Every finding on record at Southland Health Care Center

Based on review of the facility policy, the agreement with the Hospice entity, record reviews, and interviews, the facility failed to ensure coordination of hospice care and services for Resident (R)2 for 1 of 1 residents reviewed for Hospice Care and Services. Findings include: Review of the facility policy titled, Hospice Policy, states, We strive for quality of care between Hospice and the facility in the provision of Hospice care for our residents.Guidelines:5. Staff communicates with Hospice and coordinates care for the residents and provides information on policy and procedures as indicated including appropriate forms, and documentation requirements, Unit Manager and MDS Coordinator serve as Hospice points of contact.7. Staff communicates with hospice staff and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions to provide care and services as indicated.8. Staff collaborates with Hospice for the development, implementation and revision of the coordinated plan of care. Review of the Nursing Facility Hospice Services Agreement, states under Article II: Services to be Provided by Hospice, Section 2.5 Coordination of Services, states, Hospice will designate a member of the IDT who is responsible for the Resident/Patient and ensuring that the needs of the resident/patient are addressed and met 24 hours a day. The Hospice Designee shall (a) provide overall coordination of Hospice Services for each resident/patient with Nursing Facility representatives; (b) communicate with nursing facility representatives and other health care providers participating in the provision of care for the Resident/Patient to ensure quality care is provided.Section 2.6 Manner of Communication. All communications between the Hospice and the Nursing Facility pertaining to the care and services provided to the resident/patient shall be documented in the resident's/patient's clinical record. The facility admitted R2 with diagnoses including, but not limited to, dementia, congestive heart failure and sepsis. Review on 01/07/2026 at 11:20 AM of the medical record for R2 revealed an admission date of 10/29/2025 for hospice care and services. Further review of the medical record for R2 revealed missing routine nurses' assessments and supervisory visits from the registered nurses from hospice for 12/10/2025, 12/12/2025, 12/17/2025, 12/23/2025, 12/26/2025 and 12/31/2025. There was no documentation present in the medical record to ensure coordination of care from hospice nurses to the facility nurses and staff. Hospice nurses did not convey to the facility staff any changes or any findings from the visits. During an interview on 01/07/2026 at 02:30 PM with the Clinical Coordinator, she provided assessments from the hospice nurses that were faxed to the facility on [DATE], for the missing nurse assessments. During an interview on 01/08/2026 at 11:42 AM with the Unit Manager, she stated that the hospice staff usually speaks to the nurse before she leaves, but could not provide any documentation from the facility nurses of whom the hospice nurse spoke to, or any communicated information concerning R2, during the hospice visits. During an interview on 01/08/2026 at 02:25 PM with the Director of Nursing, she stated that she would expect some documentation to be in the medical record concerning the coordination of care by the hospice nurse and the facility nurse caring for the resident.

Based on review of the facility policy, record reviews, and interviews, the facility failed to provide a completed Bed-hold document for Resident (R)2 and/or her responsible party within a practicable amount of time, for 1 of 3 residents reviewed for hospitalization. Findings include: Review of the facility policy titled, Bed Hold Prior to Transfer, reviewed and revised 10/30/2022, states, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital.Notice before Transfer:1. The facility will notify residents and/or their representative to make them aware of the facility's bed-hold policy when transferred to the hospital.2. The facility will provide written information about these policies to resident and/or resident representatives prior to and upon transfer.3. The facility will give written information concerning the bed-hold policies to the resident and/or resident representative as part of the admissions packet.4. The written information given to the resident and/or resident representative will include the following:a. Medicaid will pay to hold a resident's bed for 10 days.b. A resident/resident representative may request that the facility hold a bed during the resident's absence from the facility for payment of the basic per diem rate.c. The facility policies regarding bed-hold periods include permitting residents to return to the next available bed under the following conditions: . The resident requires the services which the facility provides. The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.5. The facility will provide this written information to all facility residents, regardless of their payment source. The facility admitted R2 on 02/11/2022 with diagnoses including, but not limited to dementia, chronic kidney disease with heart failure and sepsis with severe septic shock. Review of the medical records for R2 revealed a hospital stay from 10/14/2025 and returning to the facility on [DATE]. During review of the notice of transfer and the bed-hold documents presented to R2's responsible party, revealed a bed-hold mailed to the responsible party on 10/20/2025, six days after the resident was sent out to the hospital. No documentation was found to ensure the responsible party was informed of the bed-hold amount, as the form was mailed blank on 10/20/2025. R2 was admitted back to the facility on [DATE]. During an interview on 01/07/2026 at 01:50 PM with the Admissions Coordinator, responsible for ensuring the Bed-hold information is sent timely to the resident and or the responsible party, stated, I realized after I mailed the Bed-hold to R2's daughter, that I had not filled out the Bed-hold amount. So I filled out the the amount on another form and mailed it to the resident's daughter. There was no documentation to ensure the corrected Bed-hold was mailed with the bed-hold amount, and the resident had already returned from the hospital. The Admissions Coordinator stated that it was an oversight on her part. During an interview on 01/08/2026 at 02:25 PM with the Director Nursing, she stated that she would expect the Bed-hold information to be mailed out timely to the resident representative.

Based on interviews, record review, document review, and facility policy review, the facility failed to ensure a significant medication error did not occur for 1 (Resident (R)1) of 3 residents reviewed for medication administration. During the 9:00 AM medication pass on 06/05/23, R1 received their own prescribed anti-hypertensive medication (used to treat high blood pressure), a calcium channel blocker (used to treat high blood pressure) and a beta blocker (used to treat high blood pressure and heart failure). During the same medication pass, a different nurse administered R1 antihypertensive and beta blocker medications ordered for a different resident, R6. The administration of the additional medications not ordered for R1 caused the resident's blood pressure to decrease to a level that required medical intervention. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Pharmacy Services) at a scope and severity of J. On 06/09/23 at 8:28 AM, the Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy situation. The IJ began on 06/05/23 when R1 received another resident's medications, which resulted in a decrease in R1's blood pressure. On 06/09/23 at 8:37 AM, the Administrator was provided with the completed IJ template. The Administrator signed the template and returned the original to the survey team. A Plan of Removal was requested. Findings include: Review of a facility policy titled, Medication Administration, dated 02/16/23, indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. A review of R1's Admission Record revealed the facility admitted the resident on 11/08/2018 with diagnoses that included hypertension. Per the record, on 06/08/2022, R1 received a diagnosis of heart failure. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/23, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. A review of R1's care plan revised on 03/31/23, indicated R1 had a diagnosis of hypertension. Interventions directed the staff to give anti-hypertensive medications as ordered. A review of R1's care plan revised on 05/30/23, indicated R1 had a diagnosis of congestive heart failure. Interventions directed the staff to give cardiac medications as ordered. A review of R1's Order Summary Report, indicated on 11/19/2022, the resident received an order for amlodipine besylate (a calcium channel blocker) 10 milligram (mg) one tablet by mouth one time a day for essential hypertension, carvedilol (a beta blocker) 3.125 mg one tablet by mouth two times a day for hypertension, clonidine hydrogen chloride (HCl) (an antihypertensive) 0.1 mg one tablet by mouth two times a day for hypertension, and losartan potassium (an antihypertensive) 50 mg one table by mouth two times a day related to acute on chronic diastolic heart failure. Review of R1's Medication Administration Record (MAR), for June 23, revealed during the 9:00 AM medication pass on 06/05/23, Licensed Practical Nurse (LPN) #2 administered the following blood pressure medications to R1: amlodipine besylate 10 mg, carvedilol 3.125 mg, clonidine HCl 0.1 mg, and losartan potassium 50 mg. Per the MAR, R1's blood pressure was recorded as 152/87 millimeters of mercury (mmHg) and pulse (heart rate) as 60 beats per minute (BPM). Review of the Progress Notes, dated 06/05/23 at 9:25 AM, revealed R1 yelled out, I feel dizzy. Per the note, the resident's vital signs were obtained and recorded as a blood pressure of 77/52 mmHg, pulse of 62 BPM, and respirations of 18 breaths per minute. According to the note, the resident was placed in the Trendelenburg position (a position in which a person is laid flat on their back with their feet raised above their head) and the physician was called. Contained within the facility's investigation file was an Employee Statement, signed by LPN2 and dated 06/05/23, which indicated LPN2 administered R1's morning medications according to the physician's orders. Per the statement, LPN2 was called by a certified nursing assistant to R1's room about an hour later. LPN2 indicated the resident stated they felt dizzy. According to the statement, LPN2 notified the supervisor that R1 had received medications from another nurse. Unsuccessful attempts were made to contact LPN2 on 06/08/23 at 12:31 PM, a voice mail message was left. On 06/08/23 at 7:55 PM and 06/09/23 at 2:20 PM, there was no answer. Review of the Medication Error Report Form, dated 06/05/23, revealed on 06/05/23 at 8:38 AM, a nurse administered medications to the wrong resident. The report identified the resident as R1 and the medications as losartan potassium 100 mg and metoprolol succinate extended release (a beta blocker) 25 mg. The report indicated the medication error was discovered on 06/05/23 at 9:25 AM and the contributing factor as the room numbers and names had been temporarily taken off the door due to the wall being painted/wallpaper placed. Interventions/corrective actions implemented by the facility revealed the resident's name and room number were placed on the door and staff education was provided. Review of the Progress Notes, dated 06/05/23 at 10:20 AM, revealed the physician returned the staff's call and gave new orders to start an intravenous (IV) line to administer one liter of 1/2 normal saline and if unable to start the line, send the resident to the emergency room for evaluation. Per the note, R1 had a blood pressure of 91/46 mmHg, a heart rate of 55 BPM, respirations at 18 breaths per minute, and an oxygen saturation level of 98%. Review of R1's Progress Notes, dated 06/05/23 at 10:25 AM, indicated an unsuccessful attempt to start an IV line. Review of R1's ED [Emergency Department] Provider Notes, dated 06/05/23, revealed R1 presented to the ED with a chief complaint of drug overdose; Per the note, R1 was given the wrong blood pressure medications at the nursing home. Per emergency medical services, R1 received their morning medications to include Norvasc (amlodipine), Coreg (carvedilol) and clonidine and was also administered losartan 100 mg and metoprolol 25 mg that belonged to another resident. Laboratory tests performed were normal and R1 was discharged back to the nursing home with instructions to monitor the resident's blood pressure every four hours and return to the ED if the resident's condition worsened. In an interview on 06/08/23 at 8:05 AM, R1 stated they had an issue a couple of days ago when they received their medications and then someone else gave them more medications that belonged to another resident. Per R1, they had no real problem, the nurses checked them over and they were good now. During an interview with LPN1 on 06/08/23 at 9:11 AM, she stated as she administered medications to residents (on 06/05/23) some of the room numbers and resident names were not on the residents' room doors or walls because of construction. LPN1 acknowledged at approximately 9:00 AM, she administered the medications ordered for R6 to R1. LPN1 stated she thought she had entered R6's room, but she had entered R1's room. LPN1 explained about an hour later after she administered the wrong medications to R1, the resident began to feel dizzy and when the resident's blood pressure was checked, the resident's blood pressure was low. Per LPN1, R1 was placed in the Trendelenburg position, the resident's blood pressure increased, but it decreased again, and the resident was sent to the emergency room (ER). LPN1 stated R1 was okay and returned to the facility later the same day. Review of the Progress Notes, dated 06/05/23 at 9:47 PM, revealed R1 returned to the facility on [DATE] at 8:30 PM. During an interview with the Director of Nursing (DON) on 06/08/23 at 9:21 AM, she stated LPN2 administered R1 their 9:00 AM medications (on 06/05/23) and then LPN1 administered R1 medications that belonged to another resident. According to the DON, the medication error occurred as LPN1 thought she had entered R6's room. In a follow-up interview with the DON on 06/08/23 at 2:20 PM, she stated her expectation was that this incident should never have happened. Per the DON, during orientation the importance of identification of the resident name and the correct medication was reviewed. The DON stated she expected the nurse would have ensured this was the correct resident before the administration of medications. During an interview with the Physician on 06/08/23 at 11:35 AM, he stated he was aware of the incident and ordered intravenous (IV) fluids for R1; however, the facility was unable to get an IV line started so the resident was sent to the hospital for evaluation. The Physician stated the hospital staff called and informed him that the resident's vital signs were normal, the resident experienced no negative outcome, and returned to the facility the same day. The Physician stated the concern regarding this incident would be the resident's decrease in blood pressure. Per the Physician, there was always a concern when the elderly were administered extra medications. During an interview with the Administrator on 06/08/23 at 3:09 PM, she stated R1 stated they felt dizzy, and the facility called the physician. Per the Administrator, LPN1 checked the resident's vital signs, and the resident's blood pressure was low. The Administrator explained the nurse assigned to the resident, LPN2, informed LPN1 that she had already administered R1 their medications. The Administrator stated the resident was immediately placed in the Trendelenburg position and the physician called. The Administrator stated her expectation would be that any nurse who administered medications would verify the right resident and right medication before medication administration. On 06/09/23 at 6:48 PM, a Removal Plan was submitted by the facility and accepted by the State Agency. It read as follows: 1. On 06/09/23 at approximately 8:28 AM, the Facility Administrator and Director of Nursing were notified by the Health Facilities Surveyor of the facility being placed in Immediate Jeopardy (IJ) involving R1. 2. Administrative Team held an ADHOC [a Latin word that meant 'for this situation'] Quality Assurance and Performance Improvement (QAPI) meeting on 06/09/23 at approximately 08:40 AM to discuss the IJ. 3. Attendees were: Administrator, Director of Nursing, Assistant Director of Nursing, North Hall Unit Manager, South Hall Unit Manager, Care Plan Coordinator, Social Service Director, and Medical Director via [by way of] phone. 4. Root cause identified during ADHOC QAPI to be that R1 and R6 Medical Record Photograph is similar in appearance due to R6 having a cap on in [his/her] photograph. The Director of Nursing immediately had the North Hall Unit Secretary retake R6's photograph. 5. Facility respectfully submits the below allegation of compliance for F760 Residents are free of significant medication errors. 6. R1 was affected by deficient practice on 06/05/23 at approximately 9:25 AM. R1 complained of Dizziness and both Licensed Practical Nurse (LPN) assigned to North Hall responded to the resident's room. R1 assigned nurse identified that R1 had received R6 medications. R1 vitals were immediately obtained, R1 was placed in Trendelenburg position, and Primary Physician was notified. New orders obtained to administer intravenous (ID) bolus 0.45% Normal Saline (NS) if able to obtain IV access, and if not to send to the emergency room (ER) for evaluation. 7. All residents who were assigned to North Hall Cart 1 had the potential to be affected. 8. The Director of Nursing provided education to the LPN assigned to North Cart Hall 1 on 06/05/23 on the 7 rights of safe medication administration, the importance of knowing the resident's identification before administering medications and completed a medication administration competency on 06/05/23. 9. All Licensed Nurses present in the facility were provided education on proper medication administration, the 7 Rights of Medical Administration, and the importance of knowing the resident's identification on 06/09/203 by the Nurse Management Team to include the Unit Managers, Assistant Director of Nursing, and Director of Nursing. Remaining Licensed Nurses will be educated by the end of day 06/09/23. Newly Hired Licensed Nurses will be educated during new hire orientation training. New hire skills checkoff will be verified by the Director of Nursing prior to ending orientation training. 10. The Nursing Management Team includes the Unit Managers, Assistant Director of Nursing, and Director of Nursing. The Nurse Management Team conducted a 100 percent audit of all residents Medical Record Photograph on 06/09/23. Photographs that appear blurred or unrecognizable were retaken and uploaded in the medical record on 06/09/23. No photographs will be taken with a hat in place on new admissions. The Nurse Management Team will conduct random medication administration skills check offs for a minimum of 50 percent of scheduled Licensed Nurses weekly x 4 weeks, and monthly x 3. The Director of Nursing will review and report findings during the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. 11. The Administrator is responsible for implementation and oversight of this plan. 12. All Corrections were completed on 06/09/23. 13. All Immediacy of the IJ was removed on 06/09/23. Onsite Verification: Onsite verification was conducted on 06/09/23 to verify the facility had implemented the Removal Plan. The onsite verification revealed the facility had determined the root cause of the medication error, had provided education on the importance of knowing the resident's identification before administration of medications, and completed a medication administration competency check for LPN1 on 06/05/23. On 06/09/23, 100% of all licensed nursing staff were educated on the importance of identifying the seven rights of safe medication administration, to include the right medication administered to the right resident. Licensed staff were interviewed related to the covered in-service material. 100% audits were completed on resident photographs in the electric health record. Photographs that were blurred or unrecognizable were retaken and uploaded into the residents' electronic health record. A medication administration observation was conducted, and no concerns were identified. The IJ continued until 06/09/23 at 8:14 PM, when the survey team verified the elements of the Removal Plan had been implemented. The noncompliance remained on 06/09/23 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the facility continuing training of new hires and on-going audits.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were secured and not left unattended. Additionally, the facility also failed to ensure medication carts were locked during the medication pass. These failures place the residents at risk of having their unsecured medications diverted. Findings include: Review of the facility's policy titled, Medication Storage, dated 08/2022, revealed .b. Only authorized personnel with have access to the secured compartment. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Observation on 12/07/22 at 9:44 AM of the medication cart on the 100-hall revealed Registered Nurse (RN) 1 left the medication cart unlocked and unattended while she was inside resident room [ROOM NUMBER] administering medications. The medication cart which was located outside of resident room [ROOM NUMBER] had a medication cup on top with 4 loose pills. The medication cart was out of sight of the RN1 for 4 minutes. Two staff members and one resident were in the hall within 15 feet of the unlocked medication cart that the cup of unsecured medication was on. During an interview on 12/07/22 at 10:09 AM, RN1 confirmed that the medication cart was unlocked and unattended with unsecured medication on top of the medication cart. RN1 stated I have so much trouble getting in it [medication cart]. RN1 then went into room [ROOM NUMBER] to deliver the loose medications that were in cup on top of medication cart, again leaving the medication cart unlocked and unattended. RN1 was not in sight of cart for two minutes while in room [ROOM NUMBER]. RN1 confirmed that the medication cart should remain locked and secured when not attended During an interview on 12/07/22 at 4:28 PM, the Director of Nursing (DON) confirmed that the medication carts should stay locked when unattended and medication should not be left unattended on top of the medication cart. The DON stated, A resident could come by and get that medication causing health issues.

Based on observations and interview, the facility failed to ensure the staff were appropriately screened for COVID (Coronavirus-19) prior to entering the residents residential area. The findings included: Random observations on 9/28/21 from approximately 8:10 AM to 9:20 AM revealed two (2) staff members coming up to the nursing station on the 100 Hall to complete their COVID screening. A therapist was observed taking his/her temperature with the provided thermometer and then jokingly stated 93.7, I know that is not right because I would be dead. About 10 minutes later, maintenance staff was observed taking his/her temperatures on unit and documenting the temperature in the book left on counter at nursing station. Staff had to pass resident rooms 119 through 129 before being screened for COVID. There were residents noted in 4 to 5 rooms on the hall 119 through 129. Additional observations showed visitors exiting an isolation room of a Resident without doffing PPE. Observations of isolation rooms on 9/28/21 at 9:00 AM also revealed cloth gowns being reused between individuals without sanitization. An interview around 11:45 AM with the Director of Nursing, revealed the facility has had 5 (five) COVID surveys and no citations, indicating s/he had no concerns with the current process.

Based on record reviews and interviews, the facility failed ensure that a resident received insulin per physician's order for 1 of 6 sampled residents reviewed for unnecessary medications. Resident #52 did not receive sliding scale insulin as ordered. The findings included: The facility admitted Resident #52 on 1/22/18 and readmitted date of 6/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood Sugar Sliding scale 70-150=0; 151-200=2 units; 201-250=4 units; 251-300=6; 301-350=8 units; 351-400=10 units > (greater) 400 give 12 units and call MD (Medical Doctor). Further review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52 Finger Stick Blood Sugars (FSBS) were done with no insulin given per the physician's orders on the following dates: 7/29/21 FSBS 158 no insulin given; 8/07/21 FSBS 155 no insulin given; 8/08/21 FSBS 156 no insulin given; 8/10/21 FSBS 213 no insulin given; 8/12/21 FSBS 209 no insulin given; 8/16/21 FSBS 154 no insulin given; 8/21/21 FSBS 155 no insulin given; 9/17/21 FSBS 188 no insulin given and on 9/18/21 FSBS 157 no insulin given. RN # 1 confirmed the documentation in the electronic medical record and stated s/he will look to see if any paper documentation was available. An interview on 9/30/21 at 8:46 AM with RN #1 revealed there was no additional documentation to determine that Resident #52 was given per physician orders. The documentation in the electronic record was the only documentation available.

Based on record reviews and interviews, the facility failed that a resident's medical record was accurately documented for 1 of 6 sampled residents reviewed for unnecessary medications. Resident #52 had blanks on the medication administration sheets for the month of July and August 2021. The findings included: The facility admitted Resident #52 on 1/22/18 and readmitted date of 6/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood Sugar Sliding scale 70-150=0; 151-200=2 units; 201-250=4 units; 251-300=6; 301-350=8 units; 351-400=10 units > (greater) 400 give 12 units and call MD (Medical Doctor). Further review of the medical record with RN #1 revealed there was no documentation in the electronic medical record that indicated Finger Stick Blood Sugars were done during the month of July 2021 on 7/01/21, 7/02/21, 7/03/21, 7/04/21 (PM), 7/05/21. 7/06/21 (AM), 7/07/21 (PM), 7/08/21 (PM), 7/09/21, 7/10/21, 7/11/21, 7/12/21, 7/14/21, 7/15/21, 7/16/21, 7/17/21, 7/19/21, 7/20/21, 7/21/21 (AM), 7/22/21,7/23/21, 7/24/21/ 7/25/21, 7/26/21, 7/27/21, 7/29/21 (AM), 7/30/21 and 7/31/21. During the month of August 2021, there was no documentation to indicate the FSBS were done on 8/01/21, 8/02/21,8/03/21, 8/04/21 and 8/05/21 (AM). RN #1 stated he/she did not realize blood sugars were not being documented until 8/05/21. RN #1 further stated an email was sent the nursing staff to ensure FSBS were documented per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interviews, and record review, the facility failed to safely maintain biologicals and medications in one of two medication storage rooms inspected. On inspection of the medication room, expired biologicals and medication were found in the emergency cart located inside the medication storage room. Findings include: Observation of the medication storage room on Unit 200 (South Hall), on [DATE] at 9:45 am, revealed the emergency cart located inside the storage room contained one bottle of normal saline 100 milliliters (mL) which had an expiration date of [DATE] and a [MEDICATION(S)] syringe 10 cubic centimeter (cc) which had an expiration date of ,d+[DATE]. Review of the facility's policy titled Medication Storage, revealed under Section 8.Unused medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . These prescription medications are returned to the pharmacy. OTC (over the counter) are destroyed in the drug buster . Interview with Ward Clerk #4 (WC4) on [DATE] at approximately 9:48 AM confirmed there were expired biologicals and medications located in the emergency cart inside the medication room. WC4 further stated that the medication storage room was audited for expired biologicals and medications three times a month, but there was no set schedule. WC4 stated the medication room was stocked once a week with medications and twice a week with biological supplies and when she found expired biologicals and medications, the Registered Nurse (RN) Supervisor would dispose of them.

Based on record review, interview and review of the facility's abuse policy, the facility failed to ensure that an allegation of resident abuse was reported within 2 hours after the allegation was made for 1 of 3 sampled residents reviewed. Resident #1 with an allegation of abuse made on 7/18/21 at 12:30 AM was not reported until 7/18/21 at 12:25 PM. The findings included: The facility admitted Resident #1 on 8/07/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's investigation on 8/17/21 at 11:39 AM revealed on 7/18/21 at 12:30 AM Resident #1 was heard yelling for help and noted a Certified Nursing Aide (CNA) standing over the resident. The resident made an allegation that woman is beating me, in reference to the CNA. Further review of the facility's investigation revealed the allegation of abuse was received by the state agency on 7/18/21 at 12:25 PM per a fax sheet. A review of the facility's abuse policy and procedures revealed under VII:Reporting/Response of Abuse, Neglect and Exploitation. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: Ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides jurisdiction in long term care facilities) in accordance with State law. An interview on 8/17/21 at 11:54 AM with the Director of Nursing (DON) acknowledged the facility was aware of the abuse allegation on 7/18/21 at 12:30 AM and confirmed the abuse allegation was submitted per the fax sheet on 7/18/21 at 12:25 PM. The DON further stated s/he does not have documentation to confirm the allegation of abuse was submitted within 2 hours after the allegation was made.

Based on observation and interview, the facility failed to ensure meals were prepared and served in a sanitary manner. Staff was observed in the main kitchen with hair on their heads not completely covered by hairnets, 1 of 4 sanitation buckets were not at appropriate sanitization level, uncovered food tray left in dining room to be served to resident on unit, and staff chewing gum with mouth open while serving uncovered food trays to residents in main dining room for 1 of 1 main kitchen and 1 of 1 main dining room. The findings included: An initial tour of the main kitchen on 7/29/19 at approximately 2 PM revealed the Dietary Manager and two staff members in the main kitchen with front and/or side of the hair on their heads not completely covered. An observation of the main dining room food delivery on 7/29/19 at approximately 5:21 PM revealed staff brought out small cafe hand held folding tables and placed up to three uncovered resident meals on the small folding table before delivering the meal to the residents seated in the dining room. At 5:26 PM, kitchen staff was observed delivering uncovered food trays from the kitchen with hair on their heads not covered by a hairnet. As the dining observation continued on 7/29/19 at approximately 5:28 PM, a single resident's uncovered food tray was observed placed in the open on a small folding table. Staff walked away to locate a food cover top from the main kitchen to send the tray down the hallway. Staff was then observed delivering an uncovered meal to the wrong resident. At 5:33 PM, the Dietary Manager was observed entering and exiting the main kitchen with his/her hair not completely covered by a hairnet. At approximately 5:37 PM on 7/29/19, five residents were seated still waiting to be served. The Certified Nursing Aide (CNA) who was standing over residents uncovered food was chewing gum with his/her mouth open. The CNA providing assistance informed residents who were not served that their food trays were coming and continued chewing gum with mouth opened. An interview with CNA #1 on 7/29/19 at approximately 5:42 PM confirmed he/she was chewing gum while providing meals to residents. An additional kitchen observation on 7/31/19 at approximately 10:23 AM revealed 1 of 4 sanitization buckets with a reading of 100 ppm (parts per million) sanitation levels instead of 200 ppm as required per the Dietary Manager. Observation during food temp observation on 7/31/19 at approximately 11:45 AM revealed the Dietary Manager and two other staff members in the meal kitchen with hair on their heads not completely covered by hairnets. The Dietary Manager was constantly wiping sweat from forehead on bare arms during food temps. An interview with the Dietary Manager on 7/31/19 at approximately 12:13 PM acknowledged these observations.

Based on record review, interview, and review of the facility policy titled Prevention of Decline in Range of Motion, the facility failed to develop and implement a care plan related to Resident #19's impairment of his/her upper extremity for 1 of 1 residents reviewed for position/mobility. The findings included: The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Record review on 7/31/19 at 12:29 PM of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #19 was coded for impairment on one side of the upper and lower extremity. Review of the current care plan revealed there was no care plan for limited range of motion/impairment of the upper and lower extremity. During an interview with the Minimum Data Set Coordinator on 7/31/19 at approximately 3:45 PM, s/he confirmed there was no care plan related to range of motion/impairment of extremities. Review of the facility policy titled Prevention of Decline in Range of Motion revealed under the Policy Explanation and Compliance Guidelines the following: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. 3. Appropriate Care Planning a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion.

Based on record review and interview, the facility failed to follow accepted Standards of Practice for Resident #18 by not rotating the location of application of a medical patch and for Resident #42 by not completing pacemaker checks as ordered for 2 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review on 07/31/19 at approximately 1:10 PM revealed a Medication Administration Record [REDACTED]. On (MONTH) 7th, the patch was administered to site #9, on 07/08 and 07/09 the nurse documented yes without a site number, and on 07/10 the patch was administered to site 10. In an interview on 07/31/19 at approximately 3: 14 PM, the Assistant Director of Nursing stated it appeared the administering nurse did not know how to rotate the site. In an interview on 07/31/19 at approximately 3:42 PM, the Director of Nursing confirmed that it would be expected that the administering nurse would know how to follow the order to rotate the administration site for the patch for Resident #18. The facility admitted Resident #42 on 8/26/14 with [DIAGNOSES REDACTED]. A review of the medical record on 7/31/19 at approximately 8:20 AM revealed Resident #42 had a pacemaker with a physician's orders [REDACTED]. Further review of the medical record revealed there was no documentation to indicate the pacemaker checks were done as ordered. An interview on 7/31/19 at approximately 9:28 with Registered Nurse (RN) #1 revealed one note in the medical record dated 5/10/19 that indicated to continue current therapy. The note was not verification of pacemaker checks being done. At approximately 9:38 AM, RN #1 contacted the physician's office and requested verification of pacemaker checks. Documentation received revealed pacemaker checks were done on 1/15/19 and 4/16/19. The (MONTH) 2019 pacemaker checks were not done. RN #1 confirmed there was no documentation to confirm the pacemaker checks were done every three months as ordered.

Based on record review, observation, interview, and review of the facility policy titled Prevention of Decline in Range of Motion, the facility failed to implement devices for 1 of 1 resident reviewed for positioning/mobility. Resident #19 with observed impairment to the right hand had no device or splint in place to prevent further loss of range of motion. The findings included: The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Record review on 7/31/19 at 12:29 PM of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #19 was coded for impairment on one side of the upper and lower extremity. Further record review revealed there was no order for a device and/or splint to prevent further impairment of the resident's left hand. Review of the current care plan revealed there was no care plan for limited range of motion/impairment of the upper and lower extremity. Review of therapy notes revealed on 6/6/18, a palm roll trial was done for the resident's left hand. Review of therapy notes revealed on 6/3/19 passive range of motion (PROM) to the left wrist/digits was done and a left hand posey splint was placed in which Resident #19 tolerated up to six hours. On 6/4/19 a cone was placed in the left hand after treatment for [REDACTED]. On 6/6/19, after PROM, a palm posey was applied in which Resident #19 tolerated. On 6/10/19, a left hand roll was applied to minimize skin breakdown and/or discomfort. Observation of Resident #19 on 7/28/19 at approximately 2:30 PM revealed s/he was lying in bed, contracture was noted to the left hand with no device/splint in his/her left hand. On 7/30/19 at approximately 12:27 PM, no device/splint was observed in the resident's left hand. Observation on 7/31/19 at 1:47 PM revealed Resident #19 did not have a device/splint on the left hand. During an interview with Certified Nursing Assistant (CNA #3) on 7/31/19 at 1:47 PM, s/he, after looking in the kiosk, confirmed there was no information in the kiosk related to a palm protector or hand roll. S/he continued by stating the palm cushion must be in the laundry and s/he had placed a hand roll in the resident's hand but it had become soiled and hand been removed. S/he stated the hand roll had not been replaced. During an interview with the Certified Occupational Therapy Assistant (COTA) on 7/31/19 at 1:29 PM, s/he stated Resident #19 should have had a palm posey, but it may have been misplaced. S/he confirmed Resident #19 was no longer on case load. During an interview with the Therapy Director on 7/31/19 at approximately 2:00 PM, s/he confirmed there was no physician's order nor a care plan for a palm protector for the resident. S/he stated Resident #19 should have had an order for [REDACTED]. Review of the facility policy titled Prevention of Decline in Range of Motion revealed under the Policy Explanation and Compliance Guidelines the following: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. 3. Appropriate Care Planning a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion.

Based on record review and interview, the facility failed to ensure that a resident's medical record was accurately documented and complete for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #42's pacemaker checks were not in the medical record and there was no documentation as to why the pacemaker checks were not done. The findings included: The facility admitted Resident #42 on 8/26/14 with [DIAGNOSES REDACTED]. A review of the medical record on 7/31/19 at approximately 8:20 AM revealed Resident #42 had a pacemaker with a physician's orders [REDACTED]. Further review of the medical record revealed there was no documentation to indicate the pacemaker checks were done as ordered. An interview on 7/31/19 at approximately 9:28 with Registered Nurse (RN) #1 revealed one note in the medical record dated 5/10/19 that indicated continue current therapy. The note was not verification of pacemaker checks being done. At approximately 9:38 AM, RN #1 contacted the physician's office and requested verification of pacemaker checks. Documentation received revealed pacemaker checks were done on 1/15/19 and 4/16/19. The (MONTH) 2019 pacemaker checks were not done. An interview on 7/3/19 at approximately 10:06 AM with RN #1 revealed he/she contacted the physician's office about the (MONTH) 2019 pacemaker check appointment. RN #1 stated he/she was informed the resident was transported to the physician's office but the resident refused the pacemaker check. A review of the medical record by RN #1 revealed there was no documentation in the electronic medical record and the facility's appointment calendar to indicate the resident was sent out of the facility for the appointment. RN #1 further stated there was no documentation to indicate the resident refused to have the pacemaker check as ordered.

Based on observation and interview, the facility failed to provide dignity in dining. All residents seated at the same table were not served prior to food trays being delivered to other tables in 1 of 2 dining areas served during the dinner meal. The findings included: A random observation was made on 7/29/19 at approximately 5:03 PM during the early tray delivery in the activity room. There were four residents observed seated at the first table upon entering the activity room. Three residents were served and eating independently while one resident was seated and watching the other residents eat. One resident that had his/her tray asked the resident without a tray, Are you ready to eat?. The resident without a tray just continued to look on. As the meal service continued serving trays at other tables, a Certified Nursing Aide (CNA) informed the resident that did not get a tray that his/her food tray was coming. There were residents served and two other tables before all the residents at the first table were served. An interview on 7/29/19 at approximately 5:12 PM with CNA #2 revealed the tray for the resident seated at the table and not served was in the kitchen; however, observation at approximately 5:16 PM revealed a staff member pulled the tray for the resident not served from the opened food cart that was already in the activity room.

Based on observations, record reviews and interviews the facility failed to assure that that it was free of unnecessary medications for 2 of 3 residents reviewed for unnecessary medications. [MEDICATION NAME] prescribed for Residents 55 (inadequate indication for use and inadequate monitoring) and 7 (inadequate monitoring) The findings included: RESIDENT 55: During record review on 6/27/18 at approximately 4:35 PM it was noted that Resident 55 was prescribed [MEDICATION NAME] 20 mg-10 mg on 8/30/17 with a [DIAGNOSES REDACTED]. The facility had admitted Resident 55 on 10/12/15 [DIAGNOSES REDACTED]. -9/4/17 11:34 pm Nursing: This nurse spoke to MD (physician) this AM (morning) regarding RDs (residents) behavioral issues. MD made aware RD continues to behave inappropriately towards staff by way of inappropriate sexual behaviors .and inappropriate social behaviors. -9/1/17 3:09 pm Nursing: tried to contact (Responsible Party) to update on new medication that was ordered due to inappropriate behavior such as trying to go into women's rooms, staring at women, resident trying to get staff to touch him/her on private areas. S/he did not an answer and mail box was full and unable to leave a message. -9/4/17 11:44 pm Nursing: Scheduled [MEDICATION NAME] 0.5 mg (milligram) held this HS (bedtime); PRN (as needed) dose of 1 mg administered d/t (due to) agitation toward staff when attempts to redirect inappropriate social and sexual behaviors are made. Rd has thus far this shift (7:50 pm) made gestures to (private area) and then to staff that suggest (s/he) wants staff to touch (him/her) and has several times been redirected away from roommate as (s/he) has been sitting beside roommates bed and has been laughing at roommate while roommate sleeps. With redirection attempts Rd does become agitated; can be seen in facial expressions and body language,. Rd appears to become angry, withdrawn and at times hostile pushing at staff when attempts to move w/c (wheelchair) away from roommates bed are made. Did accept HS meds without difficulty; PRN dose of [MEDICATION NAME] effective at follow-up. [MEDICATION NAME] is marketed by Pharmaceuticals and the package insert Indications and Usage section, revised (MONTH) (YEAR), states [MEDICATION NAME] is indicated for the treatment of [REDACTED]. Merriam Webster Medical definition: A condition that is marked by episodes of uncontrolled crying or laughing which is inappropriate or of disproportionate intensity and that is associated with various neurological disorders (such as [MEDICAL CONDITIONS] and stroke). None of the behaviors listed in the Progress Notes are indicators for this drug. Further review of the residents record on 6/27/18 failed to show any charted behaviors or monitoring related to PBA subsequent to the drug being prescribed. On 6/28/18 at approximately 3:00 PM, RN (Registered Nurse) # 1, during a telephone interview, stated that Resident 55 did have occasional episodes of crying for no reason, but that these were not always entered in Progress Notes or elsewhere in the medical record. RN # 1 stated that there is no specific behavioral monitoring for PBA. RESIDENT 7: During record review on 6/27/18 at approximately 6:36 PM it was noted that Resident 7 had been prescribed [MEDICATION NAME] 20 mg-10 mg on 11/8/17 with a [DIAGNOSES REDACTED]. The facility had admitted Resident 7 on 10/11/17 with [DIAGNOSES REDACTED]. Review of the Progress Notes for Resident 7 provided by Social Services on 7/27/18 at approximately 6:51 PM revealed the following: -10/11/17 4:34 pm Nursing: (s/he) is verbal but it is word salad -10/12/17 9:30 am Nursing: did speak clear when giving insulin although resident confused with words -10/13/17 3:45 am Nursing: Alert, garbled speech noted -10/15/17 1:44 pm Nursing resident speaking this shift confusion noted -10/16/17 2:09 am Nursing Note:*****10-14-17***** CNAs (certified nursing assistant) do report resistance with care from Rd; state Rd does occasionally attempt to hit staff while Rd is receiving care. -10/16/17 2:09 am Nursing: Did repeat no no no and did raise fist to nurse while attempting to obtain FSBS (finger stick blood sugar). CNAs report Rd does display said behaviors often while resident is receiving care. -10/17/17 3:09 am Nursing: garbled speech noted -10/18/17 7:59 am Medical: Cognitive testing: Patient is phasic, with dense left [MEDICAL CONDITION]. Cognitive testing: while patient has some vocalizations, these were mostly nonsensical and not understandable. No further cognitive testing couldn't be performed. -10/19/17 2:50 am Nursing: Alert, garbled speech noted -10/19/17 10:39 am Social Services: (S/he) has been able to answer very simple questions at times but for the most part her speech is garbled. Nursing staff note (s/he) is resistive to care almost daily. -10/20/17 2:04 am Nursing: Speech is garbled. -10/23/17 3:15 pm Nursing: Resident is alert and seemingly aware of surroundings but is unable to carry on a conversation with staff and speech is somewhat garbled -10/26/17 7:30 am Social Services: (S/he) is able to answer simple questions at times but (his/her) speech usually garbled.: -10/28/17 11:08 am Nursing: cursing at tech, fighting tech w/ADL's ( with activities of daily living) scratching tech. Resident did curse at tech during mouth care states: Lady, you fu**in up! -10/29/17 11:43 am Nursing: :fighting with mouth care, refusing to turn. -10/30/17 3:08 am Nursing: hitting and cursing at staff with ADL's -11/1/17 2:28 am Nursing: Resident continues to curse tech, resist care and hit during ADL's -11/2/17 1:54 am Nursing: resisting care, fighting with mouth care, and yelling out with ADL's. Yelling out during day. -11/3/17 8:58 am Nursing: yelling out this am, heard in the hall. -11/3/17 5:23 pm Nursing: yelling out hello repeatedly. -11/4/17 7:28 pm Nursing: Resident continues to yell out, Hello!, even after someone enters the room. -11/7/17 3:31 am Nursing: resident continues to yell out hello during the day. This resident did resist and did attempt to hit tech during mouth care this shift. -11/8/17 7:35 am Medical: Nursing staff states that (s/he) yells out at inappropriate times, with no response to environmental stimuli. (S/he) seems to have little in the way of impulse control. unfortunately continues to have significant verbal dyspraxia, with unintelligible speech and responses inappropriate to question contact. [MEDICAL CONDITION]: Patient is having increased outbursts, with mostly unintelligible speech. There is no real connection with environmental stimuli, raising the possibility of pseudobulbar affective disorder. Trial of [MEDICATION NAME] 10/20, one by tube daily for 1 week, then one by tube twice day. Further review of the resident's record from 11/18/17 to 6/27/18 failed to show any behaviors or monitoring related to PBA subsequent to the drug being prescribed. On 6/28/18 at approximately 3:12 PM, RN (Registered Nurse) # 1, during a telephone interview, stated that Resident 7 did occasionally state hello, hello, but that these were not always entered in Progress Notes or elsewhere in the medical record. RN # 1 stated that there is no specific behavioral monitoring for PBA.

Based on observation, record review and staff interview that facility failed to ensure the kitchen dishware were dry and stored according to standard practice to prevent the risk of bacterial contamination or growth. The facility also failed to maintain the kitchen floor in good working condition for one of one kitchen reviewed during the survey. The findings included: During the initial tour of the kitchen on 6/25/18 at 8:56 AM the surveyor observed a shelf stacked up with stainless steel steam table pans in the clean-ready to use dishware area of the kitchen. Fourteen out of sixteen large pans of approximately 2.5 inches in depth and nine out of twelve small containers of roughly 4 inches depth were stacked up wet. Next to the stainless steel pans and pots shelf there was a shelf containing clean coffee cups, one out of nine cups reviewed had dried food debris on it. Throughout the first tour and follow up visits, the kitchen floor felt extremely sticky, and it appeared stained all the way through the hall between the kitchen and the main dining room. On the last day of the survey on 6/28/18 at approximately 4:00 PM the pans were stacked up dried, and coffee cups did not have dried food debris. However, the kitchen floor continued to feel extremely sticky (the surveyor shoes were coming off his/her feet when walking on the kitchen floor) and its appearance did not change. The dietary manager confirmed wet stacked up pans and dirty coffee cups and immediately removed them and stated that the kitchen floor gets cleaned daily. However, the kitchen floor did not improve at all. The flooring was extraordinarily sticky and stained (Three other surveyors also felt the same way).

Based on limited record review, interview, and the facility policy, the facility failed to ensure to provide a written notification of emergency transfer to the resident's representative for 2 of 2 residents reviewed for transfers. Residents#9 and #19 were emergently transferred to the emergency room at local hospital for an evaluation and/or subsequently admitted related to an acute change in health status requiring a higher level of care without written notification required to the resident and the resident's representative. The findings included: Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. During record review on 6/27/18 at 1:15 PM revealed in the Nurses' Progress Notes the resident was sent out to the emergency roiagnom on [DATE] and for an Intravenous Therapy antibiotics. Further record review revealed no documentation was sent to the resident representative and the Ombudsman's on the resident having an emergency transfer. During record review on 06/27/18 at 1:20 PM revealed the report sent to the Ombudsman each month did not list resident #9. In addition the list did not include all the residents that left the facility and went to local hospital. During an interview with Assistant Director of Nursing on 6/27/18 at 1:30 PM, s/he stated they don't mail out documentation on emergency transfer. The facility will call the family and make them aware of the resident leaving the facility. During an interview on 06/27/18 at 3:50 PM with the Case Manager and Social Services Director confirmed resident # 9 emergency transfer was not mailed out to the resident's representative. S/he stated since the resident went to the hospital for evaluation was not aware a written notification must be sent to the resident's representative. Review of the facility's policy Transfer and Discharge including Against Medical Advice (AMA) under Emergency Transfers/Discharges: g. Provide orientation for transfer or discharge . Provide in form and manner that the resident can understand. k. Social Services Director, or designees, shall provide notice of transfer to a representative of the State Long Term Care Ombudsman via monthly list. The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. [MEDICATION NAME], Pain, Cognitive Communication Deficit, Seborrhea, Urinary Tract Infection, Feeding Difficulty, and Abnormal Posture. Nurse's notes reviewed on 6/27/18 at approximately 12:35 PM revealed that the facility sent Resident #19 to the hospital emergency room (ER) with symptoms of sleepiness with difficulty arousing, pinpointing eyes and delayed movements. According to the nurse's notes, the physician and resident's representative were notified via phone. Continuing the review of the resident's medical chart also revealed that the resident was admitted to the hospital on [DATE] and later on diagnosed with [REDACTED]. The hospital discharged Resident #19 to the facility on [DATE]. The chart review also showed that the facility did not have any documentation in the resident's medical record to support the notification of transfer to the resident and resident's representative. The resident's medical chart neither contained documentation to argue that the facility sent a copy of the transfer notification to the ombudsman as required per CMS regulations. During an interview with social services on 6/27/18 at 5:23 PM s/he confirmed the above findings.

Based on observation, record review and interview the facility failed to afford the resident the opportunity to formulate his/her advance directive for one of four residents sampled reviewed for advance directives. The findings included: The facility admitted Resident # 130 on 6/22/18 with [DIAGNOSES REDACTED]. Care plan reviewed on 6/27/18 at 9:36 AM addresses Resident # 130's advance directive-do not resuscitate (DNR) and states that the resident's representative will be provided education regarding advance directive upon admission and that the resident's cognitive ability will be assessed. The resident's chart reviewed on 6/27/18 at approximately 10:30 AM revealed that the advance directive acknowledgment was signed by the resident's representative and not the resident him/herself as well as others document to the resident's care including the baseline care plan. Continuing the resident's record review revealed that the physician and physician consultant had not assessed and certified that the resident is unable to make his/her own health care decisions. During an interview with social services on 6/27/18 at approximately 1:00 PM s/he stated that the physician certification of inability to make own health care decision is not in the resident's medical chart because the doctor had not seen the resident yet. The physician will be at the facility in (MONTH) the second. The form was put in the doctor's box to fill out after s/he sees the resident.

Based on limited record review, interview, and the facility policy, the facility failed to ensure to provide a written notification of bed hold to the resident's representative resident for 2 of 2 residents reviewed for transfers. Residents#9 and #19 were emergently transferred to the emergency room at local hospital for an evaluation and/or subsequently admitted related to an acute change in health status requiring a higher level of care without written notification of bed hold required to the resident and the resident's representative. The findings included: Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. During record review on 6/27/18 at 1:15 PM revealed in the Nurses' Progress Notes the resident was sent out to the emergency roiagnom on [DATE] and 05/28/18 for an Intravenous Therapy antibiotics. Further record review revealed no documentation was sent to the resident representative and the Ombudsman's on the resident having an emergency transfer. During record review on 06/27/18 at 1:20 PM revealed the report sent to the Ombudsman each month did not list resident #9. In addition the list did not include all the residents that left the facility and went to the local hospital. During an interview on 06/27/18 at 3:50 PM with the Case Manager and Social Services Director confirmed resident # 9 bed hold policy was not mailed out to the resident's representative. S/he stated since the resident went to the hospital for evaluation was not aware bed hold must be sent to the resident's representative. Review of the facility's policy Transfer and Discharge including Against Medical Advice (AMA) under Emergency Transfers/Discharges: i. Provide a notice of the resident's bed hold policy to the resident and representative at time of transfer, as possible, but no later than 24 hours of the transfer. k. Social Services Director, or designees, shall provide notice of transfer to a representative of the State Long Term Care Ombudsman via monthly list. The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. [MEDICATION NAME], Pain, Cognitive Communication Deficit, Seborrhea, Urinary Tract Infection, Feeding Difficulty, and Abnormal Posture. Nurse's notes reviewed on 6/27/18 at approximately 12:35 PM revealed that the facility sent Resident #19 to the hospital emergency room (ER) with symptoms of sleepiness with difficulty arousing, pinpointing eyes and delayed movements. According to the nurse's notes, the physician and resident's representative were notified via phone. Continuing the review of the resident's medical chart also revealed that the resident was admitted to the hospital on [DATE] and later on diagnosed with [REDACTED]. The hospital discharged Resident #19 to the facility on [DATE]. The chart review also showed no evidence/documentation to indicate that the facility discussed with and provide the bed hold policy to the resident or resident's representative. During an interview with the case manager on 6/27/18 at approximately 5:30 PM s/he stated that the bed hold policy is mailed to the resident's representative but, s/he was unable to provide evidence/documentation to support his/her claim.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations of abuse were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse while the investigation was in progress. One of one residents reviewed for an allegation of abuse. The findings included: Review of Resident #1's Nurses' Notes dated 7/11/17 at 10:57 AM indicated 3 dark red areas noted to the resident's right lower arm, resident stated s/he thought it happened during the night. Review of the Nurses' Notes from 7/1/17-7/11/17 revealed no documentation related to the resident having bruising to the right arm prior to the resident's allegation. Review of the resident's Weekly Nursing Summary Note dated 7/2/17 revealed Resident #1 had bruising to bilateral lower extremities. The Weekly Nursing Summary Note dated 7/9/17 revealed the resident had bilateral discoloration to the lower extremities. The Weekly Nursing Summary Note dated 7/17/17 noted s/he had bruising on bilateral lower extremities. There was no documentation on the Weekly Nursing Summary Notes related to Resident #1 having bruising to the arms. Review of the resident's behavior monitoring from 5/1/17-8/8/17 revealed the resident refused medication x 3 nurses on 5/18/17 at 9:26 AM. The resident was noted with behavior on 5/29/17 at 8:39 AM. The resident was noted to refuse medications on 6/10/17 at 8:59 AM. The residents behaviors was monitored twice daily and all other documentation indicated the resident had no behaviors. The physician's orders [REDACTED]. Document yes or no if behaviors occurred and please document specific behavior in comment section. Licenses Practical Nurse (LPN) #1's facility-obtained statement dated 7/11/17 indicated during report this AM, LPN #2 stated that Resident #1 was calling for two other staff members. The resident couldn't understand when they tried to tell him/her that those people weren't here, so they attempted to put his/her hearing aide in his/her ear. LPN #2, Certified Nursing Assistant (CNA) #1, and CNA #2 were the staff with the resident. Resident #1 resisted, and was striking and spitting at them and telling them to get out. LPN #1 told LPN #2 that Resident #1 didn't like anyone messing with his/her hearing aide. LPN #2 stated well (s/he) couldn't hear us. LPN #2 stated so the resident will probably tell you a tale this morning. When LPN #1 went in the resident's room this morning first thing while 7 P-7A nurse (LPN #2) was still here, the resident stated they came in and held him/her down and tried to put his/her hearing aide in. Resident #1 was very agitated. Resident #1's daughter here at 10 AM and saw bruises. Resident #1 told his/her daughter the same story, the resident told the shower team the same story. LPN #2's facility-obtained statement dated 7/12/17 indicated Resident #1 started ringing the call light repeatedly. LPN #2 went into the resident's room each time and Resident #1 told him/her to get out, s/he didn't call me. Resident #1 started yelling for other staff members. LPN #2 stated to the resident they work in the morning and they are not here. Resident #1 tried to hit LPN #2 with his/her call light. Resident #1 pushed the call light again, LPN #2 and CNA #1 went in the resident's room. LPN #2 and CNA #1 attempted to put hearing aide in resident's ear so s/he could understand the people s/he was calling were not there. Resident #1 tried to hit LPN #2 again and spit on CNA #1. CNA #1's facility-obtained statement dated 7/12/17 indicated Resident #1 was asking for people who weren't there. They kept telling the resident they weren't here, meaning the other staff members. So they tried to put the resident's hearing aide in so s/he could hear them tell him/her those people weren't there. They never got close to Resident #1 because s/he was yelling/kicking, spitting and waving the call light to get out of his/her room. CNA #1 indicated they never touched Resident #1. CNA #2's facility-obtained statement dated 7/13/17 indicated s/he didn't know anything about putting a hearing aide in Resident #1's ear. In an interview with the surveyor on 8/9/17 at approximately 10:20 AM, the Director of Nursing (DON) stated s/he talked with the staff and took statements. The DON stated s/he received the statement from LPN #1. LPN #1 left the note for the DON, so the DON contacted LPN #2, CNA #1, and CNA #2. LPN #2 told LPN #1 that they were trying to put the resident's hearing aids in. The DON stated Resident #1 could not hear them to understand what they were saying. They tried to put the resident's hearing aids in and s/he got combative. LPN #1 wrote the statement to let the DON know about the incident. The resident told his/her daughter that the staff held him/her down and put his/her hearing aids in. The DON contacted the staff and told them they needed to write statements about what happened. The DON did not report the incident to the State Agency. The DON stated s/he did not report the allegation of abuse because s/he didn't have reason to believe anything occurred. The incident happened on the night shift, 7/10-7/11/17. The DON stated the only statements s/he obtained were from LPN #2, CNA #1 and CNA #2. In an interview with the surveyor on 8/9/17 at approximately 10:45 AM, the DON stated s/he doesn't have anything documenting Resident #1 making other allegations against staff. The DON also stated s/he was not sure when the bruising to the residents arms was first noted because there was no additional information in the resident's medical record. Review of the facility's Daily Staffing Report assignment sheets dated 7/11-7/15/17 revealed LPN #2, CNA #1 and CNA #2 continued to work on the unit after Resident #1's allegation of abuse. Review of the facility's Abuse, Neglect, and Exploitation Policy revealed each resident has the right to be from abuse. The policy indicated the identification of abuse included, but not limited to, the following possible indicators: resident report of abuse, and physical marks such as bruises. Investigation of alleged abuse included to interview the resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. The entire investigation should be documented chronologically. Resident protection after alleged abuse indicated the facility will make efforts to protect all residents after alleged abuse. Example of ways to protect a resident from harm during an investigation of abuse included reassignment of nursing staff duties and time off for nursing staff. The policy indicated in response to allegations of abuse, the facility must ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made. The facility must also have evidence that all alleged violations are thoroughly investigated. The facility must report the results of all investigations to the State Survey Agency within 5 working days of the incident.