I did not do a sweep which indicated looking for the item in another resident's closet. The Housekeeping Supervisor stated when someone reported a missing clothing item, he would determine what was missing, look through the personal lost and found and perform a sweep which indicated he would go through resident's closets to see if the items were accidently placed in another resident closet. The Housekeeping Supervisor stated if the items were not found he would report it to the Administrator for a grievance to be completed. The Housekeeping Supervisor stated he did not report Resident #3's green missing pants to the Administrator which he did not have much of an excuse why he did not. The Housekeeping Supervisor stated it was important for the residents to have their clothing returned because it was their right to have their belongings. During an interview on 07/22/25 at 5:08 p.m., the Administrator stated she had not received a grievance on Resident #3's missing clothing. The Administrator stated if she received a complaint of missing clothing, she would try to locate the missing items. If she could not locate them, she would offer to replace the items. The Administrator stated her expectation was for the Housekeeping Supervisor to report the missing items so a grievance could be filed. The Administrator stated she was responsible for monitoring and overseeing missing items by following up during QAPI meetings, morning stand up and champion rounds. The Administrator stated it was important for the residents to have their clothing because it was the right thing to do. Record review of the facility's policy titled Grievances, revised 11/02/16, reflected .The resident has the right to voice grievances to the facility or other agency or entity that hears grievances. 2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: receive and track grievances to their conclusion.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 2 residents (Residents #12 and #21) reviewed for accidents and hazards.1. The facility failed to ensure Resident #12 did not have an electric razor and shaving gel on his bedside table on 07/21/25, 07/22/25 and 07/23/25.2. The facility failed to ensure Resident #21 did not have razors in his bathroom on 07/21/25, 07/22/25 and 07/23/25.These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in healthFindings include: 1. Record review of Resident #12’s face sheet, dated 07/23/25, reflected Resident #12 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included absence of right leg below knee. Record review of Resident #12’s quarterly MDS assessment, dated 06/18/25, reflected Resident #12 made himself understood and understood others. Resident #12’s BIMS score was 14, which reflected his cognition was intact. Resident #12 required supervision or touching assistance with personal hygiene which included shaving. Record review of Resident #12’s comprehensive care plan, initiated 01/08/21, reflected Resident #12 had an ADL Self Care Performance Deficit. The care plan interventions included: assist with personal hygiene as required: hair, shaving, oral care as needed. During an interview and observation on 07/21/25 at 3:14 p.m., revealed Resident #12 had an electric razor, and a can of shaving gel on his bedside table. Resident #12 stated he shaved himself and indicated staff were aware he was in possession of the items. During an observation on 07/22/25 at 8:26 a.m., revealed Resident #12 sitting up in his recliner with an electric razor, and a can of shaving gel on his bedside table. During an observation on 07/23/25 at 9:00 a.m., revealed Resident #12 sitting up in his recliner with an electric razor, and a can of shaving gel on his bedside table. During an observation on 07/23/25 at 10:15 a.m., there was no resident's wandering from room to room on the hall with Resident #12. During an interview on 07/23/25 at 2:05 p.m., RN A stated if a resident had an electric razor or shaving gel at bedside the resident must be assessed, and an order obtained from the physician. RN A asked the state surveyor if she could speak to the DON about the items at the beside and come back to complete the interview. After speaking with the DON and the Regional Compliance Nurse, RN A stated there was no policy and procedures for keeping an electric razor or shaving gel at the bedside. RN A stated the resident did not have to be assessed for razors at bedside. RN A stated it was his right for his hygienic purpose to have those items at his bedside. RN A stated a dementia resident could obtain the electric razor or shaving gel, and it could cause an injury or adverse reaction. During an interview on 07/23/25 at 3:57 p.m., the DON stated the actual policy for an electric razor and shaving gel stated to store in an appropriate place such as the counter, dresser or wherever Resident #12 would like it stored. The DON stated the policy did not state it could not be stored in his room. The DON stated Resident #12 had a private room and he was alert and oriented. The DON stated she was responsible for monitoring and overseeing resident safety by daily rounds. The DON stated there was not a particular assessment to check to see if a resident could have razors, shaving cream, soap etc. at bedside. The DON stated there was no residents who wander in other resident’s rooms. The DON stated there was no risk for having electric razors or shaving cream at the bedside. During an interview on 07/23/25 at 5:21 p.m., the Administrator stated an electric razor, and shaving gel could be stored in the resident’s room on the resident dresser. The Administrator stated the resident did not have to be assessed for safety. The Administrator stated Resident #12 was very independent and she did not go in his room often. 2.Record review of Resident 21’s face sheet, dated 07/23/25, reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #21 had diagnoses which included a stroke, arthritis (a group of over 100 conditions that cause joint pain and inflammation), glaucoma (a group of eye diseases that damage the optic nerve, leading to vision loss and potentially blindness), and high blood pressure. Record review of Resident #21’s annual MDS assessment, dated 05/14/25, reflected Resident #21 understood and was understood by others. Resident #21’s BIMS score was 15, which meant his cognition was intact. Resident #21was independent with his activities of daily living but required supervision with bathing, required help with toileting, bed mobility, dressing, transfers, personal hygiene and was independent with eating. Record review of Resident #21’s care plan, revised on 01/29/25, indicated he desired to have facial hair. The staff intervention was to shave him if he requested. It did not indicate if he was able to have unattended razors in his room. During an observation on 07/21/25 at 11:01 a.m., revealed 3 disposable razors lying on Resident #21’s sink. Resident #21 was not in his room. No wandering residents noted on the hallway. During an observation and interview on 07/22/25 at 8:30 a.m., Resident #21 had 3 disposable razors lying on his sink. Resident #21 said he shaved himself and staff (unknown) brought the razors to him. During an observation on 07/22/25 at 9:30 a.m., revealed no resident's wandering on the hall of Resident #21. During an observation and interview on 07/23/25 at 9:40 a.m., revealed a pack of unopened disposable razors lying on Resident #21’s sink. CNA C said she thought he was care planned to have razors, but said if he was not, then he should not have them in his room. CNA C said he should not have a pack of razors lying in his bathroom for his safety and the safety of others who might wander into another resident’s room. During an interview on 07/23/2025 at 9:42 a.m., RN A said no residents should have razors in their room for safety reasons. She said she could not recall any resident being able to keep razors in their room. She said Resident #21 could shave himself, but staff needed to be around for supervision and disposal of the razors when he completed the shaving process. During an interview and observation on 07/23/2025 at 9:43 a.m., the DON said Resident #21 was care planned for razors. She said he was safe to have razors. She said he had 2-3 razors on his sink this morning (07/23/25) and she removed them and gave him the new pack of razors. The DON and the state surveyor reviewed Resident #21’s care plan, and it indicated if Resident #21 wanted to be shaved, then staff should shave him. It did not indicate for Resident #21 to have razors in his room or bathroom. The DON said he was safe, and he was in the room by himself, so she did not see any risk. During an interview on 07/23/25 at 5:23 p.m., the Administrator said razors should not be in the room for the safety of others. She said it was everyone’s responsibility to ensure razors were not in rooms. She said department heads monitored with champion rounds (rounding on different resident by department heads or management). She said she was Resident #21’s champion and she went into his room but did not check his bathroom. Record review of the facility’s, undated, policy titled “Shaving, Electric/Safety Razors” reflected “…12. Store all articles in the appropriate place….”

Based on interview and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a need to alter treatment significantly for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party of her doppler study results of the lower extremities (noninvasive test that can be used to measure the blood flow through the major blood vessels in the legs), gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) to the right lower extremity, or the need for consultation with a vascular surgeon. This failure could place residents at risk of their responsible parties not being notified or involved in their plan of care. Findings included: Record review of Resident #1's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, Huntington's disease (inherited condition in which nerve cells in the brain break down over time), history of heart attack, history of acute kidney failure (condition in which the kidneys suddenly can't filter waste from the blood), Type 2 diabetes, history of stroke, hemiplegia/ hemiparesis (muscle weakness or paralysis on one side of the body that can affect the arms, legs, and facial muscles) heart failure, vascular dementia (common form of dementia caused by an impaired supply of blood to the brain), and COVID-19. The face sheet indicated Resident #1's family member was her (Resident #1's) responsible party and medical power of attorney. Record review of Resident #1's quarterly MDS dated [DATE] indicated Resident #1 sometimes understood others and sometimes made herself understood. The MDS indicated Resident #1 had both short-term and long-term memory problems. The MDS indicated Resident #1 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #1 required assistance in the form of set-up or cleanup assistance with eating. The MDS indicated Resident #1 required supervision or touch assistance with oral hygiene. The MDs indicated Resident #1 required substantial/maximal assistance with dressing her upper body. The MDS indicated Resident #1 was completely dependent on staff for toileting, showering, dressing the lower body, and personal hygiene. Record review of Resident #1's care plan revised on 5/27/24 indicated she had actual skin impairment which included scabbed areas to the great toe and 2nd toe of the right foot. The care plan also indicated she had a bunion area to the right foot. The care plan interventions included identify /document potential causative factors and eliminate/resolve those factors where possible. The interventions also included monitor/document the location, size, and treatment of skin injury and report abnormalities, failure to heal, signs/symptoms of infection and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) to the medical doctor. Record review of the wound care physician progress note dated 5/31/24 indicated Resident #1 had multiple non-pressure wounds to the right lower extremity. The wound care physician progress note indicated the depth of these wounds could not be assessed due to nonviable tissue and necrosis. The wound care progress directed to obtain an arterial doppler study of the bilateral lower extremities (both the right and left legs). Record review of Resident #1's arterial doppler study dated 6/1/24 revealed Resident #1 had severe arteriosclerosis (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff - sometimes restricting blood flow to the organs and tissues) to the right lower extremity with near absent blood flow to the right distal SFA (superficial femoral artery), ATA (anterior tibial artery), PTA (posterior tibial artery), and DPA (dorsalis pedis artery). Record review of the podiatry note dated 6/5/24 indicated Resident #1 had wounds on both legs and feet with eschar (dry, dark scab, or falling away of dead skin). The podiatry note indicated the physician had an arterial doppler exam with report which showed decreased to absent blood flow on both lower extremities. The note stated Resident #1 had severe PVD (peripheral vascular disease condition in which narrowed arteries reduce blood flow to the legs or arms). The podiatry note indicated she would be referred to a vascular surgeon for evaluation and treatment. The note indicated Resident #1 would be seen again in the podiatry clinic in 3 weeks. Record review of the wound care physician progress note dated 6/7/24 for Resident #1 revealed that due to Resident #1's severe arteriosclerosis in both the lower extremities and near absent blood flow to the right distal SFA, ATA, PTA, and DPA realistic wound care goals were palliative and not curative. The progress note revealed the wound care physician was relinquishing care to the podiatry physician who had referred her to a vascular surgeon. Record review of the podiatry note dated 6/27/24 indicated Resident #1 had skin to the bilateral extremities cool, thin with multiple wounds with eschar, and her toenails were thickened and discolored. The note indicated Resident #1 had worsening wounds with gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) to the right foot and wounds on both legs and feet stable with eschar covering the wounds. The podiatry note indicated Resident #1 was scheduled with vascular surgeon on 7/26/24 but the podiatry office would attempt to get her in sooner due to the rapid expansion of the gangrene. During an interview on 7/18/24 at 10:00 a.m., Resident #1's family member said she was Resident #1's medical power of attorney and responsible party. Resident #1's family member said she was very upset when Resident #1 was admitted to the hospital and saw the state of her right foot. Resident #1's family member said she went to the facility on [DATE] and spoke with the DON and the administrator and learned at that time she (Resident #1) had a doppler study in June. She stated she was never notified of the results, was never notified Resident #1 had gangrene, and was never notified a vascular surgeon would be needed. Record review of the nursing progress notes from 5/28/24 to 7/16/24 did not document Resident #1's family member had been notified of the Doppler study results, gangrene, or plan of care to see a vascular surgeon. During an interview on 7/19/24 at 3:36 p.m., LVN A said she regularly took care of Resident #1 Monday through Friday on 6:00 am to 2:00 p.m. shift. LVN A said she thought Resident #1's family member was aware of the doppler study results. LVN A said she had not notified her of the results because she believed the study was done on a Friday and thought the weekend shift had notified her of the results. LVN A said she was also out the week the doppler results came back. LVN A said she thought Resident #1's family member knew she needed to see a vascular surgeon. LVN A said Resident #1's family member should have been notified with the results and plan of care for Resident #1. During an interview on 7/19/24 at 3:40 p.m., LVN B said she regularly took care of Resident #1 on weekends. LVN B said she worked double weekend shifts and cared for Resident #1 from 6:00 am to 10:00 p.m. LVN B said she thought Resident #1's family member knew about the doppler study results and Resident #1's appointment with the vascular surgeon. She said she had notified the family member herself. LVN B said the weekend supervisor, RN C, would be the one to contact families on the weekend and update with items such as the doppler study results. LVN B said Resident #1's family member had the right to be notified of the doppler study results and plan of care. During an interview on 7/19/24 at 3:47 p.m. RN C said she did not know if the results of the doppler study results had been communicated to Resident #1's family member. RN C said Resident #1's family member should have been notified. During an interview on 7/19/24 at 3:56 p.m. LVN D said she regularly took care of Resident #1 Monday through Friday on the 2:00 p.m. to 10:00 p.m. shift. LVN D said she had not personally contacted the Resident #1's family member about Resident #1's doppler study. LVN D said Resident #1's family member should have been contacted because she (the resident's family member) had the right to know what was going on with Resident #1. During an interview on 7/19/24 at 4:00 p.m., the DON said she could not say if Resident #1's family member was notified of the doppler study results and could not remember if that was something she had spoken with her (Resident #1's family member) about. The DON said Resident #1's family member had the right to know what was going on, should have been notified, and the notification should have been documented. The DON said she did not know if it was communicated that the Resident had gangrene to the right foot. The DON explained the podiatry notes were sent via email and that the staff nurses would not have seen those results to communicate them to Resident #1's family. The DON explained during the time of doppler study and last podiatry visit there was a COVID-19 outbreak in the building and as result, she was working the floor often. The DON said she knew she had spoken with Resident #1's family member about the non-pressure wounds to her right foot but again could not say if she specially spoke with her about the doppler study and the gangrene. During an interview on 7/19/24 at 4:10 p.m., the Administrator said she did not know if Resident #1's family member had been notified specifically of the doppler study results. The Administrator said she felt perhaps the gravity of situation was not communicated well with Resident #1's family member and that communication with families would get better. Record review of the facility policy and procedure titled, Notifying the Physician of Change in Status revised 3/11/2013 stated . (5) the resident's family member or legal guardian should be notified of significant change in resident's status . (7) the nurse will document .all attempts to notify the family and/or legal representative .

Based on interview and record review the facility failed to facilitate resident and family participation in the care planning process for 4 of 15 residents (Resident #15, Resident #17, Resident #21, and Resident #28) reviewed for care plans. The facility failed to notify and invite Resident # 17's responsible party to care plan meetings. The facility failed to ensure Resident # 15, Resident #21, Resident #28 and their representatives were invited to their care plan meetings. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care. Findings included: 1. Record review of Resident #15's face sheet dated 06/24/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems), major depression (mood disorder that causes persistent sadness and loss of interest), heart failure (a condition in which the heart does not pump blood as well as it should), diabetes mellitus (a group of diseases that result in too much sugar in the blood stream), and high blood pressure. Record review of Resident #15's quarterly MDS date 06/09/24 indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #15 had a BIMS score of 15, which indicated she was cognitively intact. Record review of Resident #15's Care plan conference dated 05/16/24, indicated NO on the question if the resident had attended the meeting. The section to indicate why the resident did not attend was left blank. The care plan conference indicated NO on the question if the resident representative attended the meeting. The section on why the resident representative did not attend was left blank. The care plan conference indicated the staff that attended the meeting were the RN, the MDS Coordinator, the Food Service staff, the Physician, the Activity Director, the Social Service Director, and the Director of Rehab. During an interview on 06/18/24 at 03:29 PM Resident #15 said she had never been invited to her care plan meetings, but she would like to be invited and included in her care. 2. Record review of Resident #17's face sheet dated 06/18/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses Alzheimer's (a progressive disease that destroys memory and other important mental functions), psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), major depressive disorder (mood disorder that causes persistent sadness and loss of interest), and chronic pain. Record review of Resident #17's quarterly MDS assessment dated [DATE] indicated she was sometimes able to make herself understood and sometimes understood others. The MDS indicated Resident #17 had a BIMS of 1 which indicated she had severe cognitive impairments. Record review of Resident #17's care plan meeting summary dated 02/29/24 did not indicate any documentation regrading having a care plan meeting with Resident #17. Resident #17's care plan meeting summary had the signatures of the Director of Rehab, MDS Coordinator, Activity Director, and the Director of Nursing. The summary did not indicate Resident #17 or Resident 17's representative attended the meeting. Record review of Resident #17's Care plan conference dated 05/23/24, indicated NO on the question if the resident had attended the meeting. The section to indicate why the resident did not attend was left blank. The care plan conference indicated NO on the question if the resident representative attended the meeting. The section on why the resident representative did not attend was left blank. The care plan conference indicated the staff that attended the meeting were the RN, the MDS Coordinator, the Food Service staff, the Physician, the Activity Director, and the Social Service Director. During an interview 06/18/24 at 02:14 PM a responsible party said she had not been invited nor had she had a care plan meeting in over a year. 46928 3. Record review Resident #21's face sheet dated 06/18/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21 had diagnoses of chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (high blood pressure), Alzheimer's (brain disorder that causes problems with memory, thinking, and behavior) and heart failure (when the heart muscle does not pump blood as well as it should). Record review of Resident #21's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #21 had a BIMS score of 14, which indicated her cognition was intact. Record review of Resident #21's care plan meeting summary dated 10/26/23 did not indicate any documentation regrading having a care plan meeting with Resident #21. Resident #21's care plan meeting summary had the signatures of the Director of Rehab and MDS Coordinator. The summary did not indicate Resident #21 or Resident 21's representative had attended the meeting. Record review of Resident #21's care plan meeting summary dated 01/25/24 did not indicate any documentation regrading having a care plan meeting with Resident #21. Resident #21's care plan meeting summary had the signatures of the Director of Rehab, MDS Coordinator, Activity Director, and Dietary Manager. The summary did not indicate Resident #21 or Resident 21's representative attended the meeting. Record review of Resident #21's Care plan conference dated 04/25/24, indicated NO on the question if the resident had attended the meeting. The section to indicate why the resident did not attend was left blank. The care plan conference indicated NO on the question if the resident representative attended the meeting. The section on why the resident representative did not attend was left blank. The care plan conference indicated the staff that attended the meeting were the RN, the MDS Coordinator, the Food Service staff, the Physician, the Activity Director, and the Social Service Director. During an interview on 06/18/24 at 02:43 PM, Resident #21 said she had been at the facility for over a year. Resident #21 said she had not attended or been invited to a care plan meeting. Resident #21 said if she had been invited to the care plan meetings, she would have attended them. Resident #21 said she liked to know what was going on and be involved in her care. 4. Record review of Resident #28's face sheet dated 06/18/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included congestive heart failure (condition when the heart cannot pump blood well enough to meet the body's needs), atrial fibrillation (abnormal heart rhythm characterized by rapid irregular beating), old myocardial infarction (heart attack), and shortness of breath. Record review of Resident #28's annual MDS assessment dated [DATE], indicated Resident #28 was able to make herself understood and understood others. The MDS assessment indicated Resident #28 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #28's care plan meeting summary dated 12/07/23 did not indicate any documentation regarding having a care plan meeting with Resident #28. Resident #28's care plan meeting summary had the signatures of the Director of Rehab, MDS Coordinator, Activity Director, and Dietary Manager. The summary did not indicate Resident #28 or Resident 28's representative attended the meeting. Record review of Resident #28's care plan meeting summary dated 03/21/24 did not indicate any documentation regarding having a care plan meeting with Resident #28. Resident #28's care plan meeting summary had the signatures of the MDS Coordinator, Physical Therapy Assistant, and Dietary Manager. The summary did not indicate Resident #28 or Resident 28's representative attended the meeting. During an interview on 06/18/24 at 02:38 PM, Resident #28 said she had been in the facility a little over a year. Resident #28 said she had not been invited or attended a care plan meeting that she could recall. Resident #28 said she liked to be involved in her stuff so she would have attended one if she had known. During an interview on 06/18/24 at 03:25 PM the Director of Rehab said the families used to attend the meetings regularly but recently the facility had not had very many residents' families show up. She said she was unsure if they were being invited to attend the care plan meetings. During an interview on 06/18/24 at 03:40 PM the Activity Director said the social worker was responsible for sending out the care plan invitations. She said the Social Worker had been at the facility about 6 weeks and before that she would call to notify the families about the care plan meetings. The Activity Director said she did not make a note about the calls, and she was not aware that she needed to document the information. She said she invited the residents as well but could not remember when the last resident attended a care plan meeting. The Activity Director said her way of notifying the residents for care plan meetings was by telling them on the day of the care plan meeting, but she had never notified them prior to the meetings. The Activity Director said the failure placed the families of residents and residents at risk of not knowing what was going on with their care and not having input into their care. During an interview on 06/18/24 at 03:50 PM the Social Worker said she had been working at the facility for 2 days a week Tuesdays and Thursdays for about 2 months. She said when she began working at the facility, she was not sure who was responsible for sending out care plan meeting invites to the residents and families. The Social Worker said she began the process of filling out the paperwork for invitations to care plan meetings and started sending them out to residents' families because she was accustomed to completing them. She said she was not aware of the issue with the invites not being sent out to residents and families. The Social Worker said she was unsure who was responsible. She said the importance of inviting the family and residents to care plan meetings was to make sure the family knows what is going on with their loved ones and ensure resident were aware of their care. During an interview on 06/18/24 at 04:08 PM the DON said she believed the social worker was now responsible for providing invitations for care plan meetings to residents and families, and prior to the Social Worker starting the Activity Director was responsible and completing them. She said she was unaware if the Activity Director had provided letters to the residents or families. The DON said she expected the families should have been invited and notified of the care plan meetings, and residents should have been notified of meetings as well. She said it was the right of the resident to be notified of the care plan meeting prior to meeting as well as the family, and placed a risk is for family and resident not being involved in care. During an interview on 06/18/24 at 04:21 PM the Administrator said the Social Worker had been completing the care plan invitation letters and sending them out since she began to work at the facility. She said prior to the social worker, the Activity Director and MDS nurse was responsible. The Administrator said the failure of not inviting residents and families to care plan meetings placed the resident or family at risk for miscommunications or lack of coordination of care. Record review of the undated facility's Comprehensive Care Planning policy indicated . The facility will provide the resident and resident representative, if applicable with advance notice if care planning conferences to enable resident/resident representative participation. Resident and resident representative in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to effectively reseal, label and date frozen food items. 4) Dietary staff failed to store thawed raw meat below ready to eat foods. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations with [NAME] B on [DATE] at 10:05 am, the following observations were made in the kitchen walk-in refrigerator (1 of 1): - (1) large bowl of chicken salad with no preparation (prep) date and no use by date; located underneath 10 pounds of thawed ground beef. - (1) prepared bagged ham sandwich with no prep date and no expiration date; located underneath 10 pounds of ground beef. (label was unreadable on the sandwich bag). - (3) single purple onions and (1) single yellow onion had no open date, a use by date of [DATE], received on [DATE]. -(1) five-pound bag of golden harvest mild cheddar shredded cheese with no open date, and no receive date. -(1) zip lock bag of sliced ham not in original packaging had an open date of [DATE], no receive date, no expiration date and was not labeled. -(1) zip lock bag of Golden harvest Yellow slice cheese of about 50 slices had open date of [DATE], no receive date and no expiration date. -(1) zip lock bag of tomatoes had a preparation date of [DATE] and had no expiration date. -(1) two quart container of pineapples had a preparation date of [DATE] and no expiration date. -(1) container of Cranberry Juice had a preparation date of [DATE] and no expiration date. -(1) sixteen ounce container of beef base had an open date of [DATE], no receive date and no expiration date. -(1) zip lock bag of BBQ sausages had a preparation date of [DATE] and no expiration date. -(1) four quart container of ranch dressing had a preparation date of [DATE] and expiration date of [DATE]. -(1) two quart container of strawberry glaze had a preparation date of [DATE] and no expiration date. -(1) half quart of yogurt had a preparation date of [DATE], not labeled, and no expiration date. -(1) zip lock bag of cooked pork meat had a preparation date of [DATE] and an expiration date of [DATE]. -(1) gallon of 1 percent milk had no receive date, no open date and expired on [DATE]. -(1) gallon of 1 percent milk unopened had no receive date and expired on [DATE]. During observations on [DATE] beginning at 10:25 am, the following observations were made in the kitchen freezer: -(1) empty container of butter pecan ice cream had no open date and an expiration date of [DATE] . -(3) 4 fluid ounces of sherbet ice cream cups had no receive date, no expiration date. -(1) zip lock bag of turkey breast had no receive date. -(1) 24 pack of hotdogs received on [DATE] had no expiration date. -(1) bag of about 10 frozen dinner rolls opened on [DATE], had no receive date and no expiration date. -(1) open box of hamburger meat patties open to air was received on [DATE], had no open date, no expiration date. -(1) open box of popsicles opened on [DATE], had no receive date and no expiration date. During observations with [NAME] B on [DATE] beginning at 10:46 a.m., the following observations were made in the kitchen dry storage: -(1) container of brown sugar had a preparation date of [DATE] and no expiration date. -(1) 16 ounces of chicken base seasoning had a receive date of [DATE], and no open date. -(1) container of [NAME] seasoning had a receive date of [DATE] and no open date. -(1) 16 ounces of cooking spray oil had a no receive date, no open and no expiration date. -(1) 26 ounce of salt seasoning had no receive date and no open. -(1) 4.5 ounce of seasoning salt had no open date and no receive date. -(1) package of mini dinner rolls open to air held 3 rolls; there was no open date. -(1) container of beef base seasoning received on [DATE], opened on [DATE] and no expiration date. During an interview on [DATE] at 10:05 a.m., [NAME] B stated, she was the acting Dietary Manger when the Dietary Manager was not in the facility. [NAME] B stated the ready to eat foods were not supposed to be below the thawing ground beef in the refrigerator. [NAME] B stated she would throw away the sandwich and chicken salad found underneath the thawing hamburger meat. [NAME] B stated she believed the prepared foods was good for 5 days. [NAME] B stated she did not know some of the items found in the walk in freezer and kitchen was not labeled, dated and expired foods thrown away. [NAME] B stated the expired and empty box of ice cream found in the kitchen freezer belonged to a staff member at the facility. [NAME] B stated she did not know the ice cream was expired and empty container was in the kitchen freezer. [NAME] B stated the frozen ground beef hamburger patties bag should have had an open date, expiration date and bag should have been closed and sealed. [NAME] B did not know why the bag of hamburger patties was not sealed closed. [NAME] B stated she would inform the Dietary Manager of the findings located in the kitchen and freezers. During an interview on [DATE] at 10:22 a.m., [NAME] A stated she had been working at the facility for a few months as a cook but had been employed at the facility for a year. [NAME] A stated she worked the 5am to 1 pm shift at the facility. [NAME] A stated prepared food items should be discarded after 5 days. [NAME] A stated all food items should be labeled, dated with the received date or preparation date and the expiration date [NAME] A stated all freezer food items should be properly closed and sealed. [NAME] A stated the Dietary Manager oversaw her. [NAME] A stated in-services on labeling and dating was completed last week. [NAME] A stated the Dietary Manager conducted daily walk-thru in the kitchen every morning. [NAME] A stated she was not aware of expired food items in the kitchen. [NAME] A stated the Dietary Manager would normally discard expired food items during her daily walk-thru. [NAME] A stated the dietary staff was expected to ensure all food items were labeled, dated and discarded if expired. [NAME] A stated thawed meats should not be above the ready to eat foods. [NAME] A stated the risks to the residents for having thawed meat above the ready to eat foods was food contamination. [NAME] A stated it was important to ensure all food items were labeled, dated and discarded to prevent food borne illnesses. During an interview on [DATE] at 10:40 a.m., the Dietary Manager stated she had been the Dietary Manager for 4 years. The Dietary Manager stated she worked Monday thru Friday from early mornings to about 1:30 p.m. The Dietary Manager stated she thought it was 5 days that prepared foods should have been discarded but when she checked the FDA site she realized it was 7 days instead of 5 days. The Dietary Manager stated freezer food items should be properly closed and sealed. The Dietary Manager stated she oversaw the Dietary staff, and the Administrator oversaw her at the facility. The Dietary Manager stated in-services on labeling, dating and discarding expired food items was last completed on [DATE]. The Dietary Manager stated her last walk thru in the kitchen was last completed on Saturday on [DATE]. The Dietary Manager stated, I normally completed daily walk-thru on my days I work. The Dietary Manager stated she was not made aware of the expired refrigerated food items and food items not labeled. The Dietary Manager stated she did expect staff to ensure they were labeling, dating and discarding expire food items. The Dietary Manager stated, I coached to them every day and ask, What's wrong with this picture? The Dietary Manager stated it was important to ensure staff were labeling and dating food items to prevent residents from getting sick, infection control and cross contamination. The Dietary Manager stated thawed meats should not be above the ready to eat foods. The Dietary Manager stated the thawed meats should be stored on the bottom shelf. The Dietary Manager stated the risk to the residents for having the thawed meats stored above the ready to eat foods was cross contamination, food borne illnesses and bacteria. During an interview on [DATE] at 1:54 pm., the Administrator stated, she had been the Administrator for 3 years at the facility. The Administrator stated, Yes, all food items should have a receive date, prep date and expiration date. The Administrator stated all freezer food items should be properly sealed and closed. The Administrator stated she oversaw the Dietary staff. The Administrator stated she could not answer the question regarding in-services, but the Dietary Manager did in-services a lot. The Administrator stated, Yes she did walk-thrus in the kitchen. The Administrator stated, She conducted weekly rounds in the kitchen. The Administrator stated she expected staff to ensure they were labeling, dating and discarding expired food items. The Administrator stated expired food items should have been discarded in the kitchen. The Dietary Manager stated it was important to ensure staff were labeling, dating and discarding expired food items so the residents did not get food borne illnesses. The Administrator stated ready to eat foods should not have been underneath the thawing hamburger meat to prevent the residents from getting sick. Record Review of the facility's Dietary policy titled, Left-over Foods, dated 2012 indicated, (1) Left-over foods shall be refrigerated, dated, labeled and properly covered promptly after meal service; (5) Food that is spoiled, contaminated, or suspect shall not be served and shall be discarded immediately Record Review of the facility's Dietary policy titled Food Storage and Supplies dated 2012, indicated (6) When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate-when the product-was manufactured, not when it expires, and should not be interpreted as a best by date. best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product s safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration .date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in , first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used, Any product with a stamped expiration date will be discarded once that date passes.

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (nurse medication cart) reviewed for medication storage. LVN C failed to ensure the facility nurse medication cart was locked when it was left unattended when she went in Resident #31's room to check her blood sugar for insulin administration. This failure could place residents at risk of injury and drug diversion. Findings included: During an observation and interview on 06/17/24 at 04:25 PM LVN C prepared supplies to check Resident #31's blood sugar, went into Resident #31's room, closed the door, and left the nurse medication cart unlocked and unsupervised. When LVN C returned to the cart she said she was not supposed to have left the medication cart unlocked while being unsupervised. She said the failure placed a risk for residents or staff to get into the cart and take medications. During an interview on 06/18/24 at 03:58 PM the DON said she expected the nurses to lock the carts when unattended. The DON said the failure placed the risk is for anyone getting into the cart. She said nursing administration (DON and ADON) were responsible for ensuring the nurse were locking carts when not attended. The DON said the administrative nurses made rounds to ensure the nurses were locking carts. During an interview on 06/18/24 at 04:19 PM the Administrator said her expectation was for the nurses to lock the medication carts when they were not attending the cart. She said the DON and ADON was responsible for ensuring the nurses know to keep carts lock and they complete check offs upon hire and annually or if the facility had issues. The Administrator said the failure placed a risk for residents or anyone passing to be able to get into the cart and get medications out. Record review of the facility Recommended Medication Storage policy revised 07/2012 did not indicate when the facility should be locking medication carts.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #'s 34 and 27) reviewed for hospice services. The facility failed to obtain Resident #34's and Resident #27's most recent updated hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of Resident #34's face sheet dated 06/18/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #34 had diagnoses of psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), intermittent explosive disorder (impulsive, aggressive, violent behavior or angry verbal outburst), recurrent severe major depression (mood disorder that causes persistent sadness and loss of interest), chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure), and anxiety. Record review of Resident #34's comprehensive care plan dated 03/19/24, indicated Resident #34 had a terminal prognosis and/or was receiving hospice services. The care plan interventions indicated if receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #34's quarterly MDS assessment dated [DATE], indicated Resident #34 usually understood others and was able to make himself understood. The MDS assessment indicated Resident #34 had a BIMS score of 07, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #34 received hospice care. Record review of Resident #34's Hospice IDG Comprehensive Assessment and Plan of Care Updated Report dated 05/22/24, indicated Resident #34 had the following orders on his hospice plan of care update that were not on his facility's order summary report: *Abilify 5mg two tablets by mouth at bedtime for psychosis *Vitamin C 500mg one tablet by mouth daily as a supplement *Gabapentin 100mg one capsule twice a day for pain *Santyl 250 unit/Gram apply 1 cm to wound topically one time a day There was not a recent Hospice Plan of Care Update noted in Resident #34's electronic medical record or his hospice binder. Record review of Resident #34's order summary report dated 06/18/24, indicated Resident #34 had the following orders: *Call hospice nurse with any changes or concerns with an order date of 01/02/24. *May admit to [hospice company] with diagnosis of senile degeneration with an order date of 01/02/24. * Gabapentin 100mg two capsules by mouth twice a day for pain with an order start date of 03/07/24. Record review of Resident #34's electronic medical record on 06/18/24, indicated Resident #34's following orders were discontinued: *Abilify 5mg two tablets at bedtime- discontinued on 02/18/24 *Gabapentin 100mg one capsule twice a day- discontinued on 03/07/24 *Vitamin C 500mg one tablet daily- discontinued on 01/12/24 *Santyl 250 unit/gram- discontinued on 03/08/24. 45810 2. Record review of Resident #27's face sheet dated 06/18/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses senile degeneration of the brain (mental deterioration or loss of intellectual ability associated with old age), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depression (mood disorder that causes persistent sadness and loss of interest), and anxiety (a health disorder characterized by feelings of worry or fear that interfere with one's daily activities). Record review of Resident #27's care plan revised on 03/15/24 indicated she was receiving hospice services related to senile degeneration of the brain with interventions to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #27's quarterly MDS dated [DATE] indicated she usually understood others and usually made herself understood. The MDS assessment indicated Resident #27 had a BIMS score of 03, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #27 received hospice care. Record review of Resident #27's Hospice IDG Comprehensive Assessment and Plan of Care Updated Report dated 05/22/24. There was not a recent Hospice Plan of Care Update noted in Resident #27's electronic medical record or her hospice binder. During an interview of 06/18/24 at 09:24 AM, the Hospice DON said they had IDG meetings every 2 weeks and once the meeting was completed, they would print out the IDG meeting for the case manage to take to the facility. The Hospice DON said there should been an updated hospice care plan at the facility for Resident #27 and Resident #34 dated 06/05/24. The Hospice DON said she expected the updated care plan to be at the facility with the medication list reconciled and reflecting what the resident was taking. The hospice DON said when a hospice nurse visit was made, the medications were to be reconciled, so there would not be a discrepancy. The Hospice DON said failure to reconcile the medications could cause a medication error. The Hospice DON said the Hospice Case Manager was responsible for providing the facility the most recent hospice care plan and reconciling the resident's medications. During an attempted telephone interview on 06/18/24 at 09:35 AM, the RN Hospice Case Manager did not answer. During an interview on 06/18/24 at 10:20 AM, the DON said she expected the hospice documents to be up to date all the time. The DON said she was unsure of when the hospice provider had to update them. The DON said she knew that the hospice medications should be on the hospice medication profile but unsure of the other medications the resident was taking. The DON said not having an updated medication list would not affect the resident as the hospice staff does not administer medication, so a medication error was unlikely. The DON said not having the most recent updated hospice plan of care was lack of coordination of care. The DON said the hospice provider was responsible for ensuring the most recent hospice plan of care was brought to the facility. During an interview on 06/18/24 at 10:41 AM, the Administrator said she expected the hospice documents to be updated as needed. The Administrator said she would assume the hospice medication list should match the medications the resident was receiving at the facility and not updating them could cause a medication error. The Administrator said the DON and the Hospice provider were responsible of ensuring the most recent hospice plan of care with the updated medication list was at the facility. The Administrator said failure to have the most recent updated hospice plan of care was lack of coordination of care. Record review of the facility's Nursing Facility Hospice Services Agreement with the hospice company dated 02/15/21, indicated . Review and Revision of Plan of Care. The IDT, in consultation with Nursing Facility representatives and the Nursing Facility Attending Physician, shall review and revise the individualized Plan of Care as frequently as the Resident Patient's condition requires but no less frequently than every fifteen (15) calendar days .Hospice shall provide the Nursing Facility Designee with the following: a copy of the most recent Plan of Care specific to each Resident Patient .Hospice will maintain adequate records of all physician orders communicated in connection with the Plan of Care . Record review of the facilities policy Hospice Services revised 02/13/2007 indicated . The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include .Hospice Plan of Care. Current interdisciplinary notes to include nurse notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period .The plan of care must be revised and updated as necessary to reflect the resident's current status .

Based on interviews and record reviews the facility failed to ensure assessments accurately reflected the resident status for 1 of 15 residents (Resident #34) reviewed for MDS assessment accuracy. The facility failed to ensure Resident #34's anticoagulant (blood thinner) use was accurately coded on his quarterly MDS assessment dated [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #34's face sheet dated 06/18/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #34 had diagnoses of psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), intermittent explosive disorder (impulsive, aggressive, violent behavior or angry verbal outburst), recurrent severe major depression (mood disorder that causes persistent sadness and loss of interest), chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure), and anxiety. Record review of Resident #34's quarterly MDS assessment dated [DATE], indicated Resident #34 usually understood others and was able to make himself understood. The MDS assessment indicated Resident #34 had a BIMS score of 07, which indicated his cognition was severely impaired. The MDS assessment did not indicate Resident #34 had received an anticoagulant medication within the 7-day look back period. Record review of Resident #34's medication administration record dated 04/01/24-04/30/24, indicated Resident #34 had received rivaroxaban (anticoagulant medication used to prevent blood clots) 10mg daily with no documented missed or refused doses. Record review of Resident #34's comprehensive care plan dated 05/02/23, indicated Resident #34 was on anticoagulant therapy. The care plan interventions included to take medication at the same time each day and monitor for signs and symptoms of anticoagulant complications such as blood-tinged urine, sudden severe headache, or bruising. Record review of Resident #34's order summary report dated 06/18/24, indicated Resident #34 had an order for Rivaroxaban 10mg one time a day related to chronic kidney disease with an order start date of 05/02/23. During an interview on 06/18/24 at 09:51 AM, the MDS Coordinator said Resident #34's anticoagulant medication, rivaroxaban, should have been coded on his quarterly MDS assessment as having received it. The MDS Coordinator said failure to code Resident #34's anticoagulant medication would not indicate Resident #34 was at risk for bleeding or skin issues. The MDS Coordinator said she was responsible for ensuring the MDS assessments were accurate. The MDS Coordinator said when coding medications on the MDS assessment she looked at the resident's medication administration record and must have missed it. The MDS Coordinator said she made a mistake of not coding Resident #34's anticoagulant medication. During an interview on 06/18/24 at 10:20 AM, the DON said rivaroxaban was an anticoagulant medication. The DON said if there was a question on the MDS assessment asking if a resident received an anticoagulant medication, then it should have been marked that he received it. The DON said not coding the anticoagulant medication was an in accurate MDS assessment. The DON said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. During an interview on 06/18/24 at 10:41 AM, the Administrator said she expected the MDS assessments to be accurate. The Administrator said if a resident was receiving an anticoagulant medication, then she expected the MDS assessment to be coded that resident received it. The Administrator said not coding the anticoagulant could cause a mistake when completing the resident's care plan. The Administrator said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2023, indicated Coding Instructions . N0415E1. Anticoagulant: Check if an anticoagulant medication was taken by the resident at any time during the 7- day look-back period (or since admission/entry or reentry if less than 7 days).

Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents (Resident #34) reviewed for PASRR. The facility failed to refer Resident #34 for PASRR review following new mental illness diagnosis of severe major depression (mood disorder that causes persistent sadness and loss of interest) on 07/17/23. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #34's face sheet dated 06/18/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #34 had diagnoses of psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), intermittent explosive disorder (impulsive, aggressive, violent behavior or angry verbal outburst), recurrent severe major depression (mood disorder that causes persistent sadness and loss of interest), and anxiety. Resident #34's face sheet indicated the onset of the severe major depression diagnosis was 07/17/23. Record review of Resident #34's PASRR Level 1 screening dated 05/01/23, indicated there was no evidence Resident #34 had a mental illness, intellectual disability, or developmental disability. Record review of Resident #34's comprehensive care plan dated 05/02/23, indicated Resident #34 required antidepressant medication with interventions to give antidepressant medication as ordered and to monitor for signs and symptoms of depression which include sadness, irritability, crying, suicidal ideations and negative mood/comments. Record review of Resident #34's comprehensive care plan dated 07/17/23, indicated Resident had a history of making false accusations. Resident #34 alleged the facility was holding him against his will and holding him hostage and calling 911. The care plan interventions included to review medications with in-house psych services and primary care physician for any medication changes. Record review of Resident #34's comprehensive care plan dated 08/11/23, indicated Resident #34 had a current and past history of having auditory and visual hallucinations, hearing and seeing people and objects that were not there. The care plan interventions included to continue with in-house psychiatric services, adjusting medications as necessary, and to educate the patient and their family about auditory/visual hallucinations, their nature, and strategies to cope with them effectively. The care plan also indicated Resident #34 had a behavior problem related to having a history of calling 911 prior to admission to facility as reported by the sheriff's office to investigate seeing people on his property/inside his house. The care plan interventions included to monitor behavior episodes and attempt to determine underlying cause. Record review of Resident #34's psychiatric progress note dated 01/03/24, indicated Resident #34 had diagnoses of Major Depressive Disorder, recurrent episode, severe and Intermittent Explosive Disorder. Record review of Resident #34's quarterly MDS assessment dated [DATE], indicated Resident #34 usually understood others and was able to make himself understood. The MDS assessment indicated Resident #34 had a BIMS score of 07, which indicated his cognition was severely impaired. The MDS assessment indicated resident had little interest or pleasure in doing things and feeling down, depressed, or hopeless 2-6 days out of the 2-week look back period. The MDS assessment indicated Resident #34 had no behaviors and sometimes felt lonely or isolated from others. The MDS assessment indicated Resident #34 had anxiety, depression, psychotic disorder, and intermittent explosive disorder as active diagnoses. Record review of Resident #34's order summary report dated 06/18/24, indicated Resident #34 had the following orders being given for major depression: *Lexapro 5mg one tablet at bedtime with an order start date of 07/17/23. *Mirtazapine 15mg one tablet at bedtime with an order start date of 05/01/23. Record review of Resident #34's medication administration record dated 06/01/24-06/30/24, indicated Resident #34 received Lexapro 5mg and mirtazapine 15 mg daily at bedtime. During an interview on 06/18/24 at 09:51 AM, the MDS Coordinator said major depression constituted a mental illness and a Form 1012 (a form used to determine if a previously negative PASRR level 1 form needs to be changed to a positive PASRR level 1 for Mental Illness) should have been completed on Resident #34 when he was diagnosed with major depression. The MDS Coordinator said in October 2023, corporate sent a list of all residents that needed to be looked at to ensure all proper documentation was completed for residents that were considered PASRR positive. The MDS Coordinator said Resident #34 was not on that list. The MDS Coordinator said Resident #34 was missed. The MDS Coordinator said failure to complete a form 1012 on Resident #34 resulted in him not receiving the proper evaluation from PASRR services or receiving additional services. The MDS Coordinator said she was responsible for ensuring all PASRR level 1 were completed and completing the Form 1012 when a resident had a new mental illness. During an interview on 06/18/24 at 10:20 AM, the DON said Major Depression was a mood disorder and fell under the category of mental illness. The DON said the MDS Coordinator was responsible for ensuring the PASRRs were updated. The DON said failure to complete a positive PASRR for Resident #34 could have resulted in missed PASRR services. During an interview on 06/18/24 at 10:41 AM, the Administrator said Resident #34 had long-term issues with mental illness that they were not aware of when he admitted to the facility. The Administrator said after Resident #34 admitted , he started randomly calling the police and they referred him to psychiatric services. The Administrator said after speaking with Resident #34's family regarding his behaviors, they were notified of Resident #34 mental illness and requiring treatment. The Administrator said she was unsure if a positive PASRR had to be completed and not completing one he could have missed some of the psychiatric services. The Administrator said the MDS Coordinator was responsible for updating the PASRRs. Record review of the facility's policy PASRR PCSP/IDT Policy and Procedure revised 03/06/2019, did not address updating the PASRR level one after a new mental illness diagnosis.

Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 3 of 15 residents (Resident's #6, #7, and #16) reviewed for accuracy of medical records. 1. The facility did not ensure Resident #16's OOH-DNR was signed at the bottom by the witnesses. 2. The facility did not ensure Resident #6's signed her OOH-DNR. 3. The facility failed to ensure Resident #7's OOH-DNR had a license number, printed name, and date for the physician's statement. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: 1. Record review of Resident #16's face sheet, dated [DATE], revealed Resident #16 was an [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses of paroxysmal atrial fibrillation (when your heartbeat returns to normal within 7 days, on its own or with treatment) and unspecified dementia without behavioral disturbance (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life). Record review of the MDS assessment, dated [DATE], revealed Resident #16 had clear speech and was understood by staff. The MDS revealed Resident #16 was able to understand others. The MDS revealed Resident #16 had a BIMS score of 12, which indicated moderately impaired cognition. Record review of the comprehensive care plan, revised on [DATE], revealed Resident #16 had an order for DNR. Record review of the order summary report, dated [DATE], revealed Resident #16 had an order, which started on [DATE], for DNR. Record review of the OOH-DNR form, dated [DATE] revealed it was missing witness signature 1 and missing witness signature 2 at the bottom of the form. During an interview on [DATE] at 3:39 PM, the DON stated she initiated the DNR and was responsible for ensuring it was completed. The DON stated she was unaware Resident #16's DNR was missing witness signatures. The DON stated the facility had been without a social worker for the past 3 months and nursing was assisting with the completion of the DNR process. The DON stated it was overlooked during her routine audit process. The DON stated it was important that all DNRs be accurately documented and completed to ensure the resident's and family's wishes were honored. The DON stated not ensuring a DNR was completed could result in interventions not wished upon by the resident or family. During an interview on [DATE] at 4:41 PM, the Administrator stated DNRs should have been filled out completely. The Administrator stated she expected whoever was initiating the DNR to ensure it was filled out. The Administrator stated it was important to ensure DNRs were filled out for accuracy and to abide by residents wishes. 2. Record review of Resident #6's order summary report, dated [DATE], indicated Resident #6 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus (high blood sugar), and essential hypertension (high blood pressure). Further review of the order summary report, dated [DATE], indicated an active physician's order for code status: DNR with an order date [DATE]. Record review of the annual MDS dated [DATE], indicated Resident #6 understood others and made herself understood. The assessment indicated Resident #6 was cognitively intact with a BIMS score of 14. Record review of Resident #6's care plan, with an initiated date of [DATE], indicated Resident #6 had an order for DNR. The care plan interventions included all aspects of DNR will be explained to Resident #6 or responsible party, and in absence of blood pressure, pulse, respiration, CPR will not be initiated. Record review of the OOH-DNR form dated [DATE] revealed a missing signature by Resident #6. During an interview on [DATE] at 10:12 a.m., the DON stated she initiated the DNR and was responsible for ensuring it was completed. The DON stated she was unaware prior to surveyor intervention Resident #6's DNR was missing her signature. The DON stated the facility had been without a social worker for the past 3 months and nursing was assisting with the completion of the DNR process. The DON stated monthly audits were completed looking for accuracy of OOH DNR paperwork. The DON stated it was overlooked during her routine process. The DON stated it was important that all DNRs be accurately documented and completed to ensure the resident's and family's wishes were honored. The DON stated not ensuring a DNR was completed could result in interventions not wished upon by the resident or family. During an interview on [DATE] at 2:06 p.m., the Administrator stated she expected Resident #6 DNR to be completed. The Administrator stated the DON was responsible for ensuring Resident #6's DNR was accurately and documented since the facility has not had a social worker in the past several months. The Administrator stated due to open positions the facility had to divide duties amongst the department heads. The Administrator stated a potential negative outcome of an invalid DNR would be her wishes not being respected. 3. Record review of Resident #7's face sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential primary hypertension (high blood pressure), and atrial fibrillation (rapid, irregular heart rate). Record review of the Comprehensive MDS assessment dated [DATE] revealed, Resident #7 made self-understood and understood others. Resident #7's BIMS score was 9, which indicated her cognition was moderately impaired. Record review of Resident #7's care plan last revised [DATE] revealed, resident had an order for DNR (Do Not Resuscitate). Record review of the order summary report dated [DATE] revealed, Resident #7 had a physician's order for DNR (Do Not Resuscitate) with an order date of [DATE]. Record review of Resident #7's OOH-DNR revealed under the section for the physician's statement there was no date for the physician signature and no license number and no printed name for the physician. During an interview on [DATE] at 2:00 PM, the DON stated the social worker was responsible for making sure all the blanks on the DNR were filled out, but she had been overseeing the DNRs because the current Social Worker was new to her position. The DON stated she was doing audits on the DNR to ensure they were filled out completely. The DON stated for Resident #7 she must have missed auditing the DNR and that was why there were blanks not filled out. The DON stated it was important the DNRs were filled out completely so the residents code status would be honored. During an interview on [DATE] at 3:35 PM, the Administrator stated traditionally the social worker or whoever initiated the DNR should make sure it was complete. The Administrator stated due to the Social Worker being new to her position the DON was currently the one responsible for making sure the DNRs were completed correctly. The Administrator stated the DNR not being filled out correctly and leaving blanks could make the DNR invalid. Record review of the facility's policy titled, Do Not Resuscitate Order, last revised [DATE], revealed . All validly executed DNR orders will be honored by the facility. Social services will assist all interested family members and residents will information, education, and execution of the DNR form. For completion of the form, see attached instructions for out of hospital DNR from the TAHC .

Based on interviews and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 4 of 15 residents (Resident's #297, #147, #4, and #7) reviewed for comprehensive assessment and timing. 1. The facility did not ensure Resident #297's Admission MDS assessment was completed within 14 days of admission. 2. The facility failed to complete Resident #147's Admission MDS assessment with 14 days of admission. 3. The facility failed to complete an Admission MDS assessment after Resident #4 was discharged returned not anticipated and readmitted to the facility. 4. The facility failed to complete Resident #7's Admission MDS assessment within 14 days of admission. These failures could place residents at risk of not having their needs identified and met. Findings included: 1. Record review of Resident #297's order summary report, dated 04/18/2023, indicated Resident #297 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis included type 2 diabetes with hyperglycemia (high blood sugar), bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), and Parkinson's (brain disorder that causes unintended or uncontrollable movements). Record review of Resident #297's electronic medical records indicated the admission MDS assessment was in process, meaning it had not been electronically transmitted to CMS. During an interview on 04/18/2023 at 10:52 a.m., the MDS Coordinator stated she was responsible for completing all the MDS assessments. The MDS Coordinator stated all data for the admission MDS assessment should be collected by day 14, and the admission MDS assessment should be completed within 14 days of admission. The MDS Coordinator stated Resident #297's admission MDS should have been completed by 04/11/2023. The MDS Coordinator stated she tried to complete the MDS assessments by day 14 but stated it was not always possible. The MDS Coordinator stated she was aware that Resident #297's admission MDS had not been completed. The MDS Coordinator stated the importance of ensuring MDS assessments were completed timely was to ensure residents care were articulated and they were given the proper care based on their assessments. During an interview on 04/18/2023 at 11:20 a.m., the Regional Reimbursement Nurse stated the admission MDS assessment should be completed within 14 days of admission. The Regional Reimbursement Nurse stated Resident #297's admission MDS should have been completed by 04/11/2023. The Regional Reimbursement Nurse stated she was responsible for monitoring the MDS Coordinator to ensure the assessments were completed timely. The Regional Reimbursement Nurse stated she monitored to ensure timely completion by reviewing the in progress and the schedule list in PCC (healthcare software provider) weekly. The Regional Reimbursement Nurse stated if there were late assessments the MDS nurse was advised to complete in a timely manner. The Regional Reimbursement Nurse stated she was unaware the MDS assessment was not completed. The Regional Reimbursement Nurse stated the importance of ensuring MDS assessments were completed timely was to set the care plans and to ensure the baseline care was carried out for the resident. The Regional Reimbursement Nurse stated the facility had a system in place to assure assessments are conducted in accordance with the specified timeframes for each resident by following the RAI manual. During an interview on 04/18/2023 at 2:06 p.m., the Administrator stated she expected all MDS assessments to be completed on time. The Administrator stated the MDS Coordinator was responsible for making sure the MDS assessments were completed on time. The Administrator stated the Regional Reimbursement Nurse was responsible for monitoring the MDS Coordinator to ensure the assessments were completed timely. The Administrator stated it was important to complete the MDS assessments on time because it could affect the resident's quality of care. 2. Record review of Resident #147's face sheet dated 4/16/23 revealed she was a [AGE] year-old, female, and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disruption of blood flow to the brain and parts of the brain to die off, also known as a stroke), hemiplegia and hemiparesis (weakness or inability to move one side of the body), diabetes (disease too much sugar in the blood), and hypertension (high blood pressure). Record review of Resident #147's admission MDS dated [DATE] revealed the MDS Coordinator verified the assessment was completed and signed 4/14/23. The MDS Coordinator signed it on 4/15/23 indicating sections A, B, E, G, GG, H, I, J, K, L, M, N, O, P, and Q were completed. The MDS Coordinator completed section V (Care Area Assessment Summary) and signed it on 4/16/23. The MDS assessment should have been completed on 4/14/23. The MDS assessment was 2 days late. During an interview on 4/18/23 at 9:02 AM the MDS Coordinator said she had been the MDS Coordinator at the facility for a year. The MDS Coordinator said the MDS should be completed within 14 days of the ARD. The MDS Coordinator said she probably changed Resident #147's completion date because it was due on 4/14/23 and she had completed it late. The MDS Coordinator said she was behind on the MDS's, and she knew there were some late MDS's. The MDS Coordinator said the Regional MDS Coordinator, and the Administrator had done an in-service with her last week on completing the MDS's within the required timelines per the RAI Manual. The MDS Coordinator said if the MDS assessment was not completed timely, it would not show an accurate assessment of the resident and the facility could miss out on revenue. During an interview on 4/18/23 at 11:31 AM the Administrator said she would expect the MDS assessments to be completed timely. The Administrator said when the MDS assessment was not completed timely, it would not show an accurate assessment of the resident and it affects the facility financially. 3. Record review of Resident #4's face sheet, dated 04/18/2023, revealed an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included heart failure (the heart muscle does not pump blood as well as it should to meet the body's needs for blood and oxygen), localized edema (fluid trapped in the body's tissues), and chronic kidney disease, stage 3 (kidneys have mild to moderate damage and they are less able to filter waste and fluid out of the blood). Record review of Resident #4's MDS assessments in the electronic health record revealed a Discharge assessment, discharge return not anticipated, with an ARD of 01/12/2023, followed by an entry tracking record with an ARD of 01/16/2023, followed by a Quarterly assessment with an ARD of 03/31/2023. Resident #4 had no Admission assessment. 4. Record review of Resident #7's face sheet, dated 04/18/2023, revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential primary hypertension (high blood pressure), and atrial fibrillation (rapid, irregular heart rate). Record review of Resident #7's comprehensive MDS assessment with an ARD of 03/04/2023 indicated in Section A0310 it was an Admission assessment (required by day 14). The MDS assessment for Resident #7 indicated in Section A1600 an entry date of 02/19/2023. The MDS assessment in Section Z0500B was signed completed on 03/06/2023, indicating the MDS assessment for Resident #7 was completed 1 day late. During an interview on 4/18/2023 at 9:31 AM, the MDS Coordinator stated she was responsible for completing all the MDS assessments. The MDS Coordinator stated an Admission assessment should be completed within 14 days of admission. The MDS Coordinator stated she had not completed Resident #7's Admission assessment within 14 days because she was behind and was trying to catch up. The MDS Coordinator stated if a resident discharged return not anticipated she was supposed to complete an Admission assessment when the resident readmitted to the facility. The MDS Coordinator stated she had done a Quarterly assessment for Resident #4 because she had not realized she discharged him return not anticipated. The MDS Coordinator said, I do not know how I missed that. The MDS Coordinator stated the Regional MDS Nurse monitored her completion of the MDS assessments. The MDS Coordinator stated the Regional MDS Nurse was aware she had completed the admission assessments late, and she had been in-serviced last week on timely completion of the MDS assessments. The MDS Coordinator stated not completing the admission assessment and not completing it timely could result in incorrect documentation, loss of revenue for the residents to have their needs met, and the residents care would not be specific to them. During an attempted phone interview on 04/18/2023 at 3:19 PM, the Regional MDS Nurse did not answer the phone. During an interview on 4/18/2023 at 3:31 PM, the Administrator stated the MDS Coordinator was responsible for completing all the MDS assessments. The Administrator stated the Regional MDS Nurse monitored the MDS Coordinator. The Administrator stated she expected the MDS Coordinator to complete all MDS assessments according to the RAI manual. The Administrator stated not completing the admission assessment and not completing it timely could affect the information the facility staff have to form the plan of care for the residents. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 updated October 2019 indicated, .Completion of an OBRA Admission assessment must occur in any of the following admission situations . when the resident has been in this facility previously and was discharged return not anticipated .For the Admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). 46062 46892

Based on interview and record review, the facility failed to implement policies and procedures to prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. 1. CNA F failed to report when she found Resident #1, who was unable to express if she was in pain and was totally dependent on staff for her ADLs, with dark purple bruising to her right arm and shoulder on 12/25/15. 2. CNAs K, L, J, H, and G failed to report Resident #1's bruising to the charge nurse. 3. RN D failed to assess, document, and notify the physician on 12/26/15 when the RN was notified Resident #1 had large dark purple bruising to her right arm and shoulder. RN D also failed to assess Resident #1 for pain due to the bruising after she was notified the resident flinched when the bruised area was touched. Resident #1 had an x-ray on 12/29/15 of the right shoulder that reflected an acute humeral neck fracture, with mild displacement and was transported to the hospital for further evaluation on 12/29/15. These failures could affect all 45 residents for delayed assessment, delayed treatment and unrelieved pain. Findings included: Review of Resident #1's face sheet with no date reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 was severely impaired in daily decision making and severely impaired in cognition. Resident #1 was totally dependent on staff for ADLS. Resident #1 was rarely understood and had short term and long term memory problems. Review of Resident #1's Weekly Skin assessment dated [DATE] completed by LVN B reflected no skin problems on Resident #1's upper arm/shoulder. Review of Resident #1's Nurse's Note dated 12/29/15 written by the DON reflected at 2:00 PM a discoloration was noted to the resident ' s right shoulder upper arm area. The physician and family were notified and an x-ray was ordered. Review of Nurse's Notes from 12/25/2015 through 12/29/2015 reflected no other notes on Resident #1's bruise. Review of Resident #1's X-ray for the Right Shoulder dated 12/29/15 reflected acute humeral neck fracture, with mild displacement. Further review of Resident #1's Nurse's Note dated 12/29/15 reflected at 6:00 PM the doctor was notified of the results of the x-ray and gave orders to send Resident #1 to the hospital and at 6:25 PM Resident #1 was sent out via ambulance to the local hospital. At 10:30 PM, Resident #1 returned from the local hospital with new ordered pain medications and sling to right arm in place. Review of Resident #1's hospital x-ray of her Humerus (bone of the upper arm) Right Exam dated 12/29/15 at 10:27 PM reflected a mildly displaced [MEDICAL CONDITION] humeral neck with medial (pertaining to the middle) and superior displacement of the humeral shaft. Review of Resident #1's December 2015 MAR and TAR reflected no pain medication was given to Resident #1 until 12/29/15 at 3:00 PM when Resident #1 was given Tylenol 325 mg by peg tube. On 12/30/15 and 12/31/15 Resident #1 was given Tylenol #3 12.5 ml to 25 mls via peg tube every 6 hours prn. Review of Incident/Accident Report dated 12/29/15 at 2:00 PM reflected LVN B reported to the DON Resident #1 had an observed discoloration to right shoulder/upper arm. Resident #1 was alert to self at times. Resident #1 had a [MEDICAL CONDITION] shoulder. Family notified at 2:00 PM and Physician notified at 2:00 PM. In an interview on 01/21/16 at 2:29 PM, LVN B, Charge Nurse, stated between 11:00 AM and 1:00 PM on 12/29/15 she changed Resident #1 ' s gown and saw the bruising discoloration to Resident #1's upper arm and right shoulder. LVN B stated she immediately told the DON to have her look at it and assess the bruising. Review of CNA F's Witness Statement undated reflected on 12/25/15 she went in to do a bed change and noticed Resident #1's upper right arm was bruised. CNA F reported Resident #1 wore a gown with no sleeves and the bruise was clearly visible and she did not notify the nurse. In an interview on 01/21/16 at 2:35 PM, CNA F stated when she went to change Resident #1's bedding on 12/25/15 on the 2 PM - 10 PM shift she noticed a bruise on Resident #1's upper arm but the resident did not show any signs of pain. CNA F stated she did not notify the Charge Nurse and assumed since she was NPO the nurse had already noticed it. CNA F stated the bruise was about the same on 12/28/15 when she came back from being off for two days and she still did not notify the Charge Nurse. In an interview on 01/21/16 at 4:10 PM, CNA I stated she did not notice Resident #1's bruising on her upper right arm on her 6:00 AM - 2:00 PM shift on 12/26/15. CNA I stated Resident #1 seemed like she was in pain by her facial expression of grimacing and was uncomfortable when she was repositioned. CNA I stated she informed RN D and was told she gets that way sometimes. CNA I stated the RN D did not go look at Resident #1 to assess her pain level. CNA I stated she did not notify the ADON or the DON and stated they were hard to get hold of sometimes. CNA I stated she was in-serviced about reporting bruises on 12/29/2015 but was not in-serviced about pain management. In an interview on 01/21/16 at 2:49 PM, CNA K stated she provided care to Resident #1 with LVN A on 12/26/2015 when she noticed a bruise on her upper right arm. She stated she did not report it to Resident #1's charge nurse since LVN A stated she would inform RN D. CNA K stated Resident #1 did not show any signs of being in pain and was a bedbound resident except for showering. CNA K stated she had no idea how Resident #1 got the bruise. Review of LVN A's Witness Statement dated 12/31/15 reflected she was assisting CNA K on changing Resident #1 when she noticed a large bruise on the resident ' s right shoulder dark purple in color that went under and down her right arm. LVN A notified RN D of Resident #1's bruise on her right upper arm/shoulder and that Resident #1 flinched when it was touched. LVN A stated RN D researched Resident #1's clinical record found no documentation on it. LVN Walker wrote RN D said she was not going to address it Resident #1 ' s bruising because she was not told about it report and it was not documented. In an interview on 01/21/16 at 12:35 PM, LVN A stated she noticed Resident #1 had dark purple bruising on her right upper arm when she was assisting CNA K with care on 12/26/2015. LVN A stated she informed Resident #1's nurse, RN D, of the bruising. LVN A said she told RN D that she noticed Resident #1 had bruising on her right upper arm and shoulder about 3-4 inches and Resident #1 had flinched when the LVN touched her bruise. LVN A stated RN D looked through the resident's clinical record to see if anything had been documented about the bruising since she was not aware of it. LVN A revealed RN D said nothing was documented. LVN A stated RN D said I am not going to clean up after another someone else's mess, and she was not going to write an incident report. LVN A told RN D she needed to go look at it but RN D snapped at her Are you trying to tell me what to do? LVN A stated she had been taught to go up the chain of command to go to RN D and assumed she would report it her supervisor. LVN A stated she did not know she should have gone to the DON or the Administrator. LVN A stated she went to assist other residents and steered clear of RN D because she did not want to get snapped at again. LVN A stated she did not check on the resident again. LVN A stated RN D did not bring up Resident #1 ' s bruising to the next shift's nurse and LVN A had forgotten to say anything. LVN A stated she was suspended pending investigation and was written up for failure to notify the DON or the Administrator. LVN A stated she had been inserviced on 12/29/2015 for reporting bruises to DON or Administrator, completing incident/accident reports, and for pain management. Review of RN D's undated Witness Statement reflected she provided Resident #1 with a nebulizer treatment, tube feedings, and medications per feeding tube on 12/26/15 and 12/27/15. RN D's statement reflected no one reported Resident #1 had an injury or pain to her. RN D was the RN Weekend Supervisor. The surveyor attempted to contact RN D on 01/21/16 at 2:19 PM, 3:14 PM, and 4:47 PM but was unable to reach her. In an interview on 01/21/16 at 11:38 AM, MA E stated she overheard LVN A tell RN D that Resident #1 had bruising on her upper arm on 12/26/15 during the second shift. MA E stated she saw RN D going through Resident #1's clinical record. She revealed RN D said there was no documentation regarding a bruise on Resident #1 ' s right shoulder and I am not going to clean up after the other nurses and not going to write an incident statement. Review of CNA L's Witness Statement dated 12/29/15 reflected on the 10:00 PM - 6:00 AM shift on 12/27/15 she was changing Resident #1 and saw a bruise on her right upper arm. CNA L stated she was going to report it to the Charge Nurse but got side tracked. Surveyor attempted to contact CNA L on 01/21/16 at 12:00 PM, 3:10 PM, and 4:25 PM but was not able to reach her. In an interview on 01/21/16 at 2:38 PM, CNA J stated she noticed on 12/28/15 during the second shift when she gave a shower to Resident #1 a purple/yellow bruise on her upper arm but she did not notify the Charge Nurse because she assumed the nurse already knew about it since it was purple/yellow. CNA J could not recall how large the bruise was. In an interview on 01/21/16 at 11:28 AM, CNA H stated when she weighed Resident #1 on 12/29/15 she noticed Resident #1 had bruising on the right upper arm. CNA H stated she had a miscommunication with the other aide who assisted with weighing Resident #1 and thought the other aide told the Charge Nurse. CNA H stated she should have told the Charge Nurse immediately after Resident #1 was weighed. In an interview on 01/21/16 at 3:32 PM, CNA G stated she assisted weighing Resident #1 on 12/29/15 before or after lunch when she noticed the bruising on her upper arm and shoulder. CNA G stated Resident #1 did flinch when rolled to get hoyer lift pad under her but stated that was normal for her. CNA G stated she did not notify the Charge Nurse and thought the other aide had. CNA G stated she should have gone with the other aide to tell the Charge Nurse immediately. CNA G stated she did not seem to be in pain. CNA G stated prior to the inservice on skin assessments on 12/29/2015 she was told to do the body observation forms on residents only when giving a resident a shower or bath. CNA G stated now she was told to do body observation forms any time skin issues are observed and turn it into the charge nurse. In an Interview on 01/21/2016 at 10:28 AM LVN C stated she did not notice any bruising on Resident #1 on her 6 AM - 2 PM shift on 12/25/2015 when she provided care to Resident #1. LVN C stated Resident #1 did not show any signs of pain but if she did it would be facial grimacing and moaning out. In an interview on 01/21/16 at 2:12 PM, ADON stated she was not notified of Resident #1's bruising until the DON asked her to look at it on 12/29/15. The ADON stated Resident #1 could not voice she was in pain. In an interview on 01/21/16 at 3:35 PM, the DON stated LVN B came and got her out of a meeting on 12/29/15 for her to look at Resident #1's bruise. The DON stated Resident #1's bruise was a bluish/yellowish discoloration to right upper arm and the right shoulder appeared to be swollen much larger than left arm. The DON stated she worked 10:00 PM - 6:00 AM shift the night of 12/26/15 and did not see the right shoulder because it was covered by a towel. The DON revealed she was not aware of Resident #1's bruise until 12/29/15. The DON stated the doctor was notified, the family was notified, and x-rays were ordered for the shoulder on 12/29/15. The DON said Resident #1 was sent to the local hospital for an orthopedic consult due to an acute fracture. The DON stated no documentation of Resident #1's bruising was found prior to when it was reported to her by LVN B. The DON said the CNAs should have immediately notified the nurse when Resident #1's bruising to her upper arm/shoulder was noticed. The DON stated RN D was the RN weekend supervisor but the nurses or the CNAs could have contacted her about Resident #1's bruising to the upper arm/shoulder. The DON stated Resident #1 went to another nursing facility after her hospitalization . The DON stated her and the ADON did assessments on all residents, but did not have any documentation of the assessments. Review of Resident #1's Nurse's Note dated 01/02/16 reflected Resident #1 was discharged to the hospital unrelated to the fracture. In an interview on 01/21/16 at 2:53 PM, the Administrator stated she was not aware of Resident #1's bruising to her upper arm/shoulder until 12/29/15 when she was informed by the DON. The Administrator stated during the investigation she found RN D was told about the bruising by LVN A when she interviewed LVN A and MA E. The Administrator revealed in-services were conducted for reporting all incidents/accidents to the DON or Administrator. The Administrator stated during the investigation she found facility staff were aware of Resident #1's bruising to upper arm/shoulder but failed to report it to the nurse or DON. Review of Pain Management In-Services dated 12/29/15 reflected only nurses were in-serviced on pain management and assessment. Review of In-services on 12/29/2015 for Incident/Accident Reporting, Reportable Events, Change of Condition, Skin Integrity, and Body Observation Forms reflected CNA H was not in-serviced. Review of In-services reflected new CNA hires and new nursing hires since 12/29/2015 were not in-serviced on pain management, Skin Integrity, and Body Observation Forms. Review of Employee's Notice of Disciplinary Actions dated 01/10/15 of written notice for CNA F's failure to report on 12/25/2015 of Resident #1's bruise on upper arm, CNA I's failure to report on 12/26/2015, CNA L's failure to report on 12/27/2015, CNA J's failure to report on 12/28/2015, CNA G's failure to report on 12/29/2015, and CNA H ' s failure to report on 12/29/2015. CNA Ks Notice of Disciplinary Action was dated 01/12/2016 for failure to report to Resident #1's charge nurse of the bruise. Review of RN D's Disciplinary Action dated 12/31/15 reflected two employees claim to have notified RN of resident in pain and a bruise to resident ' s right arm/shoulder on 12/26/15 and RN D failed to treat, document, or assess resident. Employee denies any knowledge of this incident. RN D was suspended pending investigation. RN D was terminated on 01/04/2016 by the facility for failure to assess Resident #1's pain on 12/26/2015 and her failure to report, document, assess Resident #1's bruise on 12/26/2015. Interviews with Two of Two Interviewable Residents revealed no concerns with pain mangement and staff were attentive to their needs. Review of Three of Three Residents (Resident #3, #4, and #5) who are able to verbalize pain reflected no concerns in pain management or skin assessments. Review of facility's policy Accidents and Injuries dated 08/28/15 reflected incident reports are required for any unusual event including bruises. The physician and family must be notified and this will be documented. Nurse ' s notes will contain factual information of the incident and will reflect a good assessment. There should be a follow-up period of at least 72 hours. If abuse or neglect is even suspected the Administrator and DON will be immediately notified. Review of facility's policy Pain Management revised November 2013 reflected residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident ' s quality of life. Procedure 1. Each resident ' s pain will be assessed using the Comprehensive Pain Assessment upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .3. recognizes that a resident ' s response to pain is subjective and individual. 4. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. 5 .will treat the resident under the premise that pain is present whenever the resident says it is .7. The resident's pain will be evaluated routinely each shift. Documentation will be done on the clinical software MAR/TAR. 8. Residents will be re-assessed 30-60 minutes after pain management interventions to determine the effectiveness of the intervention. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident ' s quality of life including complications. 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual 's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. The policy reflected to consider the resident's description and your observations of the resident's physical and behavioral responses when assessing pain. Review of facility's policy Abuse revised May 2014 reflected the facility was to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a residents physical or mental health or welfare has been or may be adversely effected by abuse or neglect caused by another person. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The CMS 672 reflected a census of 45 residents.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. 1. CNA F failed to report when she found Resident #1, who was unable to express if she was in pain and was totally dependent on staff for her ADLs, with dark purple bruising to her right arm and shoulder on 12/25/15. 2. CNAs K, L, J, H, and G failed to report Resident #1's bruising to the charge nurse. 3. RN D failed to assess, document, and notify the physician on 12/26/15 when the RN was notified Resident #1 had large dark purple bruising to her right arm and shoulder. RN D also failed to assess Resident #1 for pain due to the bruising after she was notified the resident flinched when the bruised area was touched. Resident #1 had an x-ray on 12/29/15 of the right shoulder that reflected an acute humeral neck fracture, with mild displacement and was transported to the hospital for further evaluation on 12/29/15. These failures could affect all 45 residents who werat risk for delayed assessment, delayed treatment and unrelieved pain. Findings included: Review of facility's policy Accidents and Injuries dated 08/28/15 reflected incident reports are required for any unusual event including bruises. The physician and family must be notified and this will be documented. Nurse ' s notes will contain factual information of the incident and will reflect a good assessment. There should be a follow-up period of at least 72 hours. If abuse or neglect is even suspected the Administrator and DON will be immediately notified. Review of facility's policy Pain Management revised November 2013 reflected residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident ' s quality of life. Procedure 1. Each resident ' s pain will be assessed using the Comprehensive Pain Assessment upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .3. recognizes that a resident ' s response to pain is subjective and individual. 4. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. 5 .will treat the resident under the premise that pain is present whenever the resident says it is .7. The resident's pain will be evaluated routinely each shift. Documentation will be done on the clinical software MAR/TAR. 8. Residents will be re-assessed 30-60 minutes after pain management interventions to determine the effectiveness of the intervention. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident ' s quality of life including complications. 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual 's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. The policy reflected to consider the resident's description and your observations of the resident's physical and behavioral responses when assessing pain. Review of facility's policy Abuse revised May 2014 reflected the facility was to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a residents physical or mental health or welfare has been or may be adversely effected by abuse or neglect caused by another person. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident #1's face sheet with no date reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 was severely impaired in daily decision making and severely impaired in cognition. Resident #1 was totally dependent on staff for ADLS. Resident #1 was rarely understood and had short term and long term memory problems. Review of Resident #1's Weekly Skin assessment dated [DATE] completed by LVN B reflected no skin problems on Resident #1's upper arm/shoulder. Review of Resident #1's Nurse's Note dated 12/29/15 written by the DON reflected at 2:00 PM a discoloration was noted to the resident ' s right shoulder upper arm area. The physician and family were notified and an x-ray was ordered. Review of Nurse's Notes from 12/25/2015 through 12/29/2015 reflected no other notes on Resident #1's bruise. Review of Resident #1's X-ray for the Right Shoulder dated 12/29/15 reflected acute humeral neck fracture, with mild displacement. Further review of Resident #1's Nurse's Note dated 12/29/15 reflected at 6:00 PM the doctor was notified of the results of the x-ray and gave orders to send Resident #1 to the hospital and at 6:25 PM Resident #1 was sent out via ambulance to the local hospital. At 10:30 PM, Resident #1 returned from the local hospital with new ordered pain medications and sling to right arm in place. Review of Resident #1's hospital x-ray of her Humerus (bone of the upper arm) Right Exam dated 12/29/15 at 10:27 PM reflected a mildly displaced [MEDICAL CONDITION] humeral neck with medial (pertaining to the middle) and superior displacement of the humeral shaft. Review of Resident #1's December 2015 MAR and TAR reflected no pain medication was given to Resident #1 until 12/29/15 at 3:00 PM when Resident #1 was given Tylenol 325 mg by peg tube. On 12/30/15 and 12/31/15 Resident #1 was given Tylenol #3 12.5 ml to 25 mls via peg tube every 6 hours prn. Review of Incident/Accident Report dated 12/29/15 at 2:00 PM reflected LVN B reported to the DON Resident #1 had an observed discoloration to right shoulder/upper arm. Resident #1 was alert to self at times. Resident #1 had a [MEDICAL CONDITION] shoulder. Family notified at 2:00 PM and Physician notified at 2:00 PM. In an interview on 01/21/16 at 2:29 PM, LVN B, Charge Nurse, stated between 11:00 AM and 1:00 PM on 12/29/15 she changed Resident #1 ' s gown and saw the bruising discoloration to Resident #1's upper arm and right shoulder. LVN B stated she immediately told the DON to have her look at it and assess the bruising. Review of CNA F's Witness Statement undated reflected on 12/25/15 she went in to do a bed change and noticed Resident #1's upper right arm was bruised. CNA F reported Resident #1 wore a gown with no sleeves and the bruise was clearly visible and she did not notify the nurse. In an interview on 01/21/16 at 2:35 PM, CNA F stated when she went to change Resident #1's bedding on 12/25/15 on the 2 PM - 10 PM shift she noticed a bruise on Resident #1's upper arm but the resident did not show any signs of pain. CNA F stated she did not notify the Charge Nurse and assumed since she was NPO the nurse had already noticed it. CNA F stated the bruise was about the same on 12/28/15 when she came back from being off for two days and she still did not notify the Charge Nurse. In an interview on 01/21/16 at 4:10 PM, CNA I stated she did not notice Resident #1's bruising on her upper right arm on her 6:00 AM - 2:00 PM shift on 12/26/15. CNA I stated Resident #1 seemed like she was in pain by her facial expression of grimacing and was uncomfortable when she was repositioned. CNA I stated she informed RN D and was told she gets that way sometimes. CNA I stated the RN D did not go look at Resident #1 to assess her pain level. CNA I stated she did not notify the ADON or the DON and stated they were hard to get hold of sometimes. CNA I stated she was in-serviced about reporting bruises on 12/29/2015 but was not in-serviced about pain management. In an interview on 01/21/16 at 2:49 PM, CNA K stated she provided care to Resident #1 with LVN A on 12/26/2015 when she noticed a bruise on her upper right arm. She stated she did not report it to Resident #1's charge nurse since LVN A stated she would inform RN D. CNA K stated Resident #1 did not show any signs of being in pain and was a bedbound resident except for showering. CNA K stated she had no idea how Resident #1 got the bruise. Review of LVN A's Witness Statement dated 12/31/15 reflected she was assisting CNA K on changing Resident #1 when she noticed a large bruise on the resident ' s right shoulder dark purple in color that went under and down her right arm. LVN A notified RN D of Resident #1's bruise on her right upper arm/shoulder and that Resident #1 flinched when it was touched. LVN A stated RN D researched Resident #1's clinical record found no documentation on it. LVN Walker wrote RN D said she was not going to address it Resident #1 ' s bruising because she was not told about it report and it was not documented. In an interview on 01/21/16 at 12:35 PM, LVN A stated she noticed Resident #1 had dark purple bruising on her right upper arm when she was assisting CNA K with care on 12/26/2015. LVN A stated she informed Resident #1's nurse, RN D, of the bruising. LVN A said she told RN D that she noticed Resident #1 had bruising on her right upper arm and shoulder about 3-4 inches and Resident #1 had flinched when the LVN touched her bruise. LVN A stated RN D looked through the resident's clinical record to see if anything had been documented about the bruising since she was not aware of it. LVN A revealed RN D said nothing was documented. LVN A stated RN D said I am not going to clean up after another someone else's mess, and she was not going to write an incident report. LVN A told RN D she needed to go look at it but RN D snapped at her Are you trying to tell me what to do? LVN A stated she had been taught to go up the chain of command to go to RN D and assumed she would report it her supervisor. LVN A stated she did not know she should have gone to the DON or the Administrator. LVN A stated she went to assist other residents and steered clear of RN D because she did not want to get snapped at again. LVN A stated she did not check on the resident again. LVN A stated RN D did not bring up Resident #1 ' s bruising to the next shift's nurse and LVN A had forgotten to say anything. LVN A stated she was suspended pending investigation and was written up for failure to notify the DON or the Administrator. LVN A stated she had been inserviced on 12/29/2015 for reporting bruises to DON or Administrator, completing incident/accident reports, and for pain management. Review of RN D's undated Witness Statement reflected she provided Resident #1 with a nebulizer treatment, tube feedings, and medications per feeding tube on 12/26/15 and 12/27/15. RN D's statement reflected no one reported Resident #1 had an injury or pain to her. RN D was the RN Weekend Supervisor. The surveyor attempted to contact RN D on 01/21/16 at 2:19 PM, 3:14 PM, and 4:47 PM but was unable to reach her. In an interview on 01/21/16 at 11:38 AM, MA E stated she overheard LVN A tell RN D that Resident #1 had bruising on her upper arm on 12/26/15 during the second shift. MA E stated she saw RN D going through Resident #1's clinical record. She revealed RN D said there was no documentation regarding a bruise on Resident #1 ' s right shoulder and I am not going to clean up after the other nurses and not going to write an incident statement. Review of CNA L's Witness Statement dated 12/29/15 reflected on the 10:00 PM - 6:00 AM shift on 12/27/15 she was changing Resident #1 and saw a bruise on her right upper arm. CNA L stated she was going to report it to the Charge Nurse but got side tracked. Surveyor attempted to contact CNA L on 01/21/16 at 12:00 PM, 3:10 PM, and 4:25 PM but was not able to reach her. In an interview on 01/21/16 at 2:38 PM, CNA J stated she noticed on 12/28/15 during the second shift when she gave a shower to Resident #1 a purple/yellow bruise on her upper arm but she did not notify the Charge Nurse because she assumed the nurse already knew about it since it was purple/yellow. CNA J could not recall how large the bruise was. In an interview on 01/21/16 at 11:28 AM, CNA H stated when she weighed Resident #1 on 12/29/15 she noticed Resident #1 had bruising on the right upper arm. CNA H stated she had a miscommunication with the other aide who assisted with weighing Resident #1 and thought the other aide told the Charge Nurse. CNA H stated she should have told the Charge Nurse immediately after Resident #1 was weighed. In an interview on 01/21/16 at 3:32 PM, CNA G stated she assisted weighing Resident #1 on 12/29/15 before or after lunch when she noticed the bruising on her upper arm and shoulder. CNA G stated Resident #1 did flinch when rolled to get hoyer lift pad under her but stated that was normal for her. CNA G stated she did not notify the Charge Nurse and thought the other aide had. CNA G stated she should have gone with the other aide to tell the Charge Nurse immediately. CNA G stated she did not seem to be in pain. CNA G stated prior to the inservice on skin assessments on 12/29/2015 she was told to do the body observation forms on residents only when giving a resident a shower or bath. CNA G stated now she was told to do body observation forms any time skin issues are observed and turn it into the charge nurse. In an Interview on 01/21/2016 at 10:28 AM LVN C stated she did not notice any bruising on Resident #1 on her 6 AM - 2 PM shift on 12/25/2015 when she provided care to Resident #1. LVN C stated Resident #1 did not show any signs of pain but if she did it would be facial grimacing and moaning out. In an interview on 01/21/16 at 2:12 PM, ADON stated she was not notified of Resident #1's bruising until the DON asked her to look at it on 12/29/15. The ADON stated Resident #1 could not voice she was in pain. In an interview on 01/21/16 at 3:35 PM, the DON stated LVN B came and got her out of a meeting on 12/29/15 for her to look at Resident #1's bruise. The DON stated Resident #1's bruise was a bluish/yellowish discoloration to right upper arm and the right shoulder appeared to be swollen much larger than left arm. The DON stated she worked 10:00 PM - 6:00 AM shift the night of 12/26/15 and did not see the right shoulder because it was covered by a towel. The DON revealed she was not aware of Resident #1's bruise until 12/29/15. The DON stated the doctor was notified, the family was notified, and x-rays were ordered for the shoulder on 12/29/15. The DON said Resident #1 was sent to the local hospital for an orthopedic consult due to an acute fracture. The DON stated no documentation of Resident #1's bruising was found prior to when it was reported to her by LVN B. The DON said the CNAs should have immediately notified the nurse when Resident #1's bruising to her upper arm/shoulder was noticed. The DON stated RN D was the RN weekend supervisor but the nurses or the CNAs could have contacted her about Resident #1's bruising to the upper arm/shoulder. The DON stated Resident #1 went to another nursing facility after her hospitalization . The DON stated her and the ADON did assessments on all residents, but did not have any documentation of the assessments. Review of Resident #1's Nurse's Note dated 01/02/16 reflected Resident #1 was discharged to the hospital unrelated to the fracture. In an interview on 01/21/16 at 2:53 PM, the Administrator stated she was not aware of Resident #1's bruising to her upper arm/shoulder until 12/29/15 when she was informed by the DON. The Administrator stated during the investigation she found RN D was told about the bruising by LVN A when she interviewed LVN A and MA E. The Administrator revealed in-services were conducted for reporting all incidents/accidents to the DON or Administrator. The Administrator stated during the investigation she found facility staff were aware of Resident #1's bruising to upper arm/shoulder but failed to report it to the nurse or DON. Review of Pain Management In-Services dated 12/29/15 reflected only nurses were in-serviced on pain management and assessment. Review of In-services on 12/29/2015 for Incident/Accident Reporting, Reportable Events, Change of Condition, Skin Integrity, and Body Observation Forms reflected CNA H was not in-serviced. Review of In-services reflected new CNA hires and new nursing hires since 12/29/2015 were not in-serviced on pain management, Skin Integrity, and Body Observation Forms. Review of Employee's Notice of Disciplinary Actions dated 01/10/15 of written notice for CNA F's failure to report on 12/25/2015 of Resident #1's bruise on upper arm, CNA I's failure to report on 12/26/2015, CNA L's failure to report on 12/27/2015, CNA J's failure to report on 12/28/2015, CNA G's failure to report on 12/29/2015, and CNA H ' s failure to report on 12/29/2015. CNA Ks Notice of Disciplinary Action was dated 01/12/2016 for failure to report to Resident #1's charge nurse of the bruise. Review of RN D's Disciplinary Action dated 12/31/15 reflected two employees claim to have notified RN of resident in pain and a bruise to resident ' s right arm/shoulder on 12/26/15 and RN D failed to treat, document, or assess resident. Employee denies any knowledge of this incident. RN D was suspended pending investigation. RN D was terminated on 01/04/2016 by the facility for failure to assess Resident #1's pain on 12/26/2015 and her failure to report, document, assess Resident #1's bruise on 12/26/2015. Interviews with Two of Two Interviewable Residents revealed no concerns with pain mangement and staff were attentive to their needs. Review of Three of Three Residents (Resident #3, #4, and #5) who are able to verbalize pain reflected no concerns in pain management or skin assessments. The CMS 672 reflected a census of 45 residents.

Based on interview and record review the facility failed to provide services that met professional standards of quality for two (LVN A and RN D) of three nurses reviewed for professional standards. 1. LVN A notified RN D on 12/26/15 of Resident #1's dark purple bruise on her upper right arm/shoulder and that the resident flinched when touched on the bruise. LVN A failed to document in nurse's notes about the bruise. LVN A failed to follow up with management about RN D's behavior. 2. RN D was notified by CNA I of Resident #1 being in pain on 6:00 AM - 2:00 PM shift but failed to document and assess Resident #1's pain level. RN D was notified by LVN A of Resident #1 had a dark purple bruise on her upper arm/shoulder and the resident flinched when the area was touched. RN D failed to assess Resident #1 for the bruising and pain. She also failed to document the bruising. Resident #1 had an x-ray on 12/29/15 of the right shoulder that reflected an acute humeral neck fracture, with mild displacement and was transported to the hospital for further evaluation on 12/29/15. These failures could affect all 45 residents for delayed assessment, delayed treatment and unrelieved pain. Findings included: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses . The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure . Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses .shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; . (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (R) Be responsible for one's own continuing competence in nursing practice and individual professional growth. Review of Resident #1's face sheet with no date reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 was severely impaired in daily decision making and severely impaired in cognition. Resident #1 was totally dependent on staff for ADLS. Resident #1 was rarely understood and had short term and long term memory problems. Review of Resident #1's X-ray for the Right Shoulder view dated 12/29/15 reflected Resident #1 had an acute humeral neck fracture, with mild displacement. In an interview on 01/21/16 at 2:49 PM CNA K stated she provided care to Resident #1 with LVN A when she noticed a bruise on her upper right arm. In an interview on 01/21/16 at 12:35 PM, LVN A stated she noticed Resident #1 had dark purple bruising on her right upper arm when she was assisting CNA K with care on 12/26/2015. LVN A stated she informed Resident #1's nurse, RN D, of the bruising. LVN A said she told RN D that she noticed Resident #1 had bruising on her right upper arm and shoulder about 3-4 inches and Resident #1 had flinched when the LVN touched her bruise. LVN A stated RN D looked through the resident's clinical record to see if anything had been documented about the bruising since she was not aware of it. LVN A revealed RN D said nothing was documented. LVN A stated RN D said I am not going to clean up after another someone else's mess, and she was not going to write an incident report. LVN A told RN D she needed to go look at it but RN D snapped at her Are you trying to tell me what to do? LVN A stated she had been taught to go up the chain of command to go to RN D and assumed she would report it her supervisor. LVN A stated she did not know she should have gone to the DON or the Administrator. LVN A stated she went to assist other residents and steered clear of RN D because she did not want to get snapped at again. LVN A stated she did not check on the resident again. LVN A stated RN D did not bring up Resident #1 ' s bruising to the next shift's nurse and LVN A had forgotten to say anything. LVN A stated she was suspended pending investigation and was written up for failure to notify the DON or the Administrator. LVN A stated she had been inserviced on 12/29/2015 for reporting bruises to DON or Administrator, completing incident/accident reports, and for pain management. In an interview on 01/21/16 at 11:38 AM, MA E stated she overheard LVN A tell RN D that Resident #1 had bruising on her upper arm on 12/26/15 during the second shift. MA E stated she saw RN D going through Resident #1's clinical record. She revealed RN D said there was no documentation regarding a bruise on Resident #1's right shoulder and I am not going to clean up after the other nurses and not going to write an incident statement. Review of RN D's undated Witness Statement reflected she provided Resident #1 with a nebulizer treatment, tube feedings, and medications per feeding tube on 12/26/15 and 12/27/15. RN D's statement reflected no one reported Resident #1 had an injury or pain to her. RN D was the RN Weekend Supervisor. The surveyor attempted to contact RN D on 01/21/16 at 2:19 PM, 3:14 PM, and 4:47 PM but was unable to reach her. Review of Incident/Accident Report dated 12/29/15 at 2:00 PM reflected LVN B reported to DON Resident #1 had an observed discoloration to right shoulder/upper arm. Resident #1 was alert to self at times. Resident #1 had a [MEDICAL CONDITION] shoulder. Family notified at 2:00 PM and Physician notified at 2:00 PM. In an interview on 01/21/16 at 2:12 PM ADON stated Resident #1 could not voice she was in pain. In an interview on 01/21/16 at 3:35 PM, the DON stated LVN B came and got her out of a meeting on 12/29/15 for her to look at Resident #1's bruise. The DON stated Resident #1's bruise was a bluish/yellowish discoloration to right upper arm and the right shoulder appeared to be swollen much larger than left arm. The DON stated she worked 10:00 PM - 6:00 AM shift the night of 12/26/15 and did not see the right shoulder because it was covered by a towel. The DON revealed she was not aware of Resident #1's bruise until 12/29/15. The DON stated the doctor was notified, the family was notified, and x-rays were ordered for the shoulder on 12/29/15. The DON said Resident #1 was sent to the local hospital for an orthopedic consult due to an acute fracture. The DON stated no documentation of Resident #1's bruising was found prior to when it was reported to her by LVN B. The DON said the CNAs should have immediately notified the nurse when Resident #1's bruising to her upper arm/shoulder was noticed. The DON stated RN D was the RN weekend supervisor but the nurses or the CNAs could have contacted her about Resident #1's bruising to the upper arm/shoulder. The DON stated Resident #1 discharged to the hospital on [DATE] and went to another nursing facility. Review of Resident #1's hospital x-ray of her Humerus Right Exam dated 12/29/15 at 10:27 PM reflected a mildly displaced [MEDICAL CONDITION] humeral neck with medial and superior displacement of the humeral shaft. In an interview on 01/21/16 at 2:53 PM the Administrator stated during the investigation she found out RN D was told about the bruising according to LVN A's and MA E's interviews. Review of RN D's Disciplinary Action dated 12/31/15 reflected two employees claim to have notified RN of resident in pain and a bruise to resident ' s right arm/shoulder on 12/26/15 and RN D failed to treat, document, or assess resident. Employee denies any knowledge of this incident. RN D was suspended pending investigation. RN D was terminated on 01/04/2016 by the facility for failure to assess Resident #1's pain on 12/26/2015 and her failure to report, document, assess Resident #1's bruise on 12/26/2015. Review of Pain Management In-Services dated 12/29/15 reflected only nurses were in-serviced on pain management and assessment. Review of In-services reflected new nursing hires since 12/29/2015 were not in-serviced on pain management, Skin Integrity, and Body Observation Forms. Review of facility's policy Accidents and Injuries dated 08/28/15 reflected incident reports are required for any unusual event including bruises. The physician and family must be notified and this will be documented. Nurse ' s notes will contain factual information of the incident and will reflect a good assessment. There should be a follow-up period of at least 72 hours. If abuse or neglect is even suspected the Administrator and DON will be immediately notified. Review of facility's policy Pain Management revised November 2013 reflected residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident ' s quality of life. Procedure 1. Each resident ' s pain will be assessed using the Comprehensive Pain Assessment upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .3. recognizes that a resident ' s response to pain is subjective and individual. 4. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. 5 .will treat the resident under the premise that pain is present whenever the resident says it is .7. The resident ' s pain will be evaluated routinely each shift. Documentation will be done on the clinical software MAR/TAR. 8. Residents will be re-assessed 30-60 minutes after pain management interventions to determine the effectiveness of the intervention. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident ' s quality of life including complications. 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual ' s pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. The policy reflected to consider the resident's description and your observations of the resident's physical and behavioral responses when assessing pain. Review of facility's policy Abuse revised May 2014 reflected the facility was to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a residents physical or mental health or welfare has been or may be adversely effected by abuse or neglect caused by another person. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The CMS 672 reflected a census of 45 residents.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for one (Resident #1) of seven residents reviewed for pain management. 1. CNA F failed to report when she found Resident #1, who was unable to express if she was in pain and was totally dependent on staff for her ADLs, with dark purple bruising to her right arm and shoulder on 12/25/15. 2. CNAs K, L, J, H, and G failed to report Resident #1's bruising to the charge nurse. 3. RN D failed to assess, document, and notify the physician on 12/26/15 when the RN was notified Resident #1 had large dark purple bruising to her right arm and shoulder. RN D also failed to assess Resident #1 for pain due to the bruising after she was notified the resident flinched when the bruised area was touched. Resident #1 had an x-ray on 12/29/15 of the right shoulder that reflected an acute humeral neck fracture, with mild displacement and was transported to the hospital for further evaluation on 12/29/15. These failures could affect all 45 residents for delayed assessment, delayed treatment and unrelieved pain. Findings included: Review of Resident #1's face sheet with no date reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 was severely impaired in daily decision making and severely impaired in cognition. Resident #1 was totally dependent on staff for ADLS. Resident #1 was rarely understood and had short term and long term memory problems. Review of Resident #1's Weekly Skin assessment dated [DATE] completed by LVN B reflected no skin problems on Resident #1's upper arm/shoulder. Review of Resident #1's Nurse's Note dated 12/29/15 written by the DON reflected at 2:00 PM a discoloration was noted to the resident ' s right shoulder upper arm area. The physician and family were notified and an x-ray was ordered. Review of Nurse's Notes from 12/25/2015 through 12/29/2015 reflected no other notes on Resident #1's bruise. Review of Resident #1's X-ray for the Right Shoulder dated 12/29/15 reflected acute humeral neck fracture, with mild displacement. Further review of Resident #1's Nurse's Note dated 12/29/15 reflected at 6:00 PM the doctor was notified of the results of the x-ray and gave orders to send Resident #1 to the hospital and at 6:25 PM Resident #1 was sent out via ambulance to the local hospital. At 10:30 PM, Resident #1 returned from the local hospital with new ordered pain medications and sling to right arm in place. Review of Resident #1's hospital x-ray of her Humerus (bone of the upper arm) Right Exam dated 12/29/15 at 10:27 PM reflected a mildly displaced [MEDICAL CONDITION] humeral neck with medial (pertaining to the middle) and superior displacement of the humeral shaft. Review of Resident #1's December 2015 MAR and TAR reflected no pain medication was given to Resident #1 until 12/29/15 at 3:00 PM when Resident #1 was given Tylenol 325 mg by peg tube. On 12/30/15 and 12/31/15 Resident #1 was given Tylenol #3 12.5 ml to 25 mls via peg tube every 6 hours prn. Review of Incident/Accident Report dated 12/29/15 at 2:00 PM reflected LVN B reported to the DON Resident #1 had an observed discoloration to right shoulder/upper arm. Resident #1 was alert to self at times. Resident #1 had a [MEDICAL CONDITION] shoulder. Family notified at 2:00 PM and Physician notified at 2:00 PM. In an interview on 01/21/16 at 2:29 PM, LVN B, Charge Nurse, stated between 11:00 AM and 1:00 PM on 12/29/15 she changed Resident #1 ' s gown and saw the bruising discoloration to Resident #1's upper arm and right shoulder. LVN B stated she immediately told the DON to have her look at it and assess the bruising. Review of CNA F's Witness Statement undated reflected on 12/25/15 she went in to do a bed change and noticed Resident #1's upper right arm was bruised. CNA F reported Resident #1 wore a gown with no sleeves and the bruise was clearly visible and she did not notify the nurse. In an interview on 01/21/16 at 2:35 PM, CNA F stated when she went to change Resident #1's bedding on 12/25/15 on the 2 PM - 10 PM shift she noticed a bruise on Resident #1's upper arm but the resident did not show any signs of pain. CNA F stated she did not notify the Charge Nurse and assumed since she was NPO the nurse had already noticed it. CNA F stated the bruise was about the same on 12/28/15 when she came back from being off for two days and she still did not notify the Charge Nurse. In an interview on 01/21/16 at 4:10 PM, CNA I stated she did not notice Resident #1's bruising on her upper right arm on her 6:00 AM - 2:00 PM shift on 12/26/15. CNA I stated Resident #1 seemed like she was in pain by her facial expression of grimacing and was uncomfortable when she was repositioned. CNA I stated she informed RN D and was told she gets that way sometimes. CNA I stated the RN D did not go look at Resident #1 to assess her pain level. CNA I stated she did not notify the ADON or the DON and stated they were hard to get hold of sometimes. CNA I stated she was in-serviced about reporting bruises on 12/29/2015 but was not in-serviced about pain management. In an interview on 01/21/16 at 2:49 PM, CNA K stated she provided care to Resident #1 with LVN A on 12/26/2015 when she noticed a bruise on her upper right arm. She stated she did not report it to Resident #1's charge nurse since LVN A stated she would inform RN D. CNA K stated Resident #1 did not show any signs of being in pain and was a bedbound resident except for showering. CNA K stated she had no idea how Resident #1 got the bruise. Review of LVN A's Witness Statement dated 12/31/15 reflected she was assisting CNA K on changing Resident #1 when she noticed a large bruise on the resident ' s right shoulder dark purple in color that went under and down her right arm. LVN A notified RN D of Resident #1's bruise on her right upper arm/shoulder and that Resident #1 flinched when it was touched. LVN A stated RN D researched Resident #1's clinical record found no documentation on it. LVN Walker wrote RN D said she was not going to address it Resident #1 ' s bruising because she was not told about it report and it was not documented. In an interview on 01/21/16 at 12:35 PM, LVN A stated she noticed Resident #1 had dark purple bruising on her right upper arm when she was assisting CNA K with care on 12/26/2015. LVN A stated she informed Resident #1's nurse, RN D, of the bruising. LVN A said she told RN D that she noticed Resident #1 had bruising on her right upper arm and shoulder about 3-4 inches and Resident #1 had flinched when the LVN touched her bruise. LVN A stated RN D looked through the resident's clinical record to see if anything had been documented about the bruising since she was not aware of it. LVN A revealed RN D said nothing was documented. LVN A stated RN D said I am not going to clean up after another someone else's mess, and she was not going to write an incident report. LVN A told RN D she needed to go look at it but RN D snapped at her Are you trying to tell me what to do? LVN A stated she had been taught to go up the chain of command to go to RN D and assumed she would report it her supervisor. LVN A stated she did not know she should have gone to the DON or the Administrator. LVN A stated she went to assist other residents and steered clear of RN D because she did not want to get snapped at again. LVN A stated she did not check on the resident again. LVN A stated RN D did not bring up Resident #1 ' s bruising to the next shift's nurse and LVN A had forgotten to say anything. LVN A stated she was suspended pending investigation and was written up for failure to notify the DON or the Administrator. LVN A stated she had been inserviced on 12/29/2015 for reporting bruises to DON or Administrator, completing incident/accident reports, and for pain management. Review of RN D's undated Witness Statement reflected she provided Resident #1 with a nebulizer treatment, tube feedings, and medications per feeding tube on 12/26/15 and 12/27/15. RN D's statement reflected no one reported Resident #1 had an injury or pain to her. RN D was the RN Weekend Supervisor. The surveyor attempted to contact RN D on 01/21/16 at 2:19 PM, 3:14 PM, and 4:47 PM but was unable to reach her. In an interview on 01/21/16 at 11:38 AM, MA E stated she overheard LVN A tell RN D that Resident #1 had bruising on her upper arm on 12/26/15 during the second shift. MA E stated she saw RN D going through Resident #1's clinical record. She revealed RN D said there was no documentation regarding a bruise on Resident #1 ' s right shoulder and I am not going to clean up after the other nurses and not going to write an incident statement. Review of CNA L's Witness Statement dated 12/29/15 reflected on the 10:00 PM - 6:00 AM shift on 12/27/15 she was changing Resident #1 and saw a bruise on her right upper arm. CNA L stated she was going to report it to the Charge Nurse but got side tracked. Surveyor attempted to contact CNA L on 01/21/16 at 12:00 PM, 3:10 PM, and 4:25 PM but was not able to reach her. In an interview on 01/21/16 at 2:38 PM, CNA J stated she noticed on 12/28/15 during the second shift when she gave a shower to Resident #1 a purple/yellow bruise on her upper arm but she did not notify the Charge Nurse because she assumed the nurse already knew about it since it was purple/yellow. CNA J could not recall how large the bruise was. In an interview on 01/21/16 at 11:28 AM, CNA H stated when she weighed Resident #1 on 12/29/15 she noticed Resident #1 had bruising on the right upper arm. CNA H stated she had a miscommunication with the other aide who assisted with weighing Resident #1 and thought the other aide told the Charge Nurse. CNA H stated she should have told the Charge Nurse immediately after Resident #1 was weighed. In an interview on 01/21/16 at 3:32 PM, CNA G stated she assisted weighing Resident #1 on 12/29/15 before or after lunch when she noticed the bruising on her upper arm and shoulder. CNA G stated Resident #1 did flinch when rolled to get hoyer lift pad under her but stated that was normal for her. CNA G stated she did not notify the Charge Nurse and thought the other aide had. CNA G stated she should have gone with the other aide to tell the Charge Nurse immediately. CNA G stated she did not seem to be in pain. CNA G stated prior to the inservice on skin assessments on 12/29/2015 she was told to do the body observation forms on residents only when giving a resident a shower or bath. CNA G stated now she was told to do body observation forms any time skin issues are observed and turn it into the charge nurse. In an Interview on 01/21/2016 at 10:28 AM LVN C stated she did not notice any bruising on Resident #1 on her 6 AM - 2 PM shift on 12/25/2015 when she provided care to Resident #1. LVN C stated Resident #1 did not show any signs of pain but if she did it would be facial grimacing and moaning out. In an interview on 01/21/16 at 2:12 PM, ADON stated she was not notified of Resident #1's bruising until the DON asked her to look at it on 12/29/15. The ADON stated Resident #1 could not voice she was in pain. In an interview on 01/21/16 at 3:35 PM, the DON stated LVN B came and got her out of a meeting on 12/29/15 for her to look at Resident #1's bruise. The DON stated Resident #1's bruise was a bluish/yellowish discoloration to right upper arm and the right shoulder appeared to be swollen much larger than left arm. The DON stated she worked 10:00 PM - 6:00 AM shift the night of 12/26/15 and did not see the right shoulder because it was covered by a towel. The DON revealed she was not aware of Resident #1's bruise until 12/29/15. The DON stated the doctor was notified, the family was notified, and x-rays were ordered for the shoulder on 12/29/15. The DON said Resident #1 was sent to the local hospital for an orthopedic consult due to an acute fracture. The DON stated no documentation of Resident #1's bruising was found prior to when it was reported to her by LVN B. The DON said the CNAs should have immediately notified the nurse when Resident #1's bruising to her upper arm/shoulder was noticed. The DON stated RN D was the RN weekend supervisor but the nurses or the CNAs could have contacted her about Resident #1's bruising to the upper arm/shoulder. The DON stated Resident #1 went to another nursing facility after her hospitalization . The DON stated her and the ADON did assessments on all residents, but did not have any documentation of the assessments. Review of Resident #1's Nurse's Note dated 01/02/16 reflected Resident #1 was discharged to the hospital unrelated to the fracture. In an interview on 01/21/16 at 2:53 PM, the Administrator stated she was not aware of Resident #1's bruising to her upper arm/shoulder until 12/29/15 when she was informed by the DON. The Administrator stated during the investigation she found RN D was told about the bruising by LVN A when she interviewed LVN A and MA E. The Administrator revealed in-services were conducted for reporting all incidents/accidents to the DON or Administrator. The Administrator stated during the investigation she found facility staff were aware of Resident #1's bruising to upper arm/shoulder but failed to report it to the nurse or DON. Review of Pain Management In-Services dated 12/29/15 reflected only nurses were in-serviced on pain management and assessment. Review of In-services on 12/29/2015 for Incident/Accident Reporting, Reportable Events, Change of Condition, Skin Integrity, and Body Observation Forms reflected CNA H was not in-serviced. Review of In-services reflected new CNA hires and new nursing hires since 12/29/2015 were not in-serviced on pain management, Skin Integrity, and Body Observation Forms. Review of Employee's Notice of Disciplinary Actions dated 01/10/15 of written notice for CNA F's failure to report on 12/25/2015 of Resident #1's bruise on upper arm, CNA I's failure to report on 12/26/2015, CNA L's failure to report on 12/27/2015, CNA J's failure to report on 12/28/2015, CNA G's failure to report on 12/29/2015, and CNA H ' s failure to report on 12/29/2015. CNA Ks Notice of Disciplinary Action was dated 01/12/2016 for failure to report to Resident #1's charge nurse of the bruise. Review of RN D's Disciplinary Action dated 12/31/15 reflected two employees claim to have notified RN of resident in pain and a bruise to resident ' s right arm/shoulder on 12/26/15 and RN D failed to treat, document, or assess resident. Employee denies any knowledge of this incident. RN D was suspended pending investigation. RN D was terminated on 01/04/2016 by the facility for failure to assess Resident #1's pain on 12/26/2015 and her failure to report, document, assess Resident #1's bruise on 12/26/2015. Interviews with Two of Two Interviewable Residents revealed no concerns with pain mangement and staff were attentive to their needs. Review of Three of Three Residents (Resident #3, #4, and #5) who are able to verbalize pain reflected no concerns in pain management or skin assessments. Review of facility's policy Accidents and Injuries dated 08/28/15 reflected incident reports are required for any unusual event including bruises. The physician and family must be notified and this will be documented. Nurse ' s notes will contain factual information of the incident and will reflect a good assessment. There should be a follow-up period of at least 72 hours. If abuse or neglect is even suspected the Administrator and DON will be immediately notified. Review of facility's policy Pain Management revised November 2013 reflected residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident ' s quality of life. Procedure 1. Each resident ' s pain will be assessed using the Comprehensive Pain Assessment upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .3. recognizes that a resident ' s response to pain is subjective and individual. 4. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. 5 .will treat the resident under the premise that pain is present whenever the resident says it is .7. The resident's pain will be evaluated routinely each shift. Documentation will be done on the clinical software MAR/TAR. 8. Residents will be re-assessed 30-60 minutes after pain management interventions to determine the effectiveness of the intervention. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident ' s quality of life including complications. 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual 's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. The policy reflected to consider the resident's description and your observations of the resident's physical and behavioral responses when assessing pain. Review of facility's policy Abuse revised May 2014 reflected the facility was to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a residents physical or mental health or welfare has been or may be adversely effected by abuse or neglect caused by another person. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The CMS 672 reflected a census of 45 residents.