Every finding on record at Sterling Oaks Rehabilitation

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 5.26.26 to seal and cover food stored in refrigerator and out in open area of kitchen. These failures could place residents at risk for food contamination and foodborne illness.The findings included: The following observations were made on 5.26.26 beginning at 8:15 AM during initial tour of the kitchen: Observation of the following stored on counter in kitchen:Large baking dish with marble cake sitting out.Large plastic container of coffee grounds with no lid. Observation of the following stored in the refrigerator:Bag of hamburger patties in open box and open bag exposed to the open air.Bag of corn dogs in open box and open bag exposed to the open air.Bag of cheesy garlic breadsticks in open box and open bag exposed to the open air. During an interview and observation on 5.28.26 at 2:59 PM with DM of freezer revealed an open box of hamburger patties, corn dogs, and cheesy garlic bread was still open with bag open to environment. He stated that that should be covered and not exposed to the open air. He stated that it would cause freezer burn or could cause exposure to the elements which could cause the residents to get sick. He stated he would get that fixed immediately. During an interview on 5.28.26 at 10:56 AM with ADMN, he stated DM and staff were responsible for items in fridge and dry storage room and making sure all items are sealed. All staff have been trained on food storage in the refrigerator and dry storage. The facility policy was to have all items sealed. He stated the possible negative outcome could be serving exposed food to residents. Record review of the facility's policy, titled Food Receiving and Storage, revised date 2014, reflected the following:Policy Statement- Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation .7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . Record review of the FDA Food Code 2022 reflected the federally established standards. derlying surface.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #98 and Resident #128) of 12 residents observed for oxygen management and CPAP use. The facility failed on 05/26/2026 to post oxygen in use signs outside Resident #98's and Resident #128's rooms.The facility failed 0n 05/26/2026 to properly store Resident #98's CPAP machine in a bag when it was not in use. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, at risk for cross contamination, spread of infection, and at risk of fire hazards by not posting oxygen signs outside the residents' rooms.Addendum to; Observation and interview on 05/26/2026 at 9:01 a.m. with Resident #98, he stated he had been in the facility for about one week. Resident #98 stated he was prescribed oxygen therapy and wore his canula throughout the day. It was observed that the resident had an oxygen concentrator in the room at bedside and there was no oxygen-in-use sign posted outside Resident #98's room. Resident #98 stated he needed his CPAP machine to be able to sleep and said he took it off earlier in the morning when he woke up and put it on top of his nightstand. The CPAP mask was observed on top of the nightstand; it was not in a bag, and it was exposed. During an interview on 05/26/2026 at 9:41 AM with CNA C, stated that when a CPAP mask was not in use, it needed to be disinfected, stored in a bag and dated. CNA C stated this procedure was followed to prevent cross contamination and avoid the resident aspirating anything that may have fallen onto the mask if it was not properly stored. CNA C stated the potential negative outcome for leaving a CPAP machine exposed and not properly sanitized and bag could result in the resident aspirating dust or lint which could potentially make them sick to their lungs. CNA C stated it was the responsibility of all CNAs, LVNs, RNs or any staff who work with the residents to make sure their CPAP masks were properly cleaned and stored when not in use. During an interview on 05/26/2026 at 10:36 AM with LVN B, stated when a resident who uses a CPAP machine and they were not using it, the mask needed to be sanitized, bagged, labeled with the date, and stored for when the resident would be using it again. LVN B stated this was necessary to avoid the mask being contaminated with dust, lint, or anything in the air. LVN B stated it was the responsibility of any staff member who worked with the residents to ensure CPAP masks were properly stored when not in use and stated the possible negative outcome for not sanitizing and storing the mask could result in the resident wearing a contaminated CPAP mask which could make them sick to their lungs or their airways. During an interview on 05/27/2026 at 9:53 AM with RN D she said the CPAP machines were worn by some residents during the night to help them sleep better if they had a diagnosis of sleep apnea. RN D stated when residents were not wearing their CPAP mask, it needed to be cleaned, bagged and dated to safely store the equipment when not in use. RN D stated it was all staff's responsibility to ensure these masks were cleaned and stored whenever they made rounds and had contact with the residents. RN D stated there was a possibility that if the masks were not properly disinfected and stored, they could be contaminated by anything in the air such as dust or lint. RN D stated there was also the possibility that a confused resident got into the room and put on the mask, creating cross contamination. RN D stated these possible negative outcomes could make the residents sick from their air pathways or their lungs. During an interview on 05/28/2026 at 10:18 AM the Admn, stated it was an expectation that any CNA, LVN, RN or DON who had contact with the resident and if they saw a CPAP mask not properly store, that they assisted the resident to sanitize, bag and date the CPAP mask to properly store it to avoid cross contamination. The Admn stated that the possible negative outcome for leaving a mask not properly stored could result in it being contaminated and if the resident wore it without cleaning the mask first, they could get sick from their lungs or nasal passage. During an interview on 05/28/2026 at 10:55 AM with the DON, stated that CPAP masks needed to be sanitized, bagged and dated before storing them whenever the residents were not wearing the mask. The DON stated these procedures for storing the CPAP mask were done to avoid cross contamination as it posed an infection control issue if the mask were left exposed and not safely stored. The DON stated it was the responsibility of all CNAs, LVNs, RNs or DON to properly sanitize and store these masks if they had contact with the resident and saw they had a CPAP not properly stored in their room. The DON stated the potential negative outcome for a resident wearing a CPAP mask that was not properly sanitized and stored could result in them getting sick from their lungs or nasal passage. Record review of the facility document titled Infection prevention and control policies and procedures and dated 05/15/2023 revealed in part: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying reporting, investigating, and controlling infections and communicable disease. The program covers all residents, staff, consultants, students in the facility's nurse aide training program or from affiliated academic institutions, volunteers, visitors, and other individuals providing services under a contractual agreement and is a based on the individual facility assessment following accepted national standards. Infection prevention and control program consists of currently acceptable infection control standards, practices, and activities. Examples of these are: Surveillance for healthcare acquired infection (HAI) identification; data analysis, and evaluation. Infection prevention and control program plan (continued) 6. Staff Development: 10) Cleaning, disinfecting and sanitation procedures. Compliance with applicable federal, state, and local regulations concerned with patients/residents and employees. Staff are provided with information and training on: Infection prevention and control information and plans. Hand hygiene, including hand washing and alcohol-based hand rub (ABHR). Universal/standard and transmission-based precautions. Findings included: Record review of Resident #98's face sheet revealed the resident was a [AGE] year-old male. The face sheet revealed an original admission date of 05/18/2026. Record review of Resident #98's History and Physical dated 05/06/2026 revealed diagnoses that included acute respiratory failure with hypoxia (a condition where the body is not receiving enough oxygen), chronic obstructive pulmonary disease (COPD) (a chronic lung disease that makes breathing difficult), atrial fibrillation (an irregular heartbeat) and sleep apnea (a condition that causes interrupted breathing during sleep). The record revealed the resident required supplemental oxygen therapy and oxygen administration via nasal cannula related to respiratory compromise. History and Physical revealed the resident utilized CPAP therapy for sleep apnea. Record review of Resident #98's admission MDS dated [DATE] revealed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Under Section I (Active Diagnoses), the MDS identified active diagnoses that included COPD, respiratory failure. Under Section O (Special Treatments, Procedures, and Programs), the MDS recorded oxygen therapy as a respiratory treatment. Section O also included respiratory treatment categories for CPAP and non-invasive mechanical ventilation. Record review of Resident #98's care plan, last revised on 05/21/2026, revealed the resident required staff assistance and monitoring related to cognitive impairment and respiratory conditions. The care plan identified diagnoses including acute respiratory failure with hypoxia and COPD. Interventions included monitoring respiratory status, observing for signs and symptoms of respiratory distress, and implementing oxygen-related safety precautions when oxygen equipment was present or in use. During an observation and interview on 05/26/2026 at 9:01 a.m. with Resident #98, he stated he had been in the facility for about one week. Resident #98 stated he was prescribed oxygen therapy and wore his canula throughout the day. It was observed that the resident had an oxygen concentrator in the room at bedside and there was no oxygen-in-use sign posted outside Resident #98's room. Record review of Resident #128's face sheet revealed the resident was a [AGE] year-old male. The face sheet revealed an original admission date of 05/18/2026. Record review of Resident #128's History and Physical dated 05/11/2026 revealed diagnoses that included coronary artery disease (reduced blood flow to the heart), hypertension (high blood pressure), hyperlipidemia (high cholesterol), anemia (low red blood cell count), and shortness of breath (difficulty breathing). The record revealed respiratory symptoms requiring continued monitoring and nursing oversight. Record review of Resident #128's admission MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Under Section I (Active Diagnoses), the MDS revealed respiratory-related diagnoses and symptoms requiring monitoring. Under Section O (Special Treatments, Procedures, and Programs), the MDS revealed oxygen therapy as a respiratory treatment. Record review of Resident #128's Care Plan created on 05/22/2026 revealed respiratory-related symptoms that included shortness of breath. The Care Plan revealed interventions related to monitoring respiratory status, observing for changes in breathing, and implementing oxygen-related safety precautions when oxygen equipment was present or utilized. The Care Plan revealed continued nursing monitoring related to respiratory symptoms and shortness of breath. During an observation and interview on 05/26/2026 at 10:22 a.m. with Resident #128, the resident was in bed watching television, he was wearing his nasal cannula and there was an oxygen concentrator at bedside. Resident #128 stated he needed oxygen therapy to breath better and stated he had been admitted to the facility less than one week ago. There was no oxygen-in-use sign posted outside Resident #128's room. During an interview on 05/26/2026 at 10:27 a.m. with LVN B, she stated oxygen-in-use signs were required to alert staff, residents, and visitors that oxygen was present in the room. She stated the signs served as a fire safety precaution and reminded staff to monitor oxygen use and equipment. She stated LVNs, RNs, and the DON were responsible for ensuring the signs were posted. During an interview on 05/27/2026 at 9:36 a.m. with CNA C, she stated oxygen signs were required so staff, residents, and visitors were aware oxygen was being used in the room. She stated the signs helped ensure residents receiving oxygen were monitored appropriately and alerted others to potential fire hazards. She stated RNs and LVNs were responsible for ensuring the signs were posted. During an interview on 05/27/2026 at 9:50 a.m. with RN D, she stated oxygen signs were required to notify staff and visitors that oxygen was in use and to promote ongoing monitoring of residents receiving oxygen therapy. She stated the signs also served as a safety warning to reduce the risk of fire hazards associated with smoking materials or spark-producing devices. During an interview on 05/28/2026 at 10:24 a.m. with the Administrator, he stated oxygen-in-use and no-smoking signs were expected to be posted outside every room containing oxygen equipment. He stated the signs warned staff, visitors, and residents of potential fire hazards and helped prevent unsafe items from being brought into the area. During an interview on 05/28/2026 at 10:58 a.m. with the DON, she stated oxygen signs were expected to be posted outside rooms where oxygen was in use. She stated the signs identified residents receiving oxygen therapy and alerted visitors and staff to associated fire safety risks. She stated LVNs, RNs, ADONs, and the DON were responsible for verifying the signs were in place. Record review of the facility's policy titled Leadership Policies and Procedures, Section IX: Patient/Resident Care, Subject: oxygen supply – monitoring and re-ordering, revised on 11/1/2017, read in part: POLICY: The Facility has established a policy and procedure to ensure an adequate supply of oxygen for the prescribed care of patients and residents. 14. Post oxygen safety sign on the patient/resident's room door. F. Oxygen safety sign placed on patient/resident's room door.

Based on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were properly stored and or disposed of according to professional standards in 2 of 2 (Medication Room Hall 300/400) reviewed for medication storage.The facility failed to dispose of expired IV mixed solution medications.The facility failed to properly store 1 glass bottle medication in the refrigerator which led to the breaking of the bottle. This failure caused the medication to be spilled inside of the plastic zip bag and caused breakdown of the box the mediation was stored in resulting in the medication being unsafe to administer.This failure could place residents receiving medication that is expired at risk of not receiving the intended therapeutic benefit of their medication, or other adverse side effects.The findings include:In an observation on 5/28/2026 at 11:30 AM of the Medication storage room for the 300/400 hall revealed 3 residents had IV medications that had expired. A total of 27 doses of IV mixed solution medications past the date on the labels to have been administered by. A total of 11 doses of Meropenem expired on 5/25/2026, 1 dose of Vancomycin expired on 5/26/2026, 3 doses of Cefazolin expired on 4/1/2026 and 9 doses of Cefazolin expired on 4/6/2026. One refrigerated medication stored in a clear zipper sealed bag had a broken bottle and the medication and box were saturated in a fluid substance making the medication unsafe for administration. In an interview with RN-D on 5/28/2026 at 11:30 AM while observing the medication room, she stated the nurses or the nurse manager were responsible for ensuring out of date medications were removed from the storage room. She stated 3 of the expired medications belonged to residents currently in the facility, and one that had been discharged from the facility. She stated that administering medications that are out of date would not work as well, decrease the efficacy of the dose or cause infection to get worse. RN-D was unaware of the broken bottle of medication stored in the refrigerator. She stated a negative outcome would be the medication would be contaminated and could possibly contaminate other medications in the refrigerator. In an interview with DON on 5/28/2026 at 1:40 PM she stated her expectation was for medications not being used or expired were to be disposed of in the biohazard box in the medication storage room. She stated it was the responsibility of the Charge nurse, ADON and DON to ensure medications are checked to ensure medications are properly stored, labeled, and discarded when not being used or expired. She stated that medication, routine or as needed, was no longer being administered would be kept for the resident until expired in case it was needed again. A negative outcome of administering medications that were not stored properly or were expired could result in the residents not getting medications that are effective for their prescribed treatment. In an interview with ADMN on 5/28/2026 at 1:55 PM, he stated when a medication was out of date or was no longer ordered for a resident, the medication should be removed from circulation and destroyed or sent back to pharmacy for credit. He was unable to state a negative outcome for having expired medication or for contaminated medications. He stated it was the responsibility of the nurse, ADON or DON to check the medication rooms for expired or unused medications. The administrator stated facility did not have a policy related to removal or disposal of expired, broken, or unused non-narcotic medications.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #113) of 3 residents reviewed for infection control.CNA A failed to change her gloves after they became contaminated while assisting Resident #113 with incontinent care. CNA A also used the same wipe to wipe the resident's peri-area several times with the same side of the wipe. (Peri-care is the hygienic cleaning and maintenance of the genital and anal areas to prevent infection, skin breakdown, and odor, especially for individuals who need assistance). These failures could place residents at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #113's face sheet dated 05/27/2026 indicated he was admitted to the facility on [DATE] with diagnoses of stroke and muscle weakness. He was [AGE] years of age. Record review of Resident #113's Quarterly MDS, dated [DATE], revealed Section H - Bladder and Bowel. Urinary Continence = 3. Always incontinent. (no episodes of continent voiding). Bowel continence. 3. Always incontinent (no episodes of continent bowel movements). Record review of Resident #113's care plan revised on 03/25/2026 indicated in part: Resident has functional incontinence of bowel and bladder due to impaired mobility r/t CVA (Stroke) with Left sided weakness. 6/10/25 He complain of urinary pain. Resident will remain clean, dry and odor free and no occurrence of skin break down will occur over next 90 days. Monitor for incontinence per routine rounds and PRN, change promptly and apply a protective skin barrier to skin. Observation on 05/26/2026 at 10:28 AM CNA A performed incontinent care for Resident #113. The CNA sanitized her hands and put on a pair of clean gloves. CNA A then provided privacy and explained to the resident what she was going to do. The CNA undid Resident #113's brief and then took some wet wipes and wiped the resident's peri-area with side to side motions. CNA A then took some more wipes and wiped the resident's peri-area from front to back but would but would then use the same side of the wipe to wipe from the front to the back again. The CNA then turned Resident #113 on his side and took some wet wipes and wiped the resident's rectal area several times from front to back while using the same wipe and the same side of the wipe. While wearing the same gloves, CNA A took a clean brief and fastened it to Resident #113. Interview on 05/26/2026 at 3:10 PM CNA A said she understood that she should have used the wipes only one side at a time and she should have changed her gloves before she fastened the clean brief on Resident #113. The CNA said not changing her gloves or reusing the wipes could lead to cross contamination or infections. Interview on 05/28/2026 at 1:16 PM the DON said that it was expected for the CNAs to use a new wipe every time they wiped the resident's peri-area. The DON said that the CNA should have not wiped back and forth and only front to back. The DON said that the CNA should have changed her gloves and sanitized her hands before she took the clean brief and fastened it to the resident. The DON said that if the CNA did not change her gloves or wipe the correct way then it could possibly lead to cross contamination or the spread of infections. The DON said that they conducted training regarding incontinent care on a mannequin. The DON said that the CNAs received training or skill check-offs from the SDC which were done annually and also on random picks . The DON said if there was a trend or rise of UTIs then they would conduct more incontinent training. Interview on 05/28/2026 at 1:24 PM the SDC said that the CNAs were expected to wipe from front to back when they performed peri-care and not a side to side motion as that could possibly cause the spread of germs. The SDC said the CNAs were trained on an annual basis and at random times. The SDC said it was expected for the CNAs to change their gloves once they became contaminated to prevent cross contamination. The SDC said if the CNAs did not change their gloves, then that could possibly lead to the spread of infections. Interview on 05/28/2026 at 1:45 PM the ADMN said the CNA's were expected to wipe the resident's peri-area from front to back. The ADMN said the CNA should have changed their gloves after they became contaminated to prevent the spread of infections. Record review of the facility document titled Infection prevention and control policies and procedures and dated 05/15/2023 revealed in part: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying reporting, investigating, and controlling infections and communicable disease. The program covers all residents, staff, consultants, students in the facility's nurse aide training program or from affiliated academic institutions, volunteers, visitors, and other individuals providing services under a contractual agreement and is a based on the individual facility assessment following accepted national standards. Infection prevention and control program consists of currently acceptable infection control standards, practices, and activities. Examples of these are: Surveillance for healthcare acquired infection (HAI) identification; data analysis, and evaluation. Infection prevention and control program plan (continued) 6. Staff Development: 10) Cleaning, disinfecting and sanitation procedures. Compliance with applicable federal, state, and local regulations concerned with patients/residents and employees. Staff are provided with information and training on: Infection prevention and control information and plans. Hand hygiene, including hand washing and alcohol-based hand rub (ABHR). Universal/standard and transmission-based precautions. Record review of the facility document titled Staff education/orientation policies and procedures dated 01/12/2024 indicated in part: Competency: Peri-care. Performance criteria. Provides privacy, performs hand hygiene, applies disposable gloves and other PPE as indicated. Male: Gently raises penis and places towel underneath if uncircumcised retracts foreskin. Disposes of soiled gloves, performs hand hygiene, and puts on clean gloves. Washes tip of penis and urethral meatus first using circular motion from meatus outward. Rinses and dries completely unless using no rinse preparation, returns foreskin to normal position. Cleanses shaft to penis with gentle but firm downward strokes, notes abnormalities in underlying surface.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #22) reviewed for privacy, in that: The facility failed to ensure opened mail of Resident #22's was not out in a common area for anyone to see. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.The findings include: Record review of Resident #22's admission record, dated 5.26.26, revealed Resident # 22 was an [AGE] year-old female admitted on 2.7.24 with diagnoses that included, but were not limited to, hypertension, Metabolic encephalopathy, atrial fibrillation, and Dysphagia. Record review of Resident #22's annual MDS, dated [DATE], revealed- a BIMS score of 99 out of 15 which indicated her cognitive status was severely impaired. During an observation on 5.26.26 at 2:25 pm Resident #22's open mail (Your Medicare Part D Explanation of Benefits) was out in a common area. Resident #22's mail had information such as date of birth , account number, and address. During an observation on 5.27.26 at 11:27 AM Resident #22's open mail was still sitting out in common area exposed to everyone. During an interview and observation on 5.27.26 at 2:15 PM DON stated that Resident #22's mail should be in the resident's room. She stated whether Resident #22 opened it or not, it was the responsibility of the staff to make sure no personal information of any resident was sitting out in a common room for anyone to see. During an interview on 5.28.26 at 2:50 PM Administrator stated that Resident #22's mail sitting out in the common area was brought to his attention. He stated this needs to be taken care of, HIPAA was not protected for the residents. He stated this was important to all residents because it was the responsibly of the staff to protect all residents' personal information. Record review of the facility's policy titled, Safeguards, Posted Protected Health Information, dated March 2013, reflected: POLICY:All employees safeguard electronic protected health information in an effort to fulfill their duty to maintain the confidentiality and integrity of patient/resident health information as required by law, professional ethics, and accreditation requirements. Access to and the use and disclosure of electronic protected health information is limited to the minimum necessary to fulfill the employee's obligations and duties. When accessing systems or applications that contain electronic protected health information including systems or applications administered by health plans or other providers; the following procedures must be followed. Whenever possible, the de-identified information will be used.

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of six residents (Resident # 51) reviewed for accommodation of needs.Resident #51's call light was not left within his reach or within sight.This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.Findings include:Record review of Resident #51's admission record, dated 5.26.26, revealed Resident # 51 was a [AGE] year-old male admitted on 2.3.23 with diagnoses that included, but were not limited to, Cerebral infarction (a medical emergency more commonly known as an ischemic stroke. It occurs when a blood vessel supplying the brain becomes narrowed or blocked, cutting off oxygen and vital nutrients, which leads to the death of brain tissue in that area), Hemiplegia (the severe or complete paralysis of one side of the body, usually affecting the arm, leg, and face), and hemiparesis following other cerebrovascular disease affecting left non-dominant side, and Epileptic seizures related to external causes.Record review of Resident #51's annual MDS, dated [DATE], revealed- a BIMS score of 99 out of 15 which indicated his cognitive status was severely impaired.- required extensive two-person staff assistance with bed mobility and transferring.During an observation and interview on 5.26.26 at 3:30 PM Resident #51 was lying in bed and his call light was up on nightstand above the bed against the wall. Resident #51 stated all he wanted was to be changed. He stated he can't reach his call light but just wanted to be changed. During an observation and interview 5.26.26 at 4:45 PM Resident #51 stated that he was changed. Observation of call light still on night stand up against the wall out of reach of the resident. During an observation on 5.27.26 at 11:27 AM Resident 51's call light revealed it was still out of reach. During an interview and observation on 5.27.26 at 2:15 PM DON stated that Resident #51's call light should be within reach of him. She stated this should have been moved yesterday 5.26.26. She stated she was not sure why any CNA or Nurse had not moved Resident #51's call light within reach. She stated her expectation was for all residents to always have the call lights within reach of them. She stated the policy was in place for the resident's safety and with the call light out of reach the resident could be hurt or need help and not get the assistance they need.During an interview on 5.28.26 at 2:50 PM Administrator stated that it was brought to his attention about the call light in the resident's room. He stated yes, the call lights need to be in reach of the residents so they can get help anytime they need it. He stated if it's not in reach and they need it the resident could get hurt or not get the assistance the residents need. Record review of a facility provided policy titled, Call Lights, Responding To dated May 2023, revealed, PROCEDURES:6. When leaving the patient or resident room, ensure the call light is placed within thepatient's/resident's reach.

Based on observation, interviews, and record reviews, the facility failed to ensure the residents' right to secure and confidential personal and medical records for 6 (unknown resident) residents. The facility failed to ensure the privacy of the unknown residents by locking the laptop screen, so the residents' information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm, and decreased quality of life. Findings included:Observation on 4-14-2026 at 9:20 AM - During initial rounds of the facility, it was by the observed in the common area that the laptop on the crash cart was open, with Matrix electronic health care records platform displaying several residents' information on the screen. The AD asked if this surveyor needed help, and I advised the AD that the laptop screen was open, displaying the residents' information. The AD stated that was her laptop and that someone was yelling for help, so she did not think to shut the laptop. AD stated that it was more important to assist the resident than to close the laptop. An interview on 04/15/2026 at 12:20 PM with LPN B revealed that she has worked at the facility for 5 years. LPN B stated that if she ever steps away from the laptop, it should be closed or the screen locked. The LPN B stated that when she administers medication, she keeps a screen open, retrieves the medications, locks the screen, and gives the resident the medication. The LPN B stated that if the laptop is left open with the resident's information on it, someone could see it and know what's going on with the resident. The LPN B stated that leaving the laptop open with the resident's information is a HIPAA violation. The LPN B stated that she has had in-service training on HIPAA and confidentiality of residents' records. The LPN B stated the last time she had in-service training was about two weeks ago. An interview on 04/15/2026 at 12:40 PM, with AD revealed the following. AD stated that someone was in the corner and yelled for help. The AD stated that she should have closed the laptop, but she didn't think about it at the time because she was helping the resident. The AD stated that she is not supposed to leave the laptop open with residents' information on the screen. She stated that if the laptop is left open, then someone could get the residents' information. The AD stated that it is the user's responsibility to close the laptop or lock the screen when it is left. The AD stated that this is a HIPAA violation. The AD stated that the last time she had been in-serviced on HIPAA and privacy was on 3-17- 2026.An interview on 04/15/2026 at 1:42 PM with CNA A revealed that she has been at the facility for five years 5 years. CNA A stated that the laptop screen should never be left open with residents' information displayed. The CNA stated that if a laptop is left open with residents' information on it, anyone walking by could access that information. CNA A stated she's never seen anybody leave the laptop screen open with resident information on it. CNA A stated that if she saw someone leave the screen open with residents' information on it, she would close the laptop screen and remind that person that the screen cannot be left open with residents' information on it. CNA A stated that she has had in-service training on HIPAA and resident rights. The CNA A stated that they usually have that training every three months. CNA A stated that the last time she had that training was a month ago.An interview on 04/15/2026 at 1:46 pm with RN C revealed that she has been at the facility for 4 months. RN C stated that laptop screens should never be left open so that someone passing by can see the residents' information. RN C stated, Never seen any other staff at the facility leaving their laptops open with resident information on the screen. RN C stated that if she did see another staff member leaving the laptop open, she would close it and remind them that they need to keep this resident's information safe. RN C stated that leaving resident information on the screen for someone passing by to see it is a HIPAA violation. RN C stated that she has had in-service training on HIPAA and residents' rights within the last month.An interview on 04/15/2026 at 1:51 pm with DON revealed that she has been at the facility for five years. The DON stated that it is her expectation that all staff at the facility using laptops with resident information on the screen should keep it secure. The DON stated that whenever she walks away from the laptop screen displaying resident information, she will shut or lock the screen. The DON stated that she has not witnessed staff leaving laptops open with resident information on the screen. The DON stated that if she did see it, she would remind the staff to shut the laptop screen or lock it. The DON stated that she would then start an in-service training. The DON stated that she has had in-service training on HIPAA and residents' rights. The DON stated that they have been providing in-service training every three months on HIPAA and privacy policies.An interview on 04/15/2026 at 2:21 pm with the ADM he stated that the staff told him a resident was yelling for help, and the AD went to assist the resident and did not close the laptop. The ADM stated that if it were his mom yelling for help, then he would not worry about the laptop being closed. The ADM stated that if a laptop is left open, a state worker can access the residents' information. The ADM stated that he has not seen any staff members leave laptops open with resident information on the screen. The ADM stated that if he saw a screen open, he would close the screen and remind the staff members that they needed to shut or lock the screen. The ADM stated that this is a HIPAA violation; don't leave the screen open with residents' information on it.Record Review of Health Information Management Policies And Procedures Policy revised on 4-29-2022 revealed the following.POLICY: Protected Health Information (PHI) is not be used or disclosed in a manner that violates the HIPAA Privacy Rule, Facility's Policies and Procedures or any other federal or state regulation governing confidentiality and the privacy of health information. The staff prevents the prohibited uses and disclosures of PHI and limits incidental uses and disclosures when PHI is posted within the Facility for permitted purposes. PHI is not posted or displayed in a public location except as allowed by the HIPAA Privacy Rule and identified in the Notice of Privacy Practices or as required by federal and state laws and regulations. All employees safeguard electronic protected health information in an effort to fulfill their duty to maintain the confidentiality and integrity of patient/resident health information as required by law, professional ethics and accreditation requirements. Access to and the use and disclosure of electronic protected health information is limited to the minimum necessary to fulfill the employee's obligations and duties. When accessing systems or applications that contain electronic protected health information including systems or applications administered by health plans or other providers; the following procedures must be followed. Whenever possible, the de-identified information will be used.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy, in that: Resident #1's September 2025 MARs did not reflect documentation that heart rate and blood pressure was done. Resident #2's September 2025 nurse's notes did not document reasons why blood pressure medication was given when it was supposed to be held. This deficient practice could affect residents whose records were maintained by the facility, by placing them at risk for errors in care, and treatment.Record review of Resident #1's admission face sheet dated 09/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included atrial flutter (a condition where the upper chambers of the heart beat too quickly) and Essential hypertension (high blood pressure). Review of Resident #1's initial MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #1's cognitive skills for decision making were intact. Record review of Resident #1's physician's order for September 2025 revealed:Metoprolol Succinate tablet extended release 24 hr:25 mg: Amount to administer 12.5mg oral, once a day. Hold for SBP <110 and heart rate <60 for hypertension.Digoxin tablet 125 mcg (0.125) amount to administer 1 tablet once a day for typical atrial flutter. Hold if pulse was below 60. Record review of Resident #1's Medication Administration Record for September 2025 revealed: Metoprolol 12.5mg was documented as not given on 9/26/2025. The medication order stated to hold if SBP was 110 and heart rate was < 60. There was no blood pressure or heart rate documented as done on the MARs on 9/26/2025. There were blanks on the MARS for the blood pressure and heart rate. Digoxin 125 mcg (0.125mg) mg one tablet was documented as not given on 9/24/2025, however the section on the MARs for the pulse was blank on 9/24/2025. In an interview on 09/26/2025 at 3:00pm with MA B she said she was not the one who gave Resident #1 his medication. She said there should be no blanks on the MARS. She said if there were blanks on the MARs it would be difficult to determine if the medications were given or not given. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave Resident #1 his medications. She said she held the medications and should have documented on the MARs. She said she must pay more attention and always document when medications were given and or not given. Blanks on the MARs could indicate that the medication was given or not given. She said there should be no blanks on the MARs. Record review of Resident #2's admission face sheet dated 9/29/2025 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure). Review of Resident #2's initial MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #2's cognitive skills for decision making were intact. Record review of Resident #2's physician's order summary report revealed an order for Metoprolol 25 mg once a day for hypertension. Hold for SBP <120. Record review of Resident #2's MAR for September 2025 revealed the medication was administered between 7:00am -11:00am on 09/24/2025 when the SBP was 118/62 and 09/25/2025 between 7:00am and 11:00am when the SBP was 110/64. Further record review of the MAR revealed the medication was documented as given on those dates when the blood pressure was within the parameter it should be held. Record review of the nurse's progress notes for 9/24/2025 and 9/25/2025 revealed no documentation as to why the medication was not held. Observation on 09/26/2025 at 10:45 am revealed Resident #2 was lying in bed resting. Resident #2 was alert and oriented and could make their needs known. She was clean and well-groomed with no offensive odor. The call light was observed to be within reached. In an interview on 09/26/2025 at 10:45am Resident#2 said sometimes she did not get her blood pressure medication because her blood pressure was low. She said she was not getting the medication for blood pressure; she was getting it to treat her heart. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave medications to Resident#2. She said if the blood pressure was low, she would have held the medication. She said the documentation was an error. She said she was sure the medication was held and had forgotten to document it correctly. She said she was aware Resident #2's blood pressure was always low, and she had to hold it on several occasions. She said she must pay more attention and always document when medications were given and if not given to document it, and the reason it was given or not given. She said there should be no blanks on the MARS. Blanks on the MARs could indicate that the medication was not given. She said she must pay more attention and always document after completing a task. In an interview on 09/29/2025 at 11:37 AM, ADON said there should be no blanks on the MARs. She said if medications were given or not given it should be documented on the MARs. She said if there were no documentations it's hard to determine it the medications were given or not given. She said the expectations of the staff were to ensure the physician's orders were followed and documented in the resident's clinical records. She said the plan going forward was to in-service the staff, ensuring blood pressures were checked and documented. She said the staff will be in-serviced on documentation in resident's clinical records. Record review of the facility's policy and procedures on Documentation dated May 5th 2023 read in part .Subject: Documentation GuidelinesPolicy:Documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document the medical record. Guidelines:1. Print or write neatly and legibly5. Make all entries in chronological order and do not leave blank spaces between entries.6. Date and sign all entries, including the first initial last name and title of the writer.7. All entries should be based on the writer's first hand knowledge

Based on observation, record review and interview the facility failed to ensure that residents were provided pharmaceutical services to meet the needs of each resident for 1 of 5 residents reviewed for pharmaceutical services (Resident #2). The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was held as ordered by the physician when it was 118/62 and 110/64. This failure placed all residents who received medications at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including decreased in blood pressure and decreased quality of life.Record review of Resident #2's admission face sheet dated 9/29/2025 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure). Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #2's cognitive skills for decision making were intact. Record review of Resident #2's physician's order summary report revealed an order for Metoprolol 25 mg once a day for hypertension. Hold for SBP was <120. Record review of Resident #2's September 2025 MARs dated 09/26/2025 revealed Resident #2's Metoprolol 25 mg one a day for high blood pressure was administered between 7:00am -11:00am on 09/24/2025 when the SBP was 118/62, and on 09/25/2025 when the SBP was 110/64. the medication was not documented as held as ordered by the physician.Record review of the nurses notes for 9/24/2025 and 9/25/2025 revealed no documentation as to why the medication was not held. Observation on 09/26/2025 at 10:45 am revealed Resident #2 was lying in bed resting. Resident #2 was alert and oriented and could make their needs known. She was clean and well-groomed with no offensive odor. The call light was observed to be within reached. In an interview on 09/26/2025 at 10:45am with Resident #2 revealed sometimes, she did not get her blood pressure medication because her blood pressure was low. She said she was not getting the medication for blood pressure; the medication was to treat her heart. In an interview on 09/26/2025 at 3:00pm with MA B she said she was not the one who gave Resident #2 her medication. She said, if the medication was within the parameter that it should be held, then it should be held. She said the medication should be documented as held by using parentheses or asterisk to indicate it was held. She said if there was no documentation the medication was held then one must conclude it was given. She said, if the blood pressure medication was given when it was ordered to be held, it could cause the blood pressure to drop lower and it could cause the resident to get dizzy, and the resident could fall. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave medications to Resident#2. She said if the blood pressure was low, she should hold the medication. She said she documented in error. She said she was sure the medication was held, and she had forgotten to document it correctly. She said if there was no indication on the MARs then it would be difficult to say it was held. She said if the medication was given to the resident and the blood pressure was low it would make the blood pressure drop lower and the resident would get dizzy and the resident could fall. She said she was aware Resident #2's blood pressure was always low, and she had to hold the medication on several occasions. She said she must pay more attention and always document when medications were given or not given. In an interview on 09/29/2025 at 11:37am, the ADON said blood pressure medication should not be given when the blood pressure was within the parameter the doctor said should be held. She said if medications were held it should be documented and the reason why it was held. She said if the medication was given, when it was supposed to be held the blood pressure could drop lower, and the residents could get dizzy and fall. She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records. She said the plan going forward was to in-service the staff, ensuring blood pressures were checked and supervise the blood pressure medication administration. She said the staff will be in-serviced on documentation in resident's clinical records. Record review of the facility policy titled Physician's Order dated May 5, 2023, Read in Part .Policy: The qualified licensed nurse will obtain and transcribe orders according to the facility's practice guidelines.ProceduresAdmissionThe qualified licensed nurse completes an admission medication regimen review from the transfer record from an acute care hospital, home or other entity.a. A call is placed to the physician to confirm the orders and request any additional orders as needed. Medication/Treatment1. The facility should not administer medications or biologicals except upon the order of a physician/prescriber lawfully authorized to prescribe them.2. Elements of medication include:- Parameters for holding medication if indicated.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy, in that: Resident #1's September 2025 MARs did not reflect documentation that heart rate and blood pressure was done. Resident #2's September 2025 nurse's notes did not document reasons why blood pressure medication was given when it was supposed to be held. This deficient practice could affect residents whose records were maintained by the facility, by placing them at risk for errors in care, and treatment. Record review of Resident #1's admission face sheet dated 09/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included atrial flutter (a condition where the upper chambers of the heart beat too quickly) and Essential hypertension (high blood pressure). Review of Resident #1's initial MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #1's cognitive skills for decision making were intact. Record review of Resident #1's physician's order for September 2025 revealed:Metoprolol Succinate tablet extended release 24 hr:25 mg: Amount to administer 12.5mg oral, once a day. Hold for SBP <110 and heart rate <60 for hypertension.Digoxin tablet 125 mcg (0.125) amount to administer 1 tablet once a day for typical atrial flutter. Hold if pulse was below 60. Record review of Resident #1's Medication Administration Record for September 2025 revealed: Metoprolol 12.5mg was documented as not given on 9/26/2025. The medication order stated to hold if SBP was 110 and heart rate was < 60. There was no blood pressure or heart rate documented as done on the MARs on 9/26/2025. There were blanks on the MARS for the blood pressure and heart rate. Digoxin 125 mcg (0.125mg) mg one tablet was documented as not given on 9/24/2025, however the section on the MARs for the pulse was blank on 9/24/2025. In an interview on 09/26/2025 at 3:00pm with MA B she said she was not the one who gave Resident #1 his medication. She said there should be no blanks on the MARS. She said if there were blanks on the MARs it would be difficult to determine if the medications were given or not given. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave Resident #1 his medications. She said she held the medications and should have documented on the MARs. She said she must pay more attention and always document when medications were given and or not given. Blanks on the MARs could indicate that the medication was given or not given. She said there should be no blanks on the MARs. Record review of Resident #2's admission face sheet dated 9/29/2025 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure). Review of Resident #2's initial MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #2's cognitive skills for decision making were intact. Record review of Resident #2's physician's order summary report revealed an order for Metoprolol 25 mg once a day for hypertension. Hold for SBP <120. Record review of Resident #2's MAR for September 2025 revealed the medication was administered between 7:00am -11:00am on 09/24/2025 when the SBP was 118/62 and 09/25/2025 between 7:00am and 11:00am when the SBP was 110/64. Further record review of the MAR revealed the medication was documented as given on those dates when the blood pressure was within the parameter it should be held. Record review of the nurse's progress notes for 9/24/2025 and 9/25/2025 revealed no documentation as to why the medication was not held. Observation on 09/26/2025 at 10:45 am revealed Resident #2 was lying in bed resting. Resident #2 was alert and oriented and could make their needs known. She was clean and well-groomed with no offensive odor. The call light was observed to be within reached. In an interview on 09/26/2025 at 10:45am Resident#2 said sometimes she did not get her blood pressure medication because her blood pressure was low. She said she was not getting the medication for blood pressure; she was getting it to treat her heart. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave medications to Resident#2. She said if the blood pressure was low, she would have held the medication. She said the documentation was an error. She said she was sure the medication was held and had forgotten to document it correctly. She said she was aware Resident #2's blood pressure was always low, and she had to hold it on several occasions. She said she must pay more attention and always document when medications were given and if not given to document it, and the reason it was given or not given. She said there should be no blanks on the MARS. Blanks on the MARs could indicate that the medication was not given. She said she must pay more attention and always document after completing a task. In an interview on 09/29/2025 at 11:37 AM, ADON said there should be no blanks on the MARs. She said if medications were given or not given it should be documented on the MARs. She said if there were no documentations it's hard to determine it the medications were given or not given. She said the expectations of the staff were to ensure the physician's orders were followed and documented in the resident's clinical records. She said the plan going forward was to in-service the staff, ensuring blood pressures were checked and documented. She said the staff will be in-serviced on documentation in resident's clinical records. Record review of the facility's policy and procedures on Documentation dated May 5th 2023 read in part .Subject: Documentation GuidelinesPolicy:Documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document the medical record. Guidelines:1. Print or write neatly and legibly5. Make all entries in chronological order and do not leave blank spaces between entries.6. Date and sign all entries, including the first initial last name and title of the writer.7. All entries should be based on the writer's first hand knowledge

Based on observation, record review and interview the facility failed to ensure that residents are free of medications errors for 1 of (Resident #2) 5 residents reviewed for medications errors. The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was held as ordered by the physician when it was 118/62 and 110/64. This failure placed all residents who received medications at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including decreased in blood pressure and decreased quality of life. Record review of Resident #2's admission face sheet dated 9/29/2025 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure). Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating Resident #2's cognitive skills for decision making were intact. Record review of Resident #2's physician's order summary report revealed an order for Metoprolol 25 mg once a day for hypertension. Hold for SBP was <120. Record review of Resident #2's September 2025 MARs dated 09/26/2025 revealed Resident #2's Metoprolol 25 mg one a day for high blood pressure was administered between 7:00am -11:00am on 09/24/2025 when the SBP was 118/62, and on 09/25/2025 when the SBP was 110/64. the medication was not documented as held as ordered by the physician.Record review of the nurses notes for 9/24/2025 and 9/25/2025 revealed no documentation as to why the medication was not held. Observation on 09/26/2025 at 10:45 am revealed Resident #2 was lying in bed resting. Resident #2 was alert and oriented and could make their needs known. She was clean and well-groomed with no offensive odor. The call light was observed to be within reached. In an interview on 09/26/2025 at 10:45am with Resident #2 revealed sometimes, she did not get her blood pressure medication because her blood pressure was low. She said she was not getting the medication for blood pressure; the medication was to treat her heart. In an interview on 09/26/2025 at 3:00pm with MA B she said she was not the one who gave Resident #2 her medication. She said, if the medication was within the parameter that it should be held, then it should be held. She said the medication should be documented as held by using parentheses or asterisk to indicate it was held. She said if there was no documentation the medication was held then one must conclude it was given. She said, if the blood pressure medication was given when it was ordered to be held, it could cause the blood pressure to drop lower and it could cause the resident to get dizzy, and the resident could fall. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave medications to Resident#2. She said if the blood pressure was low, she should hold the medication. She said she documented in error. She said she was sure the medication was held, and she had forgotten to document it correctly. She said if there was no indication on the MARs then it would be difficult to say it was held. She said if the medication was given to the resident and the blood pressure was low it would make the blood pressure drop lower and the resident would get dizzy and the resident could fall. She said she was aware Resident #2's blood pressure was always low, and she had to hold the medication on several occasions. She said she must pay more attention and always document when medications were given or not given. In an interview on 09/29/2025 at 11:37am, the ADON said blood pressure medication should not be given when the blood pressure was within the parameter the doctor said should be held. She said if medications were held it should be documented and the reason why it was held. She said if the medication was given, when it was supposed to be held the blood pressure could drop lower, and the residents could get dizzy and fall. She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records. She said the plan going forward was to in-service the staff, ensuring blood pressures were checked and supervise the blood pressure medication administration. She said the staff will be in-serviced on documentation in resident's clinical records. Record review of the facility policy titled Physician's Order dated May 5, 2023, Read in Part . Policy: The qualified licensed nurse will obtain and transcribe orders according to the facility's practice guidelines.ProceduresAdmissionThe qualified licensed nurse completes an admission medication regimen review from the transfer record from an acute care hospital, home or other entity.a. A call is placed to the physician to confirm the orders and request any additional orders as needed. Medication/Treatment1. The facility should not administer medications or biologicals except upon the order of a physician/prescriber lawfully authorized to prescribe them.2. Elements of medication include:- Parameters for holding medication if indicated.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 2 of 5 medication carts (medication cart Hall 100 and 200) reviewed for medication storage. - The facility failed to ensure the back of 100 and 200 hall medication carts did not contain eyedrops, ointment, cream and nasal spray that were opened and not labeled with the resident's name and date. This failure could place residents at risk of adverse medication reactions and infections. Findings Include: Observation on [DATE] at 2:11 PM revealed the medication cart for 100 hall with MA A. The 100 hall medication cart had the following medications with no open date documented: 1. Latanoprost Ophthalmic solution was open and not dated 2.Timolol Maleate ophthalmic solution was open and not dated 3. Olopatadine hydrochloride solution was open and not dated 4.Lumigan Ophthalmic solution was open and not dated 5.Refresh Celluvisc lubricant eye Gel 30 single use container was open and not dated 6. Lubricant eye was open and not dated 7. Onasl Beclomethasone dipropionate nasal was open and not dated 8. Aerosol 80 mcg per spray was open and not dated 9. Saline Nasal Spray was open and not dated 10 Fluticasone Propionate nasal spray was open and not dated 11. Artificial tears lubricant eye drop was open and not dated 12. Artificial tears lubricant eye drop was open and not dated 13. Artificial tears lubricant eyedrop was open and not dated 14. Artificial tears lubricant eyedrop was open and not dated 15. Artificial tears lubricant eyedrop was open and not dated 16. Artificial tears lubricant eyedrop was open and not dated 17. Artificial tears lubricant eyedrop was open and not dated 18. Lumigan Ophthalmic solution was open and not dated In an interview with MA A on [DATE] at 2:40 PM, MA A said she was off for 2 days and she just came back, regarding medication opened and not dated, MA A said those medications should have an open date on them and it was good for 30 days after it was opened, she said she was in-serviced on drug labeling and storage. Observation of 200 hall nurses cart with LVN K on [DATE] at 2:42 PM revealed the 200 medication cart had the following ointment, cream and jelly with no open date documented: 1. Vaseline pure ultra white petroleum jelly 2. Treat Antifungal ointment moisturizer body lotion 3. Clotrimazole cream USP1% 4. Vaseline pure ultra white petroleum jelly In an interview with LVN F on [DATE] at 2:46 PM, she said when ointment, cream and jelly was open it should be dated because it was good for 30 days for it to be effective. Interview with the DON on [DATE] at 4:08 PM, she said eye drops, ointment and nasal spray when opened should be dated. The DON said she in-serviced staff about 4 weeks ago on dating medication when opened and storage for effectiveness. She said she would had to in-service again. A copy of the policy was requested . DON said the nurses were responsible for dating the medication when opened. Interview with the ADM on [DATE] at 4:15PM, he said the nurses should always date the drug when opened that was his expectations. Record review of the Medication Storage Information.pdf: Eye Drops Room Temp. (Unopened) Room Temp. (Opened) Manf. Exp. on Package Refer to facility P&P Miacalcin Nasal Spray Calcitonin Nasal Spray Refrigerator (Unopened) Room Temp (Opened **STORE UPRIGHT** Manufacture. Expired. On Vial 30 Day

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #6 and #30) reviewed for care plans. 1. The facility failed to ensure Resident #6's diagnoses were addressed in her comprehensive care plan. 2. The facility failed to ensure Resident #30's diagnoses and medications were addressed in her comprehensive care plan. This failure could place residents at risk of not receiving appropriate care. The findings included: 1. Record review of Resident #6's face sheet, dated 02/27/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included: Dementia (a general term for loss of memory, language, and other cognitive abilities); Generalized Anxiety Disorder (mental health disorder characterized by feelings of worry, fear and anxiety strong enough to interfere with daily life) and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson's disease ( Progressive movement disorder of the nervous system), Cortical age-related cataract right eye, Shortness of breath, Repeated falls, Cortical age-related cataract (begins as white, wedge-shaped spots or streaks on the outer edge of the outer edge of the lens cortex).on the left eye (History of), Cognitive communication deficit, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side ( a condition that causes partial or total paralysis of one side of the body), Visual hallucinations ( when someone sees images or things that aren't actually there) and type 2 diabetic mellitus ( high glucose in the blood). Record review of Resident #6's quarter MDS assessment, dated 12/14/2024, revealed a BIMS score of 02, iwhich indicated severely impaired cognition. Resident #6 was assessed as feeling down, depressed and had diagnoses which included Dementia, Anxiety Disorder and Depression. Record review of Resident #6's Order Summary, dated 02/26/2025, revealed physician orders which included the following: - Clorazepate dipotassium - Schedule 1V 7.5 mg (Miligram) Give 2 tablets to equal 15 mg by mouth every 12 hours ( 9:00 AM and 9:00 PM) for anxiety disorder with a start date of 08/13/2024.; - Mirtazapine Oral Tablet 15 mg Give 1 tablet by mouth one time a day (9:00 PM) for Major Depressive disorder with an order date of 11/06/2024. -Mirtazapine Oral Tablet 7.5 mg Give 1 tablet by mouth one time a day (7:00 AM) for Major Depressive disorder with an order date of 11/06/2024. -Benadryl Allergy (diphenhydramine HCL) tablet, 25mg oral twice a day 7:00 AM and 6:00PM with an order date of 1/31/2024. -Sinemet (Carbidopa-Levodopa) tablet 25-100 mg, Give 2 tablets by mouth 3 times daily for Parkinsonism at 9:00AM, 1:00PM and 5:00 PM with an order date of 12/04/2024. - -Glipizide tablet 5mg oral once a day for 7:00 AM with an order date of 2/27/2024 Record review of Resident #6's Comprehensive Care Plan initiated 12/20/2024 revealed there were no focus areas addressing the resident's diagnoses of Generalized Anxiety Disorder, Depression or Dementia, and no focus areas which indicated the resident's active orders for anti-anxiety, anti-depressants, and anti-Parkinson's disease medications. 2. Record review of Resident #30's face sheet, dated 03/24/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had a diagnosis which included: Generalized Anxiety Disorder (mental health disorder characterized by feelings of worry, fear and anxiety strong enough to interfere with daily life). Record review of Resident #30's quarter MDS assessment, dated 1/13/2025, revealed a BIMS score of 99, which indicated severely impaired cognition. Record review of Resident #6's Order Summary, dated 02/26/2025, revealed physician orders which included: - Lorazepam 0.5 mg by mouth every hours of sleep (between 8:00 PM to 10:00 PM) for anxiety disorder with a start date of 11/5/2024. Interview with LVN-MDS A on 2/27/25 at 2:47 PM, LVN-MDS A said she had been working as the MDS person for 3 years, she completed care plans, with the Activities Director and Social Services. Resident #6 and Resident #30's Comprehensive Care Plan did not address their diagnoses of Anxiety, Parkinson's Depression or Dementia, and did not address their active orders for anti-anxiety and anti-psychotic medications, but it should have. MDS-A stated these diagnoses and medications were ordered/documented prior to her Care Plan being completed, so should have been included on her Comprehensive Care Plan. LVN MDS-A stated these diagnoses and medications should automatically trigger a Care Area Assessment (CAA) area and she did not know why they were not triggered or why they were missed. LVN MDS-A stated she was responsible for the quarterly and annual assessments of the Comprehensive Care Plan. LVN MDS-A further stated it was important for these diagnoses and medications to be addressed in the Care Plan so staff had the information needed to meet the resident's specific care needs. Interview with the DON, on 02/27/2025 at 4:05 p.m. revealed the Comprehensive Care Plans needed to address and include all of the residents' nursing, mental and psychosocial needs, and contain the interventions and services the resident would need to meet these needs. The DON said she would be assessing and in-servicing staff to ensure the resident needs were being met to include completion of assessments and Care Plans. Record review of the facility's, undated, policy titled Comprehensive Care Planning, revealed Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. 35822

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 8 residents (Resident #14) reviewed for respiratory care. The facility failed to change Resident #14's oxygen tubing and humidifier bottle every 7 days. This failure could place residents at risk for respiratory infections, unwanted hospitalization and decrease in quality of life. Findings include: Record review of Resident #14's, undated, face sheet revealed a [AGE] year-old female who was admitted to the facility originally on 01/12/22 and again on 02/13/25. Resident #14's had diagnoses which included cerebral infarction (when blood flow to the brain is blocked), spinal stenosis (spaces inside the bones of the spine get too small putting pressure on the spinal cord and the nerves that travel through the spine) , cough, obstructive sleep apnea (intermittent airflow blockage during sleep), Meniere's disease (disease of the inner ear) , hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and shortness of breath. Record review of Resident #14's annual MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident cognition was intact. Section O-Special Treatments, Procedures, and Programs reflected the resident was receiving oxygen therapy which consisted of oxygen and BIPAP (non-invasive ventilation technique that provides air to help a person with breathing difficulties). Record review of Resident #14's Comprehensive Care Plan, dated 09/08/2021 and revised on 12/18/2024, reflected the resident was being care planned for diagnoses which included obstructive sleep apnea, history of shortness of breath, and used a BIPAP may use oxygen via NC as ordered by physician; at risk for SOB. The intervention included changing tubing per facility protocol. Record review of Resident #14's Physician Order Summary Report for the month of February 2025 reflected the following orders: -Dated 09/09/21 BIPAP at HS, assure good seal on mask and O2 1L connected to tubing; refill distilled water in BIPAP as needed (DX: obstructive sleep apnea) at bedtime; 8:00PM. -Dated 02/28/23 Oxygen 2 liters PRN via nasal cannula for O2 sat < 92% every shift PRN. -Dated 11/03/23 Equipment Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly frequence (once on Sunday). Record review of Resident #14's TAR for the month of February 2025 reflected the resident was receiving BIPAP and oxygen as ordered by the physician. The TAR reflected documentation of oxygen equipment was changed on 02/23/25. The initials on the TAR read. Observation on 02/25/25 at 10:12AM revealed Resident #14 was awake in bed. Further observation was made of an oxygen machine in the room with a humidifier bottle attached to the machine. The date on the humidifier bottle read 02/16/25. The oxygen tubing was dated 2/16/25. Observation on 02/26/25 at 2:04 PM revealed Resident #14 was not the in room. The date on the resident's oxygen tubing read 02/23/25. Further observation of the humidifier bottle revealed it was dated 02/16/25. Observation on 02/27/25 at 9:16 AM revealed Resident #14's oxygen humidifier bottle was dated 02/16/25. Interview on 02/25/25 at 9:16 AM Resident #14 said she used her oxygen at nighttime. Interview on 09/27/25 at 9:16 AM, Resident #14 said she was still being placed on her BIPAP machine with oxygen at night. Interview on 09/27/25 at 9:20 AM, ADON E said she worked at the facility Monday-Friday and was assigned to Halls 300 & 400. ADON E said respiratory equipment should be changed once a week on a Sunday on the night shift. ADON E said this was for infection control. ADON E said when respiratory equipment was not changed as ordered, it placed the resident at risk for upper respiratory infections. ADON E said once the nurse changed out the equipment, it was documented on the TAR that the task was completed. ADON E said it was the responsibility of the ADON's to ensure this was being done. ADON E said when she reported to work, she looked at the oxygen equipment to ensure it was being done. ADON E said each resident had a guardian angel who did room checks as well-made as rounds on each room assigned. ADON E said the guardian angels assigned to Hall 300 were the Maintenance Director and the Medical Records Director. ADON E said LVN K was the nurse who worked the night shift. Interview on 02/27/25 at 9:30 AM, the Medical Records Director said she was not assigned to Resident #14's room but the Maintenance Director was. The Medical Records Director said when she made rounds on resident rooms, she checked for the room being clean and tidy, resident's had fresh water to drink, check the bathroom, make sure resident's were groomed and comfortable, and she also check respiratory equipment making sure that nothing was out dated. The Medical Records Director said if the equipment was outdated, she reported this to the nurse. The Medical Records Director said she utilized a check list of things to observe in the resident rooms. Interview on 02/27/25 at 10:00 AM, the DON said respiratory equipment such as oxygen tubing and oxygen humidifier bottles were changed every week on a Sunday by the night shift nurse to prevent infections. The DON said she would have to investigate what staff dated Resident #14's oxygen tubing for 02/23/25. The DON said the Maintenance Director was on leave on 02/23/25 (Monday) and did not return to work until 02/27/25. The DON said LVN K worked on 02/23/25 (Sunday) and did not return to work until 02/26/25 (Wednesday). Interview on 02/27/25 at 10:18 AM, the Infection Control Nurse said when staff did not change respiratory equipment per facility protocol (every 7 days), bacteria could form inside the tubing placing the resident at risk for upper respiratory infections. Attempted interview on 02/27/25 at 11:45 AM with LVN K, via phone was unsuccessful, a voicemail was left with a call back number. Interview on 02/27/25 at 5:55 PM, the DON said she spoke with LVN K who said he intended to change Resident # 14's respiratory equipment but got distracted. The DON said she would continue to investigate the matter. Record review of the facility's policy on Respiratory Equipment Change Schedule addressed nasal cannula, revision date February 02, 24 reflected in part: Nasal cannula change weekly, when soiled on an as needed basis or per state regulations

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 halls reviewed for infection control. 1. The facility failed to dispose soiled linen inside of a waste barrel in the soiled utility room on Hall 200. 2. The facility failed to place a trash bag in the trash barrel instead of on the floor in the utility room on Hall 300. These failures could place residents at risk for cross contamination, infections, and a decrease in quality of life. Findings include: Observation on 02/25/25 at 8:20 AM in the soiled linen room on hall 200 revealed two waste barrels. Sitting on top of one of the barrels was a large plastic bag with soiled linen. Further observation revealed a large towel laying on the floor. Observation on 02/25/25 at 10:26 AM on Hall 300 utility room revealed a trash bag tied up laying on the floor. There were no barrels in the soiled utility room. Interview on 02/25/25 at 8:25AM, Laundry Aide B said all soiled materials should be placed inside of the barrel and not on the floor to avoid cross contamination. Interview on 02/25/25 at 10:26 AM, the Manager of Housekeeping said she was the Manager of housekeeping, laundry, and floor tech. The Manager of Housekeeping said staff should not be placing trash on the floor but inside of the trash barrel receptacles and the same went for soiled linen barrels to avoid cross contamination. The Manager said it was the responsibility of the nursing staff to bring full barrel receptacles for trash and linen to the main soiled utility room and leave by her door to empty. The nursing staff then took an empty receptacle back to the soiled utility room on the halls. The Manager said normally at the end of each shift, the CNA's brought the yellow linen barrels to the main soiled utility room and got an empty barrel for trash and linen to be taken to the soiled utility rooms on each hall. Interview on 02/26/25 at 1:40 PM, LVN A said she was the nurse for Hall 200. LVN A said all soiled material was supposed to be stored inside of the soiled utility rooms inside of designated barrels and not on top of the barrels or on the floor to avoid contamination. Record review of the facility's policy on Infection Control, revised May 15, 2023, reflected in part: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases .proper handling of linen, wastes, equipment and supplies

Based on interviews and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 Residents (Resident #1, #2, #3). The facility failed to administer Resident #1's medication according to her physician order at the prescribed time. The facility failed to administer Resident #2's medication according to her physician order at the prescribed time. The facility failed to administer Resident #3's medication according to her physician order at the prescribed time. The facility failed to administer Resident #3's medication because they did not have the correct dosage. These failures could affect all residents and place them at risk of injury, pain, decline in health, or diminished quality of life. Findings Included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, cellulitis of right toe, lack of coordination, muscle weakness, dysphagia, cough, muscle wasting atrophy, pain, hypotension (low blood pressure), altered mental status, overactive bladder, and trigeminal neuralgia (A chronic pain condition affecting the trigeminal nerve in the face). Record review of Resident #1's Quarterly MDS dated [DATE] revealed she had a BIMS score of 12 which meant minimum cognitive impairment. Resident #1's pain frequency was rarely or not at all. Record review of Resident #1's physician orders dated 05/2024 revealed carbamazepine tablet; 200 mg; amt : 2 tablets; oral [DX: Trigeminal neuralgia] Every 12 Hours; 07:00 AM, 07:00 PM Observation on 05/30/24 at 10:34 AM during medication pass revealed Resident #1 was administered two carbamazepine 200 mg tablets 3 hours and 34 minutes past the prescribed time. Record review of Resident #2's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cognitive communication deficit, unsteadiness of feet, hemorrhoids, dysphagia, muscle weakness, insomnia, major depressive disorder, constipation, and aphasia. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she had a BIMS score of 99 due to the resident being unable to complete the interview. Record review of Resident #2's physician orders dated 05/2024 revealed .acetaminophen [OTC] tablet; 500 mg; amt: 2; oral Special Instructions: Give two 500mg to equal 1000mg Every 8 Hours; 06:00 AM, 02:00 PM, 10:00 PM Observation on 05/30/24 at 10:39 AM during medication pass revealed Resident #2 was administered two acetaminophen 500 mg, 4 hours, and 39 minutes past the prescribed time. Record review of Resident #3's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pain in the right hip, atherosclerotic heart disease, urinary tract infection, pain in shoulder, dysphagia, lack of coordination, muscle wasting atrophy, diarrhea, hypothyroidism, anxiety, mood disturbance, hypertension (high blood pressure), and dementia. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she a BIMS score of 15 which meant she had limited cognitive impairment. Resident #3 was diagnosed with hypertension (high blood pressure). Record review of Resident #3's physician orders dated 05/2024 revealed AZO Cranberry (otc) tablet; 500mg; amt: 2; oral Special Instructions: Take 2 (two) soft gels daily with water. [DX: Urinary tract infection, site not specified] Once A Day; AM Cartia XT (diltiazem hcl ) capsule, extended release 24hr; 120 mg; amt: 120mg; oral [DX: Essential (primary) hypertension] Every 12 Hours; 07:00 AM, 07:00 PM Observation on 05/30/24 at 10:48 AM during medication pass revealed Resident #3 was administered one tablet of diltiazem hcl 120 mg, 3 hours, and 48 minutes past the prescribed time. Resident #3 was not administered cranberry AZO 500 mg, the bottle on the medication cart was cranberry AZO 450 mg. In an interview on 05/30/24 at 10:50 AM Resident #3 stated she usually received her medications but sometimes they came late . In an interview on 05/30/24 at 10:52 AM Med Aide A stated the facility did not have the 500 mg of Cranberry Azo. She stated she had the 450 mg tablets on her medication cart. She will speak with the nurse to have the order changed to 450 mg or the nurse will order 500 mg Cranberry. In an interview on 05/30/24 at 1:51 PM Med Aide A stated she was running behind, the facility had a lot of patients. She had to assist the nurse aides with some duties, so she was running behind on the medication pass. She stated staff can give medications 1 hour before or 1 hour after prescribed times. She should have let nurse know she was running late. Depending on the drug the physician wants to make sure the medications were on time and the resident doesn't have any reactions. In an interview on 05/30/24 at 2:06 PM the DON stated when the med aide was running behind or helping staff the ADON or Nurse would help with med pass. The medication aide was not usually running late, and this does not happen often. The DON said she will call the physician to follow up on the residents. The staff can give the medications an hour before or an hour after the prescribed time . In an interview on 5/31/24 at 2:17 PM the Central Supply staff said she was responsible for reordering the OTC meds. If the brand or strength was not correct, she should let the nurse know, should have tried to get a medication from somewhere else, or have the order changed. She was not aware of the cranberry Azo medication. If she was made aware she could have had it taken care of . In an interview on 05/31/24 at 3:04 PM Med Aide B stated when or if she was running late, the staff report that to the nurse, and the nurse will help with the medication pass. The med aide should report to the nurse if a medication was out. She lets the nurse or the staff that orders the medications know . In an interview on 05/31/24 at 3:12 PM Med Aide C stated if the medication was running low staff were supposed to inform the nurse to let them know. If the Med Aide was running late, they let the nurse know, so the, the nurse would step in, and help. In an interview on 05/31/24 at 3:50 PM LVN D stated if the Med Aides were running late, the nurse would assist with the meds. OTC go through Central Supply, the staff were supposed to notify her. The medication would be ordered, the physician notified, and family notified. Labs could be run to determine if the resident still required the medication. In an interview on 05/31/24 at 3:37 PM the DON said when Med Aides were running late, they would let the nurse know and the nurse would assist. The staff would let the physician or NP know the meds were late and see trends to determine if meds can be moved. Med Aide A said she was assisting with cleaning up a resident which caused her to run behind. She explained to the Med Aide A to communicate the situation. The nurse would have made sure the 7AM meds were given. The Med Aides were good and will assist with care. Typically, they don't give out meds in that area, they know to provide privacy, it cuts down on errors. It was important to give the residents meds on time so it will not contradict any other medications and the residents get the full effect of the medication. Record review of the facility policy Medication Management Program dated 5/5/23 revealed .Policy: The Facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .Administering the Medication Pass 2. Licensed or certified/permitted medication aide follows the MAR by identifying the eight rights .

Based on interview and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for five of five residents (five residents interviewed during a confidential group interview) who utilized laundry services at the facility. -The facility failed to ensure residents who utilized laundry services clothing was returned to them in a timely manner. These failures could place the residents at risk of decreased quality of like due to the lack clothing. Findings include: A confidential group interview was conducted with five residents on [DATE] at 1:57 PM. There were five residents present during the interview. All five residents reported lost items from the laundry services. The residents said laundry would go missing for an extended period of time and then would be found and returned, or the facility would replace it. One resident said she was missing all but two pairs of her pants. The same resident said the previous year she had to wear a nightgown and had spoken to the facility's administrator while wearing the nightgown because she had no other clothing. The resident said that day three loads of her clothing were returned to her. The residents all said the laundry services take a long time to return their clothing. They stated the clothing goes missing, was misplaced in other resident's rooms, or was delayed in return. Interview on [DATE] at 1:05 PM with The HKM, she said she had been employed for three days. The HKM said all laundry was to be labeled completely with the resident's name and room number. The HKM said in other facilities when there was unclaimed or unlabeled laundry, the CNA's will review it see if they can identify which residents clothing it was. The HKM said as she just started, the facility had not begun that process yet. The HKM said personal clothing was washed separate and there was no bleach put in the resident's clothing. The HKM said she had not seen a green laundry bag with a drawstring Interview on [DATE] at 9:58 AM with the HKM, she said she had been employed for four days. The HKM said her duties included scheduling, ordering supplies, ensuring staff coverage on all halls, ensuring housekeeping duties were completed timely, ensuring the cleaning chemicals were at appropriate levels, overseeing all housekeeping services including all laundry services, and reviewing grievances. The HKM said she had been made aware of resident complaints of missing laundry items. The HKM said she had begun to hang-up all the laundry which did not have a name on it. The HKM said she would set a date with the activities director to bring all of that laundry to a centralized location for the residents and staff to claim. The HKM said she would be present and would ensure each unlabeled piece of clothing was then labeled and returned to the resident. The HKM said in order to prevent that from occurring in the future she had spoken to the intake director and asked that she be informed when a new resident admitted , and she would personally label all clothing for that resident. The HKM also asked that staff inform her if residents received new clothing and she would label that personally as well. Interview on [DATE] at 10:58 AM with The Administrator, he said he had been employed by the facility for two years, and with the company for almost three. The Administrator said his primary duties included protection of all the residents, financial oversight of the facility, customer service, and any other duties needed. The Administrator said his expectations for the third-party laundry services provider were that the laundry would be completed and completed properly. The Administrator said he expected the onsite third-party laundry personnel to fix mistakes and elevate issues which needed further review from the facility. The Administrator said he expected unclaimed laundry to be brought to a central location for claiming once monthly. The Administrator said the amount of unclaimed laundry in the laundry facility could have occurred in one month, but he was unsure if it had. The Administrator said some of the unclaimed laundry may have been from residents who had expired. The Administrator said he was aware that the facility had received nine separate grievances related to laundry in the previous six months. The Administrator said the facility's resident's complaints related to missing laundry were an ongoing concern. The Administrator said he had spoken to the third-party vendor's management about his concerns with the laundry services provided, and he had also spoken to his corporate leadership about the missing and late laundry concerns. The Administrator said the laundry's timeliness and missing laundry continued to be a concern for the facility. The Administrator said the third-party laundry services provided to the residents was not meeting his expectations. Record review of the facility's grievance log from [DATE] through [DATE] revealed nine resolved concerns related to laundry and no unresolved concerns. Record review of the facility's contract with the third-party vendor revealed the contract was initiated on [DATE]. The contract documented the third-party vendor would provide management, consulting services, and perform housekeeping services on the facility premises. Record review of the facility's Maintenance/Housekeeping Policies and Procedures: Laundry policy dated ,d+[DATE] revealed a policy statement which read Laundry services will comply with appropriate guidelines to assure that measures are implemented to provide pro effective laundry service. The policy documents the personnel would be trained appropriately in healthcare laundry, participate in education, and were properly dressed for the services at all times. Per the policy, the facility was required to have sufficient clean linens to meet the demands of the facility and access to clean linens was maintained during all shifts.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 5 Residents (Resident #38) and 1 of 8 medication carts (100 Hall Medication Aide Cart) reviewed for medication storage. The facility failed to ensure LVN B secured insulin from Resident #38's bedside when left unattended. The facility failed to ensure MA A locked 100 Hall Medication Cart before leaving it unattended. These failures could place residents at risk for possible drug diversions or accidental ingestion. Findings included: Resident #38 Record review of Resident #38's face sheet dated 01/04/2024 revealed the resident was admitted on [DATE]. Resident #38 was a [AGE] year-old male. The resident's admitting diagnosis included Type 2 diabetes mellitus (elevated blood sugar). Record review of Resident #38's care plan problem onset dated 06/08/2023 revealed: Problem: Resident #38 was a diabetic attempted to control by insulin; Goal: Diabetic status would remain stable as evidenced by Resident #38's blood sugar would remain within the resident's normal range; Approach: Administer medications as ordered. Record review of Resident #38's quarterly Minimum Data Set (MDS) dated [DATE] revealed Cognitive Patterns Brief Interview for Mental Status (BIMS) Summary Score of 15 out of 15 indicating resident's cognition was intact. Record review of Resident #38's Physician Order report dated 12/04/2023-01/04/2024 revealed Lantus U100 Insulin. Administer 23 units once a day in the morning. Record review of Resident #38's Diabetic Administration History dated 01/01/2024-1/04/2024 revealed LVN B administered insulin to Resident #38 on 01/04/2024. During an observation on 01/04/2024 at 8:08 AM revealed LVN B removed Resident #38's Lantus insulin Flex Pen (disposable insulin pen with dial up dosage and push button extension to dispense insulin) from the medication cart. During this observation LVN B dialed the flex pen to administer 23 units of insulin. LVN B placed the inulin flex pen on a small tray. As the observation continued at 8:12 AM LVN B carried the tray with insulin to Resident #38's bedside. Resident #38 was sitting up in bed with his tray table across in front of him. Resident #38 was observed eating breakfast independently using his right hand. LVN B placed the tray with insulin on the tray table next to Resident #38's breakfast tray. The tray with the insulin flex pen was within reach of Resident #38's right hand. LVN B pulled the resident's privacy curtain around the resident. The resident's bedside was not in view from the doorway. LVN B walked away from Resident #38's bedside to go to the medication cart parked in the hall at the doorway of the room. The resident's insulin was left unattended at the resident's bedside. LVN B returned to Resident #38's bedside at 8:13AM. During an interview on 01/04/2024 at 10:30 AM Resident #38 stated he saw the insulin left on his tray table. Resident #38 stated he had not seen anyone leave it there in the past. During an interview on 01/04/2024 at 1:25 PM LVN B stated medications should never be left at the bedside. LVN B stated she should have taken the medication with her. LVN B stated she thought she did take it with her. LVN B stated the risk was the resident could have taken it. LVN B stated it could cause harm to the resident. LVN B stated it was unlawful to leave medications unattended in the resident's reach. 100 Hall Medication Aide Medication Cart During an observation on 01/04/2024 at 8:25 AM revealed MA A was at Hall 100 Medication Aide Medication Cart in front of room [ROOM NUMBER]. MA A dispensed medications for the resident in room [ROOM NUMBER]. During the observation MA A left the medication cart unlocked parked in the hall in front of room [ROOM NUMBER]. MA A carried the medications into room [ROOM NUMBER]and closed the resident's privacy curtain. At 8:27 AM MA A returned to the medication cart. During an observation on 01/04/2024 at 10:18 AM an inventory of 100 Hall Medication Aid Medication cart accompanied with MA A revealed the following: Right Side: Drawer #1: Vitamins C, B, D, A; stool softeners; Calcium; Melatonin; Sodium tablets; Fiber tablets; Acidophilus (good probiotic for normal bacterial found in the intestine). Drawers #2, # 3, #4: Resident individual medication containers for 41 residents LEFT SIDE: Drawer #1: Artificial tear eye drops, nasal spray; Drawer #2: locked narcotic box for 11 residents; Drawer #3: liquid medications, antacid, laxatives, lactulose; Drawer #4: Medication supplies During an interview on 01/04/2024 at 3:26 PM MA A stated all medication carts were to be locked when left unattended. MA A stated the risk of the medication cart not being locked was that someone could get into it and take something they should not have. MA A stated she believed she left the cart unlocked because was nervous and forgot to lock it. MA A stated she normally locked the cart when she left it. MA A state next time she would think about what she was doing to make sure it was locked before she left it. In an interview on 01/04/2024 at 3:35 PM the DON stated Resident #38 could have done something with the insulin syringe, while it was left with him. She stated her expectations are that medication carts were locked when not attended. The DON stated it was important to ensure no one had access to any medications they should not have. The DON stated other resident could have taken something out of the unlocked medication cart. The DON stated the staff were trained quarterly and annually on medication storage. The DON stated the staff working on the medication cart was responsible for locking the cart before leaving it. The DON stated nurses, charge nurses, administration all were responsible to monitoring daily as they round the halls. The DON stated they would make more frequent rounds to do spot checks of medication carts and reeducate the staff. In an interview on 01/04/2024 at 3:46 PM the administrator stated leaving insulin at the bedside and medication carts unlocked when out of site was not best practice. The administrator stated medication carts should be locked when not in sight. Record review of the facility policy titled Pharmacy Services Policies and Procedures revision dated 04/01/2022 read in part . SECTION 8-MEDICATION STORAGE SUBJECT: 8.2 GENERAL GUIDELINES FOR STORAGE OF MEDICATION AND BIOLOGICALS POLICY: 1. Medications and biologicals are stored safely, securely and properly following manufacture's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartment under proper temperatures and other appropriate environmental controls to preserve integrity .

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Residents #105 and #77) reviewed for comprehensive assessments. -The facility failed to ensure Resident #105's comprehensive care plan reflected the use of antidepressant and anticoagulant medications. -The facility failed to ensure Resident #77's comprehensive care plan reflected the resident was receiving physical therapy services. These failures could place residents at risk of not receiving the care and treatment listed in the care plan and could lead to a diminished quality of care. Findings include: Record review of the admission sheet for Resident #105 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #105's comprehensive MDS assessment, dated 09/23/2022, revealed the BIMS score was 14 out of 15, which indicated intact cognitive mental status. Further view of section N0410 revealed Resident #105 was coded for receiving antidepressant and anticoagulant medications. Record review of Resident #105's physician orders, dated 09/21/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #105's physician orders, dated 09/21/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review, revealed an order, dated 09/21/22, for [MEDICATION(S)] tablet; 75 mg; amt: 1 tab; oral Once A Day 07:00 AM - 12:00 PM Record review of Resident # 105's care plan, initiated 09/22/22, revealed the resident was not care planned for receiving antidepressant or anticoagulant medications. Record review of Resident # 105's care plan, after surveyor's intervention revealed a care plan initiated 9/22/22 and revised on 10/12/22 read in part: .Problem: High risk for increase bleeding R/T BLOOD THINNING AGENT Resident currently takes: [ ] [MEDICATION(S)] [ ] [MEDICATION(S)] [ ] [MEDICATION(S)] [ x] ASA [x] Other [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] Goal: [Resident #105] will have no side effects from medication.Approach: Monitor for side effects. Notify MD if bleeding is not stopped with pressure. Soft bristle tooth brush for brushing teeth Problem: Resident #105 is at risk for adverse consequences R/T receiving antidepressant medication ([MEDICATION(S)]) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach: Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, [CONDITION(S)], or anticholinergic symptoms. Monitor Resident #105's mood and response to medication . Resident #77 Record review of the admission sheet for Resident #77 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #77's comprehensive MDS assessment, dated 09/13/22, revealed the BIMS score was 12 out of 15, which indicated moderately impaired cognitive mental status. Record review of Resident #77's Comprehensive Care Plan, dated 9/13/22, revealed therapy was not care planned. In an interviewed with Physical Therapist on 10/13/22 at 1:13p.m., she said Resident #77 started receiving PT, OT and speech therapy on 7/12/22 and was D/C on 8/12/22 due to change of payor source. Resident #77 resumed therapy on 09/09/22 to end on 11/07/2022. In an interview on 10/12/22 at 2:13p.m., with MDS Nurse A and MDS Nurse B, MDS Nurse A said foley, g-tube, falls, [CONDITION(S)], meds, PT services had to be care planned. She said, pretty much it's a group effort. Initial baseline care plan was initiated by the floor nurse, since they were the first contact with the resident. The MDS nurses updated the care plan quarterly and on change of condition to add behaviors and follow up on falls. She said ADONs were responsible for care plan on antidepressants, foley and [NAME]. MDS Nurse B said she was responsible/assigned for completing Resident#105's MDS and update the comprehensive care plan quarterly. In an interview on 10/12/22 at 2:21p.m., with ADON A, she said the floor nurses completed the baseline care plan and ADON looked over it. She said, all the department heads could add on the comprehensive care plan. In an interview on 10/12/22 at 2:36p.m., with the DON, she said the care areas that were triggered on CAAs were care planned. She said antidepressant meds were care planned as it gave the indication of having depression or risk of depression, anticoagulants for bleeding and services required. She said nursing was responsible for updating and completing the comprehensive care plan. She said it was important to update the care plan because nurses followed the care plan. No policy on care plan was provided on exit.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident #34 and #105) reviewed for respiratory care in that: -The facility failed to ensure Residents #34's and #105's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice could affect residents, who received oxygen therapy, and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Finding included: Record review of the admission sheet for Resident #34 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's Comprehensive MDS, dated [DATE], revealed the BIMS score was 99 out of 15, revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Further review of Section O0100: Resident was not coded for receiving oxygen therapy. Record review of Resident # 34's Care plan initiated 12/8/21 and revised on 2/5/22 revealed resident was not care planned for receiving oxygen therapy. Record review of Resident #34's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review 22 revealed an order, dated 09/16/22, for O2 at 2 liters per minute via nasal cannula Every Shift - PRN An interview and observation on 10/11/22 at 9:16 a.m. of Resident #34 revealed he was lying in his bed. He had a nasal cannula in place and an oxygen concentrator at his bedside. The concentrator was on and set to deliver 10 LPM (liters per minute). The oxygen tubing and the nebulizer mask were not dated. During an observation and interview on 10/11/22 at 9:28 a.m., ADON A confirmed Resident #34's concentrator was on and set to deliver between 10 LPM (liters per minute). The oxygen tubing was not dated. Further observation revealed a nebulizer mask was sitting on top of the side drawer in a clear bag, not dated. ADON A said she did not know Resident's oxygen administration orders. She said the tubing was changed weekly by the floor nurse. She said there should have been a date written to show when the tubing/neb mask was last changed. She said the ADONs were responsible to ensure the tubing was changed. She said that the importance of changing the tubing it was best infection control practice. In an interview and observation on 10/12/22 at 10:10 a.m., of Resident #34 revealed he was lying in his bed. He had a nasal cannula in place and an oxygen concentrator at his bedside. The concentrator was on and set to deliver 10 LPM (liters per minute). The oxygen tubing was not dated. Observation and interview on 10/12/22 at 10:12a.m., this Surveyor reviewed Resident #48's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, he was decompensating last week so we turned it up a little. I noticed he was on 10 L this morning at 10:00 am. His 02 stats were 99% so I texted and notified the physician. She said the physician told her to decrease O2 according to the order. She said if the resident had [CONDITION(S)], it could make it worst. She said, more is not always better it was important to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident#105 Record review of the admission sheet for Resident #105 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #105's Comprehensive MDS, dated [DATE], revealed the BIMS score was 14 out of 15, which indicated intact cognitive mental status. Further view of section O0100: Resident was not coded for receiving oxygen therapy. Record review of Resident # 105's Care plan initiated 9/22/22 and revised on 10/12/22 revealed resident was not care planned for receiving oxygen therapy. Record review of Resident #105's physician orders, dated 9/21/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Every Shift - PRN Record review of Resident #105's physician orders, dated 9/22/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview and observation on 10/11/22 at 9:43 a.m. of Resident #105 revealed she was lying in her bed. She had a nasal cannula in place and an oxygen concentrator at her bedside. The concentrator was on and set to deliver 2 LPM (liters per minute). The oxygen tubing was not dated. During an observation and interview on 10/11/22 at 9:46a.m., ADON A confirmed Resident #105's concentrator was on and set to deliver between 2 LPM (liters per minute). The oxygen tubing was not dated. In an interview on 10/12/22 at 2:36p.m., with the DON, she said the oxygen tubing was changed weekly on Sundays by the night shift nurses and the ADON checked weekly to ensure, as it placed risk for infections. She said it was important to adhere to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident#34 changed the setting and it was later adjusted as ordered. She said the nurses should be checking the oxygen setting daily to follow physician order. At the time policy on following physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of facility's Respiratory Policies and Procedures, revised 04/01/22, read in part: .Subject: Equipment Change schedule. Policy: The facility shall have a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community policies. Procedures: Equipment will be changed as follows: Equipment: Nasal Cannula-change on and as needed basis or per state regulations . No policy on following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program designed to provide safe , sanitary and comfortable environment and help prevent the transmission of communicable diseases and infections for 5 of 91 residents ( Resident #1, #2, #3, #5 and CR#4) reviewed for infection control. The facility failed to demonstrate an effective screening system when an HHSC surveyor completed the screening form required for entry. The facility failed to demonstrate an effective screening system when a staff member entered the facility and began working. The facility failed to separate COVID19 positive residents from COVID19 negative residents. The facility failed to prevent cross-contamination by ensuring COVID19 positive staff did not provide care to COVID19 negative residents. The facility failed to ensure staff who worked in an area designated for PUI residents for COVID19 donned appropriate PPE before entering the unit. An immediate jeopardy was identified on 07/16/20. While the IJ was lowered on 07/21/20, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread due to facility requiring more time to monitor the plan of removal for effectiveness. These failures placed all residents in the facility, staff and visitors at risk for exposure COVID19 infection. Findings include: Record review of the nursing facility COVID-19 Response read in part A nursing facility must have a COVID-19 response plan that includes the following:(1) Cohorting plans that include designated space for COVID-19 negative, quarantine, and isolation cohorts.(2) Spaces for staff to don and doff PPE that minimize the movement of staff through other areas of the facility.(3) Resident transport protocols. (4) Plans for obtaining and maintaining a two-week supply of PPE including surgical facemasks, gowns, gloves, and goggles or face shields. (5) Resident recovery plans for continuing care when a resident recovers from COVID-19 (c) A nursing facility must screen all residents, staff and people who come to the facility in accordance with the following criteria of this subchapter: (1) Fever defined as a temperature of 100.4 Fahrenheit and above, or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; (2) Signs or symptoms of COVID-19 including, but not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; (3) Additional signs and symptoms as outlined by the CDC: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html; (4) Contact in the last 14 days, unless to provide or receive critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED]. For updated information on affected countries visit: https://www.cdc.gov/coronavirus/2019-ncov/[MEDICATION NAME]/map-and-travel-notices.html. (d) A nursing facility must screen according to the following timeframes: (1) each resident at least three times a day, occurring at least once each shift; and (2) each employee or contractor before entering the facility at the start of their shift. (e) A nursing facility must cohort residents based on the residents' COVID-19 status. (f) A resident with unknown COVID-19 status must be quarantined and monitored for fever and symptoms of COVID-19 per CDC guidance. (g) A COVID-19 positive resident must be isolated until they meet CDC guidelines for the discontinuation of transmission-based precautions. (h) A nursing facility must implement a staffing policy requiring the following: (1) The facility must designate staff to work with each cohort and staff should not change designation from one day to another, unless required in order to maintain adequate staffing for a cohort. (2) Staff may not work with more than one cohort. (3) Staff must wear appropriate PPE as described in subsection (a)(6) of this section based on the cohort with which they work. (4) Staff must report to the facility via phone prior to reporting for work if they have known exposure or symptoms. (5) Staff must perform self-monitoring on days they do not work. (6) A policy regarding staff working with other long-term care (LTC) providers that includes the following: (A) Limits the sharing of staff with other LTC providers and facilities, unless required in order to maintain adequate staffing at a facility. (B) Maintains a list of staff who work for other LTC providers or facilities that includes the names and addresses of the other employers. (C) Requires all staff to report to the facility immediately if there are COVDI-19 positive cases at the staff's other place of employment. (D) Requires the facility to notify the staff's other place of employment if the staff member is diagnosed with [REDACTED]. (i) All NF staff must wear a facemask while in the facility. Staff who are caring for COVID-19 positive residents and those caring for residents with unknown COVID-19 status must wear an N95 mask, gown, gloves, and goggles or a face shield. All facemasks and N95 masks must be in good functional condition as described in the COVID-19 Response for Nursing Facilities, and worn appropriately, completely covering the nose and mouth, at all times. Screening Record review of CDC.gov website read in part, screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Fever is either measured temperature >100.0oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. Observation and record review on 07/8/2020 at 10:00am revealed when an HHSC surveyor entered the main entrance to the facility, her temperature was checked, and she answered questions on the facility COVID19 Prevention Worksheet, located at the front desk. One of the questions asked if the surveyor had worked in any building that had COVID19 positive cases. The surveyor wrote 'y' or 'yes' to indicate she had. The form reflected if any of the questions prompted a 'yes' response, entry to the facility was not to be granted. Continued observation revealed the staff did not review the answers before leaving the area to summon the administrator that a surveyor was at the facility. When the Administrator arrived at the front desk, she asked the surveyor if she had been screened. The surveyor answered that she had. The Administrator escorted the surveyor to her office. Observation and interview on 07/14/20 at 10:25 a.m., LVN B said she was the Charge Nurse for the 400 Hall. Observation revealed she was wearing full PPE except for gloves. She said the 400 Hall did house some COVID19 positive residents. Observation at that time revealed all visible staff had on full PPE, with the exception of gloves for some. Observation on 07/16/20 at 8:29 a.m. revealed HR A exit her vehicle and enter the facility via a door leading to the 400 Hall. She was wearing no PPE other than a mask. Record review on 07/16/20 at 8:32 a.m., revealed no one had been screened at the front desk yet that day. The surveyor was screened at that time. Observation on 07/16/20 at 8:35 a.m. revealed HR A was in her office working. Interview at that time revealed HR A said after she had entered, she walked down the 400 Hall to the nurses' station and was screened. She said no one was there to take her temperature, so she went to her office near the 400 Hall. She said she entered through that door because her office is close to the 400 Hall. Record review of the 07/16/20 COVID19 Prevention Worksheet for the 400 revealed HR A's name was not on the sheet as being screened. Record review of the CMS Form 802 dated 07/16/20 revealed 16 of the 19 residents living on the 400 Hall were COVID19 positive. The COVID19 status of the other 3 residents was 'unknown' according to a list provided by the facility. Interview on 07/16/20 at 8:50 a.m. with the Administrator, she said the DON was out due to having an increased temperature. She said the DON's COVID19 test results were obtained on 07/15/20, and that she had tested positive. Interview on 07/16/20 at 9:05 a.m. with the Administrator , she said the screening process was for staff to fill out the sheet (COVID19 Prevention Worksheet) and have their temperature taken. She said the worksheets were reviewed by the DON or NM E. Observation on 07/19/2020 at 12:23am, revealed surveyor entered COVID19 hall 100/200 hall without any screening provided. There was no screening set up and no PPE donning area before entering the hall. Observation on 07/19/2020 at 12:25am revealed an area beside the dining room with a plastic container that contained PPE. Further observation revealed a binder on the desk at the nurses' station with screening questions. There were two nurses and two aides around and Surveyor was not screened. Record review of facility daily screening questionnaire dated 7/17/2020 revealed staff member who came in at 2:00pm for the afternoon shift answered yes to having cough/sore throat and new loss of taste or smell/headache . Further review of record revealed another staff member who came in at 6:03pm answered yes to having pain, repeated shaking, from chills and shortness of breath/difficulty breathing .These staff members worked despite yes responses. Interview on 7/19/2020 at 12:40am , LVN#1 when asked why surveyor was not screened prior to being allowed entry into the covid19 positive hall said, she did not know who moved the PPE containers and the screening set up. She said the PPE container and screening set up should have been placed outside the entry door so that people could put them on and e screened before entering the hall. She said she had been off duty for a couple days and wasn't sure who changed the set up. LVN#1 said her understanding was staff exhibiting symptoms should not be allowed to work but could see that two staff members who had symptoms as identified on the screening questionnaire worked regardless. LVN #1 said confirmed the two staff members on the questionnaire dated 7/17/2020 above worked. She said she will share these concerns with the facility administration. LVN#1 further said the all visitor and staff entering the 100/200 hall for Covid19 positive residents should be screened with full PPE worn at all times while in the hall. She said she forgot to screen surveyor and confirmed there were no doffing station used PPE for hall 100/200 except the box found side the hall entrance/exit. Observation on 07/20/20 at 10:10 a.m. revealed the 100/200 Halls were designated COVID19 positive units. Record review on 07/20/20 at 10:11 a.m. of the 100/200 Halls COVID19 Prevention Worksheet revealed MA C answered yes to the question regarding having chills, muscle pain, or repeated shaking from chills. Observation and interview on 07/20/20 at 10:20 a.m. revealed MA C at a medication cart on the 200 Hall. He said the screening process was to don PPE, take temperature, answer the questions, wash hands, then start working. He said LVN D had asked him the screening questions. He denied having chills at the time of the interview. Interview on 07/20/20 at 10:30 a.m. with LVN D , she said she screened MA C when he arrived. She acknowledged MA C had answered yes to the question regarding chills. She said she thought it was because he was three weeks status [REDACTED]. She said if he was symptomatic he should have been sent home. She said she would report it to the ADON and the Administrator. Interview on 07/21/20 at 9:40 a.m. with the Administrator , she was unaware that MA C had answered yes to one of the screening questions. Cohorting Record review of CDC.gov website read in part, For patients with COVID-19 or other respiratory infections, place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Further review of CDC.gov website read in part Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19. Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Ensure HCP practice source control measures and social distancing in the break room and other common areas (i.e., HCP wear a facemask and sit more than 6 feet apart while on break). Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. Ensure that HCP have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended personal protective equipment (PPE). Assign dedicated resident care equipment (e.g., vitals machine) to the cohort unit. Cleaning and disinfection of shared equipment should be performed between residents and the equipment should not leave the cohort unit. Interview on 07/8/2020 at 11:00am with the DON she acknowledged the staff members on the 200 Hall worked with both COVID19 positive and COVID19 negative residents. She said the staff would change their PPE before entering a COVID19 negative resident's room. She said the facility had several staff members quit, and that they were using agency staff. Interview on 7/8/20 at 11:30AM, the DON said when they received the COVID test results there was several residents on the 200 hall that tested positive and their roommates did not. The DON said the 100 hall was their original COVID unit but after receiving the results they had to overflow COVID positive residents onto the 200 hall. The DON said they currently had both COVID positive and negative residents on 200 hall and the rooms were not separated in the hallway by any barrier. She said there were some rooms that had COVID positive residents next to rooms with COVID negative residents and the staff were to just change their PPE as they went in and out of each room. The DON said everything had happened so quickly with getting the results and having so many positive cases, the current setup was the best they could do at the time. The DON said she had a plan to move all the negative residents on 200 hall to one end of the hallway and to create a barrier on the hallway to separate them from the COVID positive residents. The DON said they were retesting the residents today (7/8/20) and she did not plan on moving the residents around on the 200 hall until they received the results of the testing they were about to conduct. The DON also confirmed she had staff members who worked with both the negative and positive residents and to avoid cross contamination the staff were supposed to change their PPE before entering COVID negative resident rooms. The DON said because of staff shortage they could not designate staff members to only work with COVID positive residents. Observation and interview on 07/14/20 at 10:25 a.m. with LVN B , she said she was the Charge Nurse for the 400 Hall. Observation revealed she was wearing full PPE except for gloves. She said the 400 Hall did house some COVID19 positive residents because the COVID19 Unit (100/200 Halls) was full. Observation revealed the 300 Hall and 400 Hall were at a 90-degree angle from each other and shared a common nurses' station. There were no barriers and no closed fire doors to separate the COVID19 positive area from the COVID negative area. Observation on 07/14/20 at 11:50 a.m. revealed 11 rooms on the 300 Hall and 2 rooms on the 400 Hall had Droplet Precautions signs. The remainder of the rooms on the 400 Hall were occupied with COVID19 negative residents. Interview on 07/14/20 at 12:00 noon with NM E , she said all of the residents on the 300 and 400 Halls had been exposed. She said the facility received the results on 07/13/20, and that some residents had tested positive. Interview on 07/14/20 at 1:15 p.m. with the Administrator , she said originally the 400 Hall was the COVID19 Unit. After a facility-wide testing, there were more COVID19 positive residents than the 400 Hall could house. The 100 Hall was then converted into the designated COVID19 hall. The 200 Hall was for the PUI residents. The 100 Hall had filled to capacity, and the COVID19 positive residents then overflowed onto the 200 Hall. She said the COVID19 positive residents on the 200 Hall were moved closest to the 100 Hall, and the PUI residents were moved to the end of the 200 Hall farthest from the 100 Hall. She said there was no physical barrier between the COVID19 positive and the PUI residents. Observation on 07/14/20 at 2:00 p.m. revealed the 100 Hall and 200 Hall were at a 90-degree angle from each other and shared a common nurses' station. There were no barriers and no closed fire doors. Interview on 07/14/20 at 3:25 p.m. with LVN F , she said the resident in 214A (Resident #1) was COVID19 negative and the resident in 214B (Resident #2 was 'inconclusive.' She said the resident in 206 (Resident #3) was COVID19 negative. That resident had no roommate. Interview via telephone on 07/15/20 at 10:52 a.m. with a family member of CR #4 revealed she said she was concerned for CR #4 because a staff member told her that CR #4's roommate was tested positive. She said she asked for them to be separated, but the facility did not separate them. She said she decided to take CR #4 home for her safety. She provided the name of the roommate (Resident #5). Record review of the Face Sheet of CR #4 revealed she was discharged from the facility on 07/02/20. Record review of a PN dated 07/04/20 at 12:28 a.m. revealed Resident #5 (CR #4's roommate) had tested positive for COVID19. Record review of Resident #5 revealed she was not moved until 07/05/20. Interview via telephone on 07/15/20 at 11:01 a.m. with FE G , she said there were residents who were COVID19 positive residents in rooms with COVID19 negative residents when she was working at the facility. She said COVID19 positive residents were moved to the 100 Hall, but COVID19 negative residents were still in the 200 Hall, which was unsafe due to no barrier. Interview on 07/16/20 at 8:50 a.m. with the Administrator , she said the facility had residents tested in late May and early June of 2020. She said there were 'a few' COVID19 positive residents. She said she thought the reason it spread was they had a COVID19 positive unit (400 Hall) but had not anticipated the number of COVID19 positive residents. She said they had to create another COVID19 positive unit in the 100 Hall. She said the facility was trying to not cohort, but some research said to leave the COVID19 positive and COVID19 negative residents together because the negative resident would have already been exposed. Interview on 07/16/20 at 2:40 p.m. with the Administrator, she said the COVID19 negative residents were moved to the front end of the 100 Hall since yesterday. She said Rooms 109-116 were for the COVID19 negative residents, and the rest of the 100 Hall continued to house COVID19 positive residents. She said that due to staffing issues, the COVID19 positive and COVID19 negative residents would be cared for by the same staff. Record review of the Resident Testing result sheet (no date) revealed there were 79 COVID19 positive residents in the facility. Test result was provided for review on 7/16/2020 PPE Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure . Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. Eye Protection -put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. Gloves Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. If there are shortages of gowns, they should be prioritized for: aerosol generating procedures, care activities where splashes and sprays are anticipated, high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP. Examples include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care . Observation on 07/14/20 between 10.05a.m to 10:10a.m. revealed an opaque plastic curtain that separated a hallway from the 200 Hall (PUI). Observation revealed that a door to the kitchen/dining area was just outside of the divider from the 200 Hall. Observation from the kitchen side revealed someone working on the divider, on the 200 Hall side. Observation revealed Resident #4 was being returned to the facility by a Transporter. The Transporter spoke to the person on the other side of the divider and said the resident was returning form an appointment. Observation revealed HS H separated part of the divider from the wall to speak with the Transporter. HS H was wearing a N95 facemask, but no other PPE. Observation and interview on 07/14/20 at 10:15 a.m. revealed there was a sign on the door of room [ROOM NUMBER]. The sign reflected Droplet Precautions. HSKP I was in the room, cleaning the side of the room closest to the window. Observation revealed she was wearing no PPE except gloves and a face mask. CLD J was observed at bedside to the resident closest to the door. She had on full PPE. Interview at that time revealed CLD J said the residents in the room were on Droplet Precautions for COVID19. Interview on 07/14/20 with NM E , she said full PPE was to be worn in the rooms with Droplet Precaution signs on the doors. Observation on 07/14/20 at 3:15 p.m. revealed SW K was in her office on the 100 Hall, the designated COVID19 positive unit. She had no PPE on, but donned a face mask when the surveyor introduced himself. She said she had tested positive for COVID19, so her office was on the unit. Interview on 07/16/20 at 9:05 a.m. with the Administrator , she said the staff on the 100 and 200 Halls should be wearing full PPE. Record review of the facility policy Infection Prevention and Control Policies and Procedures Subject: [MEDICAL CONDITION] Disease 2019 (COVID-19) revealed .Procedures: 1. Facility staff should avoid exposure to [MEDICAL CONDITION] by maintaining a safe distance from persons exhibiting symptoms and/or infected with [MEDICAL CONDITION] and by using appropriate personal protection equipment (PPE) when appropriate . The Administrator was notified of the IJ on 07/16/20 at 2:45 p.m. due to the above failures. A copy of the IJ template was provided at this time .The Administrator verbalized understanding. She said she sought assistance from local health departments and used the guidance provided by HHSC, and believed the facility was in compliance. The DON was not in the facility and was not available for interview. A POR was requested at that time. The final POR was accepted on 07/19/20 after several revisions. The Immediate Jeopardy Plan of Removal was accepted on 07/19/2020 after several revisions and read : The Pandemic Response Plan was developed and implemented on 3/5/20 revised on 7/2/20 and again on 7/13/20, a staffing plan was developed for the current status of the facility. The Pandemic Response Plan was reviewed post IJ by the administrator on 7/16/20 and 7/17/20 who is responsible for validation of the implementation of this plan. Unit I (100/200) and Unit II (300/400) are the designated areas of the facility for residents who test positive for COVID 19. Unit I and Unit II have designated entrances/exits identified by signage, as well as with designated donning and doffing areas for full PPE. Employees assigned to these areas will enter and exit only through these doors and will not cross over into any other areas of the facility. Employees who are assigned to these areas will be screened in and out at their assigned entrance/exit by the assigned Charge Nurse for that day/shift. The oncoming and outgoing Charge Nurse for each Unit will screen the staff leaving and the staff reporting for duty. The licensed nurses will be educated by 7/20/20 regarding this expectation and assignment sheets will indicate the assigned charge nurse. The completed screening form will be kept with the 24-hour Report and will be reviewed each shift by the charge nurse. Screening was initiated in March 2020 which included all staff. This process will continue with the charge nurses being re-educated on the screening process and anyone not passing screen will not be allowed to begin working. The administrator will be notified. There are currently no visitors in facility unless allowed for end of life which will be decided by the clinical team and administrator and will receive the same screening, only be allowed be allowed to visit their loved one. Vendors or essential personnel entering facility will also be screened and will not be allowed to enter if screen not passed. Unit Q is the designated quarantined area for residents who test negative for COVID 19. Employees assigned to these areas will also have a negative COVID 19 test results. Unit Q has a separate entrance and exit identified by signage, along with designated donning and doffing areas for full PPE. Employees assigned to these areas will enter and exit only through these doors and will not cross over into any other areas of the facility. Employees who are assigned to these areas will be screened in and out at their assigned entrance/exit by the assigned Charge Nurse for that day/shift. The oncoming and outgoing Charge Nurse for each Unit will screen the staff leaving and the staff reporting for duty. The licensed nurses will be educated by 7/20/20 regarding this expectation and assignment sheets will indicate the assigned charge nurse. The completed screening form will be kept with the 24-hour Report and will be reviewed each shift by the charge nurse. Screening was initiated in March 2020 which included all staff. This process will continue with the charge nurses being re-educated on the screening process and anyone not passing screen will not be allowed to begin working. The administrator will be notified. There are currently no visitors in facility unless allowed for end of life which will be decided by the clinical team and administrator and will receive the same screening, only be allowed be allowed(Sic) to visit their loved one. Vendors or essential personnel entering facility will also be screened and will not be allowed to enter if screen not passed. Re-education was initiated on 7/16/20 to facility staff regarding the above information and will be completed by 7/20/2020. Any staff not receiving this re-education by 7/20/2020 will receive prior to their next scheduled shift. Resident rooms are being deep cleaned using appropriate disinfectant to reduce [MEDICAL CONDITION] loads prior to receiving a new resident. This has been an on-going process since facility opened. Re-education on this process was initiated to housekeeping department on 7/16/20. Positive and quarantined areas will be separated by a plastic sheeting which was put in place initiated on 7/15 and placement secured on 7/16/2020. Donning and doffing stations are located at each designated entrance and exit. This education was initiated on 7/16. The central supply technician will provide inventory numbers of PPE to the clinical consultant daily and supplies will be monitored and replenished as indicated. Staff members crossing the barrier will be suspended pending investigation. Staff member without PPE will be suspended pending investigation. The front entrance is the designated section of the facility for administrative staff who are negative or have no exposure and will be screened upon entrance. The screenings will be kept by the administrator. Education will be provided to those who are responsible for completing the screens that the screening is to be given to the administrator/designee after change of shift and as need (TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #3) reviewed for pain management, in that: Resident #3 had a fall and complained of pain which was not effectively managed. Resident #3's physician was not consulted when administered pain medication was not effective. Resident #3 was sent to the hospital 7 hours later at the family's request due to uncontrollable pain and was diagnosed to have a [MEDICAL CONDITION] requiring surgery. These failures affected one resident and placed her at risk of unnecessary pain and mental anguish. Findings include: Resident #3 Record review of Resident #3's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with a recent readmission from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3's Significant Change in Status MDS dated [DATE] revealed she entered from an acute care hospital. She had a BIMS score of 1 indicating a severe cognitive impairment. She required extensive assistance of 2+ staff for bed mobility, transfers, and personal hygiene. She required extensive assistance of 1 staff for dressing, eating and toileting. She was totally dependent on one staff for bathing. She used a manual wheelchair for ambulation and had a lower extremity impairment on one side. She was always incontinent of bowel and had a urinary catheter. Her primary [DIAGNOSES REDACTED]. She received treatment for [REDACTED]. Observation on 9/5/19 at 1:25 pm revealed Resident #3 lying in bed asleep. Record review of Resident #3's Care Plan dated 9/5/19 revealed Resident #3 is at risk for falling related to cognitive impairment, decreased safety awareness, history of falls, impulsiveness, weakness and unsteady gait. The goal said, Resident #3 will remain free from further serious injuries. Interventions included toileting at regular and frequent intervals, fall mats, call light in reach, proper footwear, and teaching safety measures. Further review revealed her actual falls from 8/4, 8/9, and 8/20 were not recorded on the care plan. Record review of Resident #3's Radiology Report dated 8/20/19 revealed acute comminuted intertrochanteric left femoral neck fracture. It was signed at 10:45 pm. Record review of Resident #3's Nursing Note dated 8/21/19 revealed Correction from 8/20/19 at 4:14 pm. Patient observe in her room on the floor. No loss of conscious. Vital signs stable. Blood pressure 115/67 pulse 63 Resp 18 Temp 97.4 Sat's 96% on 2 liters of oxygen nasal cannula. Nurse noting observed swelling to left knee. ADON, NP, alone with family. Patients states pain to left knee. NP gave STAT orders for x-ray of the left lower extremity. Patient is currently sitting in the tv/lobby in front of the nurse's station. One-time order for Tylenol 650 mg by mouth pain med given. Will continue to monitor. Signed by LVN #1. Record review of Resident #3's Physician order [REDACTED].>- [MEDICATION NAME] cream 5% one time dose ordered 8/20/19 - Tylenol 325 mg - 2 tablets one time dose ordered 8/20/19 Record review of Resident #3's SBAR dated 8/20/19 revealed The change in condition, symptoms, or signs observed and evaluated is/are was filled in with day shift 1630 (4:30pm) It said the her condition was worse since it started and repositioning her lower left extremity made it worse. Her symptoms included facial grimacing, grunts, loud cries, and holding her left leg. She was noted to be frightened with a pain of 10/10. Staff name and signature was blank. Record review of Resident #3's Nursing Note dated 8/20/19 revealed After Tylenol 650 mg was administered, Resident #3 had facial grimaces and was holding left knee. Tylenol 650 mg ineffective, received verbal order per NP for Tylenol #3 Q6H PRN by mouth for pain. TOVRB. RP made aware and agreed to order. One-tab Tylenol #3 pulled from stat safe and administered. Will continue to monitor as needed. Signed by RN #1. Record review of Resident #3's Physician order [REDACTED].>- Tylenol-[MEDICATION NAME] 300-30 mg 1 tablet every 6 hours PRN ordered 8/20/19 Record review of Resident #3's Nursing Note dated 8/20/19 recorded as a late entry on 8/21/19 at 3:28 am revealed 1820 (6:20pm) this nurse received report from RN #1 day shift nurse: Resident s/p fall found on floor of room [ROOM NUMBER]. N/O: 72-hour NEURO, STAT x-ray, PRN, Tylenol-[MEDICATION NAME] 300-30 mg PO crushed Q6H Dx: pain, report results to NP and ADON #2, transfer resident out to acute care hospital if fractured exist. (1645 (Sic 4:45pm) last PRN pain med given.) resident sitting calmly in WC X two person assist for x-ray. Resident begin crying out with c/o pain during changes in position. 1955 (7:55pm) continue monitoring resident laying supine position, observed facial grimaces, grunts, loud cries. Consoling ineffective. 2005 (8:05pm) report made to NP and ADON #2. TOVRB ( Telephone order verified and read back ) transfer resident to hospital. 2010 (8:10pm) requested emergency medical transportation. continued monitoring. 2145 (9.45pm) resident received PRN Tylenol-[MEDICATION NAME] X 1 tab. Continued monitoring. 2220 (10.20pm) Resident transferred out via stretcher by EMS. 2230 (10.30pm) RP, NP, ADON #2 notified. Report made to hospital charge nurse. Signed by LVN #3. Record review of Resident #3's Nursing Note dated 8/25/19 revealed This nurse called (Hospital) to get an update on Resident #3 and (her nurse) stated, The surgery went well, but she's getting treated for [REDACTED]. RP was notified of update for Resident #3. NP made aware, ADON/DON Made aware. Signed by RN #1. Record review of Resident #3's Incident/Accident Investigation Worksheet dated 8/20/19 revealed different handwritings throughout the form. Resident #3 was found on the floor at 4 pm and a bruise was noted on her left knee. The physician and RP were notified. Her leg was elevated, and an ice pack was applied. Her blood pressure following the event was 146/78. Further review revealed while doing rounds, nurse observed resident on floor mat next to bed laying on her left side. Upon assessment, swelling noted to left knee. Call light in reach. NP gave order for Tylenol #3 every 6 hours and PRN for pain. A STAT x-ray was also ordered. The findings/analysis read Upon investigation it appears patient attempted to transfer herself from wheelchair and lost her balance. Further review revealed staff gave Tylenol 650 mg po ineffective. Tylenol #3 STAT and PRN every 6 hours for pain. Ice pack applied to left knee. Elevated left lower extremity. STAT x-ray of left leg and hip to rule out fracture. The report was signed by LVN #1. The signature spots for the DON, Administrator, and medical director were blank. Record review of Resident #3's Provider Investigation Report dated 8/28/19 revealed on 8/20/19 at 4:05 pm, Resident #3 was found lying on the floor mat next to her bed on her left side. She complained of pain upon nurse assessment. LVN #1 checked vitals which were all within normal limits and swelling was noted to left knee. Tylenol 650 mg was administered. LVN #1 informed RP of incident and NP that Tylenol 650 was ineffective who ordered Tylenol #3 and a STAT x-ray. She began to complain of pain during repositioning. The nurse called the RP to provide an update and RP requested she be transferred to the hospital. The NP was notified of RP's request and she was transported to the hospital. The facility reeducated on Abuse/Neglect. X-ray results revealed an acute intertrochanteric comminuted left femoral neck fracture where she received surgery to place an intramedullary nail. Further review of above providers investigation report revealed it did not reflect Resident #3 was left in the facility for 7 hours before transferred to the hospital . During an interview on 9/5/19 at 2:15 pm LVN #1 said she worked from 6am - 6pm the day of Resident #3's fall on 8/20/19. She said RN #1 alerted her and said Resident #3 was on the floor. She said she went to help and saw Resident #3 was on the floor. She said the call light was in reach, bed was low, and fall mats were in place. When asked if she completed the assessment post-fall she said, RN #1 probably did that assessment. She said RN #1 would have called the NP and RP, because she was Resident #3's nurse. She said she did the incident report because she wanted to learn how to do one. She said after getting Resident #3 up she kept rubbing her knee. You could just see the grimace on her face. She said they placed Resident #3 in her wheelchair, put her in the TV room and monitored her. When asked if Resident #3 complained of pain she said She wasn't crying out or screaming. She just kept rubbing her knee. She could not recall if she interviewed the resident and said the X-ray was taken after she left for her shift. During an interview on 10/10/19 at 11:15 am, RN #1 said, LVN #1 told her Resident #3 had a fall on 8/20. She said Tylenol 650 mg was administered per the NP but it was ineffective, so she called the NP and got an order for [REDACTED].#3 looked like she was in pain via facial grimacing and was grabbing her leg. When asked who ordered the [MEDICATION NAME] she administered she said I don't remember about [MEDICATION NAME]. Is there a note in there for [MEDICATION NAME]? She said she usually wrote a note when a new order was received and transcribe it in the computer. During an interview on 10/10/19 at 11:40 am, ADON #2 said Resident #3 had a fall in her room on 8/20 and believed it was in the afternoon. She said she did not administer medication. When asked if her initials were on the MAR for the Tylenol #3 she said, I might've been the one to help do the order, but I didn't administer it. When asked if it was protocol to sign for something that she did not administer she said she did not usually do that. She could not recall who gave the medication. Record review of Resident #3's PRN Medication Administration History dated (MONTH) 2019 revealed ADON #2 administered Tylenol-[MEDICATION NAME] #3 at 3:32 pm for pain and was somewhat effective. This was the only time the medication was administered per the document. During an interview on 10/10/19 at 11:47 am, the DON said she remembered being called back to Resident #3's room on 8/20 due to complaints of pain and believed it was in the morning. She said Resident #3 had facial grimacing and appeared to be in pain at an 8/10. She asked the nurses what Resident #3 had for pain and was told the NP wrote an order for [REDACTED]. When asked if any of the communication was or assessments were documented she said I can't say. During an interview on 10/8/19 at 2:10 pm, the NP said she received a call at an unknown time from the facility on 8/20/19 stating the resident had a fall and was in pain. She said she gave orders for Tylenol #3 and x-rays. She said later that evening she was contacted again by the facility because Resident #3's RP wanted her to go to the hospital due to the uncontrolled pain. When asked why she did not order a transfer out initially she said I was not there. The assessment didn't show a visible fracture. She said she was not told Resident #3 had swelling. During an interview on 10/16/2019 at 6:00, LVN #3 said she did not recall Resident #3's fall at the moment and would have to review her notes and get back with the surveyor. LVN #3 did not return with information regarding CR#2's fall. Record review of the facility's Pain Management Policy dated 7/1/16 did not address the above concerns.

Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment, consistent with professional standards of practice, to promote healing of existing pressure ulcers and prevent further development of pressure ulcers for 2 of 4 (Resident #3 and #6) reviewed for pressure ulcers. The facility failed to ensure Resident #3 who was identified to be at risk for skin break down did not develop a new blister to her right heel which became a stage two pressure ulcer. The facility failed to ensure Resident #3's unstageable sacral pressure ulcer, did not worsen by developing an odor and increasing in size. The facility failed to ensure Resident #6 was repositioned frequently to promote wound healing. The facility failed to ensure Wound Care Nurse used proper technique in order to prevent infections during wound care of Resident #6. These failures affected two residents and placed them at risk for further skin break down , worsening of pressure ulcers, infections and pain. Findings include: Resident #3 Record review of Resident #3's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with a recent readmission from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Her code status was DNR. Record review of Resident #3's Significant Change in Status MDS dated [DATE] revealed she entered from an acute care hospital. She had a BIMS score of 1 indicating a severe cognitive impairment. She required extensive assistance of 2+ staff for bed mobility, transfers, and personal hygiene. She required extensive assistance of 1 staff for dressing, eating and toileting. She was totally dependent on one staff for bathing. She used a manual wheelchair for ambulation and had a lower extremity impairment on one side. She was always incontinent of bowel and had a urinary catheter. She had one stage three pressure ulcer, a surgical wound, and moisture associated skin damage. Record review of Resident #3's physician's orders [REDACTED].>- Clean sacral wound with normal saline, apply silver alginate and allevyn dressing daily ordered on [DATE] and discontinued on 9/5/19 - Clean sacral wound with normal saline, apply santyl and silver alginate, cover with an allevyn dressing daily ordered 9/5/19 discontinued 9/10/19 - Clean sacral wound with normal saline, apply Santyl and drawtex, cover with an allevyn dressing daily. Notify physician of any changes. Ordered 9/10/19 - Apply skin prep to left heel wound daily and apply foam dressing daily ordered 9/10/19 and discontinued 9/11/19 - Clean right heel with normal saline, apply alginate and a foam dressing daily ordered 9/11/19 Record review of Resident #3's Care Plan dated 9/5/19 revealed Resident is at risk for skin breakdown related to incontinence, fragile skin, and cognitive impairment. The goal read Skin will remain clean, dry and intact without evidence of breakdown over the next 90 days. Interventions included repositioning, encourage fluids, providing medications as ordered, regular and frequent incontinent checks, and skin assessments. Further review did not reveal interventions for current skin break down. Observation on 8/9/19 at 3:45 pm revealed Resident #3 lying on her back asleep. During an interview on 10/8/19 at 12:00 pm with Resident #3's family member, she said following her readmittance to the facility. Resident #3 would tell her that her foot hurt for days. She finally asked staff to take off her shoe and they noticed a sore. During an interview on 10/8/19 at 2:10 pm, the NP said Resident #3 was readmitted to the facility following hip surgery with a sacral pressure ulcer that she was treating. She said she would see the wounds once a week unless there were any reported changes. She said she notified Resident #3's family that it was pretty huge and the likelihood of it improving was really low. She said on the 10th it had odor, but the family did not want her to go out all again. The only goal was did not want Resident #3 in pain. She said the plan was to discharge Resident #3 to hospice. When asked about Resident #3's blister to heel (that opened up) she said it was identified on 9/9 by the Wound Care Nurse. She said the blister never opened, but she would have changed the order if it had. When informed that the Wound Care Nurse's note mentioned the blister opened and a new order was received from her she said She must have called me on that day. I didn't get to document it. She was unable to answer why her following notes mentioned the blister was not open. Record review of Resident #3's Physician's Progress Note dated 9/6/19 revealed Follow up dislodged foley catheter - nurse reported yesterday patient pulled out her foley catheter with balloon intact. Patient was discharged from hospital with foley catheter due to patient impulsive and tries to get out of bed when she gets the urge to urinate. Record review of Resident #3's Physician's Progress Note dated 9/9/19 revealed sacral wound measurement 7.2 x 8cm unstageable, to the center of wound, area is dark and black like eschar tissue, skin to the peripheral pink granulated skin with some slough. Clear edges, and some sero sang discharge. There was no mention of an odor to the wound. Further review revealed Resident #3 was to have boots on both feet at all times. Record review of Resident #3's Physician's Progress Note dated 9/10/19 revealed Patient has a large wound to sacrum, pink granulated skin along the periphery of the wound, black eschar tissue to the center, wound has an odor, and tender when cleaning. Further review revealed Sacral wound unstageable - Measurement 9 x 9.5cm, wound may be deep when eschar tissue opens up, strong odor, continue to clean with NS, apply santyl and drawtak to wound and cover with foam dressing. To be changed daily. Record review of Resident #3's Physician Note dated 9/11/19 revealed Follow up Leukocytosis/pneumonia - nurse called late last night reported WBC 23 and lab reported critical, and chest x-ray showed pneumonia worse than last x-ray. Asked nurse to start IV fluids, IV antibiotics and continue breathing treatments. Yesterday patient had an episode of [MEDICAL CONDITION], choking and labored breathing, breathing treatments, labs and chest x-ray and KUB was ordered. Today, patient awake to verbal stimuli, does not appear in pain, very frail and tired. Denied any problems breathing. Further review revealed sacral wound measurement - pink granulated skin around the periphery, large center with eschar tissue and slough. Foul odor to wound. Wound soft and tender in the center. Dressing to left hip, no drainage or swelling or redness. Both heels red and tender, skin to heels very thin, and has risk to develop a blister. The plan read PICC line placed yesterday, IV [MEDICATION NAME] 1 gm qd for 10 days, IV d5 ½ NS at 100cc/hr one liter per day for 3 days. During an interview on 10/10/19 at 12:18 pm, the Wound Care Nurse said she started working in the facility in July. When asked what training she had on wound care she said she did RELIAS training and went around with the NP. She said she was treating 3 wounds for Resident #3 including a left hip incision, blister to heel, and a sacral pressure ulcer. She said the blister on Resident #3's right heel was found during her weekly skin checks. She said at first, they skin prepped it and then she was using alginate once it opened. When asked if she called the NP once it opened she said I'm sure I called her. She doesn't ever give me orders without seeing. She said the NP usually gave verbal orders in which she transcribed on the computer. When asked if she wrote note with new orders she said, I try to. She said Resident #3 returned from the hospital with the sacral wound and it was unstageable due to it being completely eschar. She said there was an odor to the wound but she was put on hospice so we didn't want the wound care specialist looking at it. She said Resident #3 returned from the hospital with the sacral wound and it was unstageable due to it being completely eschar. She said Resident #3's sacral wound had an odor as soon as she came back with it in which the NP was aware. She said Resident #3 was put on hospice so we didn't want the wound care specialist looking at it. When asked when Resident #3 was admitted to hospice she said she was not sure. Record review of Resident #3's Weekly Skin Assessments from (MONTH) 2019 revealed no new skin issues were identified before 9/11/19. Record review of Resident #3's Wound Care Administration History dated (MONTH) 2019 revealed - 9/5 - the sacral wound was moist, pink, red, yellow, brown with normal skin surrounding the wound - 9/6 - the sacral wound was moist, pink, red, yellow, brown with normal skin surrounding the wound - 9/7 - the sacral wound was saturated, red, with macerated surrounded skin - 9/8 - the sacral wound was saturated, yellow, and the surrounding skin was reddened - 9/9 - the sacral wound was saturated, pink, red, yellow, and the surrounding skin was normal - 9/10 - the sacral wound was saturated, pink, red, yellow, and the surrounding skin was normal - The document did not have the order or wound documentation after 9/10 Record review of Resident #3's Wound Care Note dated 09/11/2019 revealed Resident #3 has two wounds being treated daily. Her sacrum measures 9.0 x 9.5 and is composed of mostly slough. Drainage is moderate and odorous. This wound is treated daily with santyl and drawtex, covered with a foam dressing. Resident #3 also has R heel wound measuring 2 x 3.5cm that has a red wound bed and scant drainage. It is treated daily with alginate and a foam dressing. Resident #3 does have pain when moving and dressing changes are performed in accordance with her medication schedule. Signed by the Wound Care Nurse. Resident #6 Record review of Resident #6's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with a recent readmission following hospitalization date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's Significant Change MDS dated [DATE] revealed a BIMS of 5 indicating severe cognitive impairment. She required extensive assistance of 2+ staff for ADLs. She had one stage 4 pressure ulcer. Record review of Resident #6's Care Plan dated 10/15/19 revealed Resident #6 has a wound to the sacral area. Will decrease in size without signs and symptoms of infection and comfort will be maintained. The goal was Wound care as ordered. See treatment record. Interventions included weekly skin checks, assessing pain every 4 hours, and cleaning skin after soiling. There was no mention of repositioning. Observation on 9/5/19 at 10:45 am revealed Resident #6 was lying on her right side asleep on an air mattress with her knees facing the window. Observation on 9/5/19 at 12:40 pm revealed Resident #6 lying in the same position. Observation on 9/5/19 at 1:43 pm revealed Resident #6 lying in the same position. Observation on 9/5/19 at 3:50 pm revealed Resident #6 lying in the same position. During an interview on 9/5/19 at 3:55 pm, CNA #11 said she was assigned to Resident #6. She said interventions included putting a pillow under her knee and boots on both of her feet. When asked if she had been repositioned she said, That's why I was coming in here. She said she had not repositioned Resident #6 on her shift yet. Observation and interview of wound care for Resident #6 provided by Wound Care Nurse and assisted by RN #1 on 10/10/2019 at 1:00 PM revealed Wound care nurse gathered 4 X 4 gauze, several pieces from a multi-use sleeve of 4 X 4's from her cart that had already been opened and half of the gauze was missing. Wound Care Nurse used bare hand (not washed and not gloved) to retrieve 4 X 4 gauze and placed (3) 4 X 4 gauze in 3 different plastic clear cups and added normal saline to them and placed them on bed side table. Wound Care Nurse then placed gloves and calcium alginate on bed side table. Wound Care Nurse and RN #1 then washed their hands and donned gloves. Resident #6 was repositioned and by Wound Care Nurse and RN #1. Wound Care Nurse then used same gloves to remove wound dressing and packing from wound bed and her right gloved hand touched the wound bed. Wound Care Nurse then removed her gloves and washed her hands and new gloves donned. When dressing was removed a foul odor permeated the room. Wound Care Nurse said Resident #6's sacral wound was a stage IV and had a foul odor that would come and go and that she would pack the wound bed with Dakin's solution because of the odor. Wound Care Nurse said the wound had tunneling that needed to be packed with every dressing change. Sacral wound was a baseball size wound that had 1.5 of redness surrounding the outer edges of the wound. Wound Care Nurse used a cotton swab to insert [MEDICATION NAME] gauze into the tunneling of the wound bed, touching the swab to the outer area of the wound before pushing the gauze under the flap of skin. Wound Care Nurse then used gloved hand to pack the rest of the wound bed, applied foam dressing over wound packing and then applied brief with same gloves. Interview with Wound Care Nurse on 10/10/19 at 1:45 PM, she said Resident #6 had multiple wounds and its difficult at times to perform the wound care perfectly. Wound Care Nurse said she was nervous during wound care. Wound Care Nurse said that she usually performs wound care when the CNAs are giving the resident a bath because the resident would be clean and undressed and she doesn't have to worry about applying the brief or repositioning the resident. Wound Care Nurse did not say why she used 4 X 4's from an opened container or why her hands were not gloved during set up for wound care. Record review of Wound Care Policies and Procedures dated (YEAR) received from DON read in part . Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically unavoidable. Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure ad shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. The Wound Care Policy did not mention providing wound care or dressing changes.

Based on interview and record review, the facility failed to thoroughly investigate allegations involving abuse and neglect for 10 of 34 residents (CR #3, Resident #18, #27, #35, #32, #8, #14, #17, #15, and #43) reviewed for abuse and neglect. The facility did not thoroughly investigate incidents of abuse of Residents #18, #27, #35, #32, #8, #14, #17, #15, and #43 by CR#3. These failures affected 10 residents who were placed at risk of abuse and neglect. Findings included: Intake # 5 CR #3 Record review of CR #3's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. with late onset, essential hypertension, [MEDICAL CONDITION], and lymphoid [MEDICAL CONDITION]. Record review of CR #3's admission MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 indicating the resident was severely impaired. Her MDS also revealed no issues with mood or behaviors. Further review of the MDS revealed CR #3 required supervision with walking on and off the unit and limited assistance with transfers. Resident used a walker or wheel chair to ambulate. The resident received antipsychotic medication 7 days, antianxiety medication 2 days, and antidepressant medication 6 days. Record review of CR #3's Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition . The MDS also revealed no mood or behaviors. The resident [DIAGNOSES REDACTED]. CR #3 required only supervision for all activities of daily living (ADL's). Resident used a walker or wheel chair to ambulate and received antipsychotic medication for 7 days and antidepressant medication 7 days during the look back period. Record review of CR #3's care plan dated 8/20/18 revealed resident receive antipsychotic medication due to behavioral disturbances. On 12/22/18 resident experienced confusion, yelling at staff and asking them, you have to leave now, I have to close the store. 12/31/18 Resident experienced behavior and being combative with residents and staff. Pushing and hitting behavior. Interventions starting on 1/1/19 were to implement a behavior management plan: during 24-hour report nurses and caregivers will discuss effective and ineffective approach by increasing visual monitoring every shift to identify and remove any triggers, physiological URI, internal or external factors. Identify contextual triggers (time, place, with specific resident/specific nurse). Identify pattern of aggressive behavior (raising hand, kicking, punching) will gather input, increase monitoring every shift and approach resident in gentle and calm tone and tell the resident, I need you to be calm. Intervention starting on 12/22/18 were to increase visual monitoring for the next 7 days and assess for any side effects of medication such as confusion/behavioral disturbances on every shift. Intervention starting on 9/12/18 was to redirect the resident when she hoards items in her bra and under her pillow. Inappropriate items will be removed. She loses her glasses in her bra. Intervention starting on 9/11/18 listed to monitor resident's behavior and response to medication. See order/Medication Administration Record [REDACTED]. Approach starting on 8/20/18 were to attempt a gradual dose reduction (GDR) in 2 separate quarters the first-year medication is received, unless clinically contraindicated. Attempt yearly GDR thereafter unless clinically contraindicated. Pharmacy consultant to review per facility standard and as needed. Record review of CR#3's care plan dated 11/26/18 revealed residents' behavioral symptoms in group programs often disrupting, distracting, and offending other residents within the activity. Interventions starting on 11/26/18 listed for staff to offer activities in which resident can succeed, that are broken into simple steps, and that involve small group or one on one activities. Staff will try activities that are short and repetitive and can be stopped if overwhelmed. Record review of CR #3's care plan dated 1/2/19 revealed resident demonstrated combative behavior towards other residents which is causing a concern for patient/staff safety. Resident had a [DIAGNOSES REDACTED]. Interventions listed included: attempt non-pharmacological interventions including physical needs met, activity programs, quiet time/rest, redirection/reassurance, increased observation, validation, consistent caregivers, psychological services, etc. Identify behaviors: combative, hitting, punching, and calling staff and other residents derogatory names. Notify Physician and family of changes in resident status. Rule out environmental causes (noises, overcrowding, new surroundings, temperature irregulates, lighting) . Record review of CR#3's admission records revealed Prescription note from a Physician's office for CR #3 dated 8/6/18 stated, Recommend long term care for Alzheimer's with delusions, not safe for patient and other patients to be at home. Record review of CR #3's progress notes dated 8/6/18 at 10:20AM revealed Resident admitted under skilled care. Resident was coming from home, she arrived via private vehicle with beside her, she provided information for resident's well-being. Resident is allergic to [MEDICATION NAME], regular diet with admitting [DIAGNOSES REDACTED]. Resident refused her vital signs to be taken, or any assessment, observed to use walker for ambulation, and verbalized, I am fine no need to put that on me and grabbed her water bottle heading towards the door. She informed the nurse she was leaving going home. Resident stated, this place stinks. She was redirected and remained calm. Record review of CR #3's progress notes dated 08/09/2018 at 09:40PM revealed a CNA reported to nurse that resident was refusing help with ADL cares. Resident became loud and cussing at the CNA. Nurse went to the room to assess the situation and resident was in the hallway yelling at other staff saying, GET OUT OF MY HOUSE. The resident was very agitated and continued to use foul language and racial slurs. Resident followed the CNA into the hallway and threatened to hurt her. The Medication aide reported all scheduled medications had been given, per orders. Resident began going into other resident rooms yelling loudly and causing a disruption in sleep. Nurse Practitioner (NP) was notified and gave orders to send resident to the emergency room (ER) for psych eval. Resident began going to other residents in TV area and yelling at them. The nurse stepped between the residents to separate and provide safety. The second resident (Resident #27) was fearful and called 911. Emergency Medical Technicians (EMT) arrived on scene and resident became more agitated and yelling became louder. Responsible party (RP) was contacted via phone and notified of incident. RP notified of NP order to send to ER for evaluation/treatment. Resident was transported via Emergency Medical Services (EMS) to the emergency room , RP was aware of transfer. The Director of Nursing (DON) was notified. Note made by ADON #1. Record review of CR#3's nurses notes and interviews with ADON #1, ADON #2, and DON on 1/19/19 at 11:30pm revealed no additional information or documentation concerning the above behavioral episode. An incident report was not done, and they did not consider this an incident. Record review of CR #3's history and physical from hospital visit dated 8/10/18 revealed CR #3 resided in a nursing facility where she became physically combative hitting the staff. The police department was called, and EMS brought her to the ER. She received Versed (a sedative) 5mg and 7.5 Intramuscular (IM) prior to her arrival. Resident was lethargic. Resident presented with combative and agitated behavior. EMS stated resident was somnolent (sleepy; drowsy). Blood glucose level was over 100. Family reported the resident had never been previously combative, but resident had not been happy with moving into the nursing facility. Mostly her behaviors included name calling and being angry. Resident did not remember what happened. Urinary Analysis (UA) was done and diagnosed resident with UTI. Resident was started on intravenous (IV) [MEDICATION NAME]. Record review of CR #3's progress notes dated 08/12/2018 at 09:40PM revealed CR #3 was readmitted to the facility from the hospital where she was diagnosed with [REDACTED]. CR#3's RP requested the facility administer [MEDICATION NAME] upon CR#3's arrival to the facility which was given to her. The NP verified the resident's medications, but the [MEDICATION NAME] was to be discontinued in the morning due to high dosage with [MEDICATION NAME]. Resident was to start on antibiotic Cefdnir 300 MG, one capsule twice a day (BID) for seven days for UTI. Resident was to be monitored closely and redirected as needed. Record review of CR #3's progress notes dated 08/15/2018 at 09:00PM revealed resident refused to take medication yelled at the nurse to get out of the room. RP reported that it would be best if the family did not get in touch with CR #3 via phone, so she can get adapted to her new place and to let the resident know that her family members were on vacation and will visit her when they come back. Resident continued to be monitored. Will report to the oncoming night nurse, communication for NP regarding behavioral issue is in communication log. Record review of CR #3's progress notes dated 08/16/2018 at 07:25AM revealed at the beginning of the shift, Resident was agitated, and asked staff that went into her room to assist her to get out. She refused treatments and after 2 hours the resident calmed down and rested in her bed for the remainder of the shift. Continued to monitor. Record review of CR #3's progress notes dated 08/16/2018 at 1:58PM revealed Resident ate all her meals and was brought to the nurse's station to monitor since she pulled out her first IV that was put in. New IV for [MEDICATION NAME] was put in left anterior hand. Continued to monitor. Record review of CR #3's progress notes dated 8/17/18 at 7:40AM revealed resident refused care and medication. IV [MEDICATION NAME] continued and no complaints of dysuria (painful urination) . Record review of CR #3's progress notes dated 8/17/18 at 3:01PM revealed resident pulled her IV out. RP, NP, ADON and DON notified. PRN [MEDICATION NAME] was given, and NP ordered to have the line put back in when resident calmed down. Record review of CR #3's progress notes dated 8/17/18 at 10:55PM revealed resident continued to refuse IV reinsertion. Counsel on importance of IV and medication was attempted with the resident, but she was highly confused and unable to retain information. NP gave one-time order for [MEDICATION NAME] 1GM IM and to attempt IV insertion in the morning. IM administered, and resident tolerated well. Record review of CR #3's progress notes dated 8/20/18 at 5:59PM revealed staff attempted to have a midline placed but the resident became confused and refused to have it put in. The NP was able to counsel the resident and get her to agree but shortly after the NP left the resident was confused again and did not know what was going on. After having the procedure explained to the resident several times the midline was placed in her right upper arm to receive antibiotics [MEDICATION NAME]. Record review of CR #3's progress notes dated 9/3/18 at 8:23PM revealed resident had refused her blood sugars being checked that shift. Record review of CR #3's NP progress notes dated 9/11/18 revealed a follow up from Pharmacist recommendations. Resident was said to have [MEDICAL CONDITION] with verbal outburst and the Pharmacist stated the current [DIAGNOSES REDACTED]. The NP's plan stated, continue [MEDICATION NAME] 50MG Three times a day (TID), patient has done well participation in group activities, no reports of any verbal outburst since medication was increased from BID to TID. Record review of CR #3's Physician's initial visit note dated 9/14/18 revealed CR #3 had Dementia that had become gradually worse. She had issues with behavior's and required hospitalization at a behavioral hospital for control of behaviors where she was given [MEDICATION NAME] at 40mg a day and [MEDICATION NAME] at 300mg per day. This controlled her behaviors and she became better and more functional. They were at the process or trying to peel back some of her [MEDICATION NAME]. It was noted resident was on rather significant doses of [MEDICATION NAME] and [MEDICATION NAME]. Record review of CR #3's progress notes dated 9/14/18 at 3:01PM revealed an IDT (interdisciplinary team) meeting was held to discuss residents plan of care. They decided to continue current plan of care and noted the resident had no increased behaviors and she was adjusting well to recent admission to the facility. Record review of CR #3's NP progress notes dated 9/17/18 revealed a new [DIAGNOSES REDACTED]. Record review of CR #3's NP progress notes dated 9/19/18 revealed in part, [MEDICAL CONDITION]/Depression - Nurse reported resident is sleeping most of the day, waking up late at night. Currently managed with [MEDICATION NAME] 50MG TID, [MEDICATION NAME] and Memantine. Further review the NP's plan stating, [MEDICAL CONDITION]/Dementia - Behavior for the last 2-3 weeks has been controlled, no reports of patient being physically aggressive. Plan to continue [MEDICATION NAME], Memantine and [MEDICATION NAME]. Reduce [MEDICATION NAME] to 25MG at 9AM and 2PM and continue 50MG at bedtime (HS). Continue to evaluate any changes in behavior. Record review of CR #3's progress note dated 10/4/18 at 2:26PM revealed an IDT meeting was held for the residents plan of care. Resident was to remain on anxiety medication and behavior monitoring. Resident was noted to be adjusting well to recent move. Resident was to remain on current plan of care. Record review of CR #3's NP progress notes dated 10/8/18 revealed in part, 2. Reduced [MEDICATION NAME] from 40MG to 30MG every day (QD). 3. [MEDICATION NAME] was discontinued, changed to [MEDICATION NAME] 20MG HS. 4. CR#3's family member wanted Donepezil discontinued since it normally helps in early dementia. Record review of CR #3's progress notes dated 10/20/18 at 12:01PM revealed, Resident alert and Demented. Resident stayed up all night, pushing a resident around, when resident was redirected the resident became violent with the aid, and the Nurse, calling them inappropriate names. Resident was monitored and redirected all night. Focusing on safety and explaining safety to the patient. Interventions effective. Resident left in bed, Call [NAME] in reach, ADON informed/DON informed RP contacted. Note was written by LVN #3. Record review of CR #3's NP progress notes dated 10/22/18 revealed, Follow up [MEDICAL CONDITION]/physically aggressive behavior - nurse called over the weekend, stated patient has aggressive behavior towards staff, she tried to hit her and asked her to leave her room. Explained to nurse it is how you approach the patient, nurse also reported CR#3's family member wanted her urine checked. Asked nurse to get STAT CBC, CMP, and UA C&S. Record review of CR #3's NP progress notes dated 11/2/18 revealed, Follow up [MEDICAL CONDITION]/ physically aggressive behavior - patient's family member has been concerned about patient behavior and [MEDICATION NAME] dosage. Today, discussed about possibly reducing patient PM dosage, because nurse reported patient has been sleeping until late in the morning. Further review of the note revealed a plan, [MEDICAL CONDITION]/ aggressive behavior - family member stated she is concerned about changing evening dose, because patient has history of [MEDICAL CONDITION] and behavior problems at night in the past. Plan to reduce [MEDICATION NAME] to 25MG every morning (QAM) and 50MG HS. Record review of CR #3's progress notes dated 11/13/18 at 2:05PM revealed in part, resident was confused at times and, needs supervision as she wanders, exit seeks but does not need assistance with activities of daily living (ADL's), transfers, eating, toileting, and bed mobility. Resident is able to walk around the facility with no assistance and has no difficulty. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/15/18 at 3:19PM revealed, This afternoon, CR #3 was noted to be pushing another resident's wheelchair in the common area. Staff intervention was attempted as CR #3 began yelling verbal racial slurs at staff. A female employee stood in front of the other resident's wheelchair to prevent CR#3 from pushing the resident's wheelchair. CR#3 then stated to the employee, Get away from me you Mexican! You all are a bunch of [***] es around here! CR#3 then made a fist and stuck the employee to the right-side rib cage. Note was written by the social worker. Record review of CR #3's progress notes dated 11/15/18 at 3:19PM revealed, CR #3 verbalized abusive words towards other resident and staff. CR #3 was going to bring another resident to the bathroom, the CNA tried to help the resident to the bathroom and CR #3 held tight to the resident wheel chair and verbalized abusive words towards the staff. It took three staff to get the resident out of CR #3's hands and finally helped resident to the bathroom. Note was written by LVN #13. Record review of CR #3's NP progress notes dated 11/16/18 revealed, Social worker reported today, patient was pushing another patient in her wheelchair yesterday, there was a concern that patient may accidentally hurt patient in the wheel chair, and CNA stopped the wheelchair, and patient attacked CNA physically. Informed social worker there was a steady dose reduction on [MEDICATION NAME] over the last few weeks. Patient had verbal outburst previously, but she has not attacked anyone in the past. Further review revealed a plan stating, informed social worker and nursing that patient has paranoid behavior, and something made patient afraid and she responded physically. Plan to increase [MEDICATION NAME] from 25MG in AM and 50MG in PM, to [MEDICATION NAME] 25MG 9AM, 4PM and 50MG 9PM. The end of the progress notes also revealed a conversation was held with the family discussing CR #3 plan of care, 1. Family very concerned about patient's physical response yesterday, family also concerned that patient may be removed from this facility due to her behavior. 2. Educated family that normally all measures are taken to help patient, and facility makes decision to transfer to another facility only when all measures have failed, at this moment plan to increase dose of [MEDICATION NAME] which was reduced about two weeks ago. 3. Discussed in detail, about inpatient evaluation of behavior and possibly changing medication, family stated they were not against inpatient evaluation of patient. Record review of CR #3's of progress notes dated 11/22/18 at 11:18AM revealed, Around 8 pm, Nurse was called to resident's room by CNA. Upon arrival, resident was sleeping on roommates' bed with roommate in the bed. Roommate was uncomfortable. Nurse tried to explain to resident that she had to go to her own bed as roommate wanted to sleep. Resident started screaming, yelling at nurse and two other staff that this was her house, she could go to which bed she wants. She used all sorts of profanities on staff, calling them [***] ing retards. When Nurse insisted that she had to go to her bed, she called Nurse a dumb nigger who is nothing but a piece of[***] Nurse and other staff insisted that she had to go to her bed and she finally went and ask staff to go out. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/23/18 at 3:12PM revealed, Resident was attempting to take another resident to the bathroom. Staff approached her and told her to let us help the other resident go to the bathroom. Resident said no she will take her to the bathroom, she does not need staff help. Staff insisted and explained to resident that she cannot take the other resident to the bathroom, she should let staff help her. Resident got upset, striking out and staff and calling them a bunch of [***] ing niggers who are no good. She tried hitting, kicking and punching staff. Staff stayed in the room, away from resident to ensure safety of resident and other two residents in the room. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/23/2018 at 3:24PM revealed, Resident later left the room and started walking down the hallway. NP called, and she said the manner of approach towards resident matters. She said resident lashes out only when she is approached in a confrontational manner. She asked where resident was, and Nurse said she was walking down the hallway. NP said to leave resident alone and she will calm down. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/25/2018 at 1:54 PM revealed, During Lunch time at the dinner room, writer saw resident fighting the other resident at the dinner room. The other resident poured water on resident to move away from the table that it's not her regular chair she sit at that it belongs to another resident. Writer separated them and ask what was going on, the other resident stated that resident don't suppose to sit where he is sitting that she needs to get up and go to another table. Writer spoke to resident to move from the table to another table, writer separated the two residents from each other. Writer took the other resident to her room and change her cloth, the two residents remain calm at this time. No injury or bruises from two resident. RP made aware, she thanked me and stated she will come see mother. ADON/DON made aware. Resident remain stable, will continue to monitor for any changes. Note was written by LVN #8. Record review of CR #3's progress notes dated 11/26/18 at 4:27PM revealed a quarterly note for activities. The note revealed the resident was very disruptive in activities and wanted to be the center of attention. She was noted to be demanding when she was not answered immediately and could be cruel and hateful with her words when she was angry. She lashed out at staff when she was angry by using racial slurs. She walked the halls during the day and evening and could be redirected by staff for short periods of time if she was not angry. One on one visits were done with resident if resident was not angry. Note written by the Activities Director. Record review of CR #3's progress notes dated 11/27/2018 at 11:34AM revealed, IDT met on this date to review quarterly plan of care. CR #3 had a recent gradual dose reduction (GDR) of her antipsychotic medication ([MEDICATION NAME]). The GDR had failed, behaviors began to increase once medication was titrated. NP notified and changed medication back to original dosage and RP made aware. Resident continues behavior monitoring. Resident self ambulates throughout room and corridor with a slightly unsteady gait. Enjoys conversing with other residents in the dining room and attends most meals in the dining room. CR #3 sleeps in during the morning and is usually a late riser, she then has coffee in the TV area before she begins ambulating throughout the halls. Plan of care continues. Record review of CR #3's NP progress notes dated 11/27/18 revealed she was following up on aggressive behaviors/[MEDICAL CONDITION]. The weekend nurse had told her CR #3 had hit someone. The Resident was irritated in the morning after the nurse had woke her up to give medications. She took the medications but refused to have her blood sugar and blood pressure checked. The resident was noted to have a history of verbal outbursts and recent hitting. Resident becomes more aggressive when she is argued with. The plan included to continue residents' current dose of [MEDICATION NAME] 25MG at AM, PM, and 50MG QHS. The NP also encouraged staff to speak to resident in calming manner and redirect as needed. She noted she would order labs if resident behavior continued. Record review of CR #3's progress notes dated 11/30/2018 at 2:30 PM revealed, At about 1:30pm, resident was wheeling another resident into her room, this nurse redirected her, she displayed an impulsive behavior, slapped this nurse and accidentally hit the resident in the w/c. Resident in the w/c was assessed, no apparent injury. I was finally able to get her under control. RP notified. She was very remorseful and said sorry. DON/ADON notified. Note was written by LVN #6. Record review of CR #3's progress notes dated 12/2/18 at 9:44PM revealed, After dinner time, around 6:00PM, resident was noted by staff in room [ROOM NUMBER]A trying to get another resident up from her wheel chair to her bed. This Nurse was doing rounds when she found that resident was being aggressive toward staff. Nurse redirected this resident to her room. And staff help resident in 208A with ADL. ADON, DON notified. RP was notified. Record review of CR #3's NP progress notes dated 12/3/18 revealed resident RP called the NP concerned about resident's behavior as she was informed about the resident being physically abusive towards staff. Resident was observed by NP sitting in the living area, she was upset, being verbally abusive and did not want to be disturbed. Plan of care was for labs CBC, BMP, and UA and C&S with I&O Cath to be done. Record review of CR #3's NP progress notes dated 12/4/18 revealed resident did not want to be disturbed and she was irritated by the NP was asking questions for an assessment. Resident asked to be left alone. There were no reports of aggressive behaviors from nursing staff and her behaviors were currently being controlled with Memantine and [MEDICATION NAME]. Record review of CR #3's progress notes dated 12/7/18 revealed resident was diagnosed with [REDACTED]. Record review of CR #3's progress notes dated 12/11/18 revealed resident continued to get agitated when in the TV area and the nurse would try to redirect her. The redirection would temporarily work. Record review of CR 3#'s progress notes dated 12/22/18 at 1:10AM revealed, Resident in 201A (Resident #27) reported to this writer that this resident is being loud and waking her up. This resident was in hallway standing by nursing cart and seemed confused telling staff to go home she needs to close her store. This nurse approached the resident in calm non-threating manner and remained with the resident while level of confusion is high, displayed listening and respect, answered her questions in warmth and comforting manner, resident was re-directed then became calm and agreed that nurse walks her to her bed. Note written by RN #6. Record review of CR #3's progress notes dated 12/23/18 at 7:00PM revealed resident was observed pushing another resident to her room, the resident was reeducated not to push any residents to her room. Redirection was successful. Record review of CR #3's progress notes dated 12/26/18 at 3:49PM revealed resident was diagnosed with [REDACTED]. Record review of CR #3's progress notes dated 12/31/18 at 3:26PM revealed, Writer noted CR #3 pushing another resident after Lunch on his wheelchair, writer and other staff try to stop CR #3 from pushing resident on the wheelchair around, when other staff was trying to stop CR #3, she raised her hand up to hit the staff. Writer intervene and stop resident from hitting staff, writer educate CR #3 that's not appropriate for her to do. ADON/DON made aware of behavior. RP called and explain to RP about behavior, stated she will come see her. Note was written by LVN #8. Record review of CR #3's Incident report dated 12/31/18 at 7:00PM for a behavior related incident. LVN #1 described what happened as CR #3 was pushing another resident down the hallway in his wheel chair. He tried to redirect CR #3, but she got abusive and started calling the nurse nigger and other profanities. CR #3 hit the nurse in the chest and another resident came up trying to pull the resident in the wheel chair away when CR #3 punched the other resident in the neck and chin area. Nurse was able to redirect CR #3 and got the other resident away from her. Follow up steps were taken to keep the two residents separated at all times. Education was provided to CR #3 that she could not push another resident in a wheelchair and she could not hit anyone. Both residents were evaluated with no apparent injuries noted. Incident was reported to state agency. Record review of CR #3's progress notes dated 12/31/2018 at 9:49 PM revealed, Writer noticed CR #3 pushing another resident (Resident #14) in his wheelchair. Nurse approached CR #3 and tried to redirect her not to push another resident. Resident got agitated, told staff he was nothing, but a nigger and she proceeded to hit staff in the chest. Another resident (Resident #18) came and tried to pull the other resident that CR #3 was pushing in the wheelchair away. CR #3 also hit the other resident (Resident #18) in the neck. Nurse Practitioner was called, and an order was given for CR #3 to be sent to Behavioral hospital for combative behaviors. RP was called, and she said it is ok to send her to be evaluated. Hospital was called to give a report, but no one picked up the phone. Resident is transferred to behavioral hospital via stretcher accompanied by two ambulance staff. CR# 3's family member called to be informed she was on her way. DON/ADON notified. Note was written by LVN #1. Interview on 1/18/19 at 3:23PM, LVN #1 said he had been involved in several of CR #3's behavioral episodes. He was the nurse who witnessed the incident on 12/31/18 between CR #3, Resident #18, and Resident #14. He said CR #3 was pushing Resident #14 down the hall in his wheel chair. He went to redirect CR #3 to not push Resident #14 and she became angry and started yelling and hitting him. He said Resident #18 then came up and tried to pull Resident #14 away, he tried to tell Resident #14 to leave so she would not get hurt but CR #3 swung and hit Resident #18 in the neck area. He said Resident #14 went to her room and called the police. LVN #1 said it was hard to redirect CR #3 and she was set off anytime she was not allowed to do what she wanted to do. He said sometimes she was able to be redirected and others she would explode with violent outburst of throwing things, hitting, and verbal abuse. He said she would threaten the staff and residents when she would have her behavioral episodes. He said other residents have expressed having issues with CR #3 and he thought the residents were afraid of her. LVN #1 said other residents respond to CR #3's behaviors by avoiding her and said there had been occasions where residents had called the police because they were afraid of CR #3 when she would have her behavioral episodes. Record review of CR #3's progress notes dated 1/1/19 at 3:10AM revealed resident returned to the facility via EMS and was put to bed. Record review of CR #3's progress notes dated 01/02/2019 at 03:34PM revealed, Counseling session attempted for initial evaluation of services by LCSW from a Behavioral Services organization. CR #3 was noted to be sitting in the common area of facility with other residents. LCSW informed me that she simply sat down next to resident. She asked CR #3 How are you doing? response was, not good. LCSW asked resident if she wanted to just talk a little bit? CR #3 said, no I don't

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, mistreatment, are reported immediately, but no later than 2 hours after the allegation is made for 9 of 34 residents (CR #3, #27, #35, #32, #8, #14, #17, #15, and #43) reviewed for abuse and neglect. The facility did not report incidents of abuse of Residents #27, #35, #32, #8, #14, #17, #15, and #43 by CR#3. These failures affected 9 residents who were placed at risk of abuse and neglect. Findings included: Intake # 5 CR #3 Record review of CR #3's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. with late onset, essential hypertension, [MEDICAL CONDITION], and lymphoid [MEDICAL CONDITION]. Record review of CR #3's admission MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 indicating the resident was severely impaired. Her MDS also revealed no issues with mood or behaviors. Further review of the MDS revealed CR #3 required supervision with walking on and off the unit and limited assistance with transfers. Resident used a walker or wheel chair to ambulate. The resident received antipsychotic medication 7 days, antianxiety medication 2 days, and antidepressant medication 6 days. Record review of CR #3's Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition . The MDS also revealed no mood or behaviors. The resident [DIAGNOSES REDACTED]. CR #3 required only supervision for all activities of daily living (ADL's). Resident used a walker or wheel chair to ambulate and received antipsychotic medication for 7 days and antidepressant medication 7 days during the look back period. Record review of CR #3's care plan dated 8/20/18 revealed resident receive antipsychotic medication due to behavioral disturbances. On 12/22/18 resident experienced confusion, yelling at staff and asking them, you have to leave now, I have to close the store. 12/31/18 Resident experienced behavior and being combative with residents and staff. Pushing and hitting behavior. Interventions starting on 1/1/19 were to implement a behavior management plan: during 24-hour report nurses and caregivers will discuss effective and ineffective approach by increasing visual monitoring every shift to identify and remove any triggers, physiological URI, internal or external factors. Identify contextual triggers (time, place, with specific resident/specific nurse). Identify pattern of aggressive behavior (raising hand, kicking, punching) will gather input, increase monitoring every shift and approach resident in gentle and calm tone and tell the resident, I need you to be calm. Intervention starting on 12/22/18 were to increase visual monitoring for the next 7 days and assess for any side effects of medication such as confusion/behavioral disturbances on every shift. Intervention starting on 9/12/18 was to redirect the resident when she hoards items in her bra and under her pillow. Inappropriate items will be removed. She loses her glasses in her bra. Intervention starting on 9/11/18 listed to monitor resident's behavior and response to medication. See order/Medication Administration Record [REDACTED]. Approach starting on 8/20/18 were to attempt a gradual dose reduction (GDR) in 2 separate quarters the first-year medication is received, unless clinically contraindicated. Attempt yearly GDR thereafter unless clinically contraindicated. Pharmacy consultant to review per facility standard and as needed. Record review of CR#3's care plan dated 11/26/18 revealed residents' behavioral symptoms in group programs often disrupting, distracting, and offending other residents within the activity. Interventions starting on 11/26/18 listed for staff to offer activities in which resident can succeed, that are broken into simple steps, and that involve small group or one on one activities. Staff will try activities that are short and repetitive and can be stopped if overwhelmed. Record review of CR #3's care plan dated 1/2/19 revealed resident demonstrated combative behavior towards other residents which is causing a concern for patient/staff safety. Resident had a [DIAGNOSES REDACTED]. Interventions listed included: attempt non-pharmacological interventions including physical needs met, activity programs, quiet time/rest, redirection/reassurance, increased observation, validation, consistent caregivers, psychological services, etc. Identify behaviors: combative, hitting, punching, and calling staff and other residents derogatory names. Notify Physician and family of changes in resident status. Rule out environmental causes (noises, overcrowding, new surroundings, temperature irregulates, lighting) . Record review of CR#3's admission records revealed Prescription note from a Physician's office for CR #3 dated 8/6/18 stated, Recommend long term care for Alzheimer's with delusions, not safe for patient and other patients to be at home. Record review of CR #3's progress notes dated 8/6/18 at 10:20AM revealed Resident admitted under skilled care. Resident was coming from home, she arrived via private vehicle with beside her, she provided information for resident's well-being. Resident is allergic to [MEDICATION NAME], regular diet with admitting [DIAGNOSES REDACTED]. Resident refused her vital signs to be taken, or any assessment, observed to use walker for ambulation, and verbalized, I am fine no need to put that on me and grabbed her water bottle heading towards the door. She informed the nurse she was leaving going home. Resident stated, this place stinks. She was redirected and remained calm. Record review of CR #3's progress notes dated 08/09/2018 at 09:40PM revealed a CNA reported to nurse that resident was refusing help with ADL cares. Resident became loud and cussing at the CNA. Nurse went to the room to assess the situation and resident was in the hallway yelling at other staff saying, GET OUT OF MY HOUSE. The resident was very agitated and continued to use foul language and racial slurs. Resident followed the CNA into the hallway and threatened to hurt her. The Medication aide reported all scheduled medications had been given, per orders. Resident began going into other resident rooms yelling loudly and causing a disruption in sleep. Nurse Practitioner (NP) was notified and gave orders to send resident to the emergency room (ER) for psych eval. Resident began going to other residents in TV area and yelling at them. The nurse stepped between the residents to separate and provide safety. The second resident (Resident #27) was fearful and called 911. Emergency Medical Technicians (EMT) arrived on scene and resident became more agitated and yelling became louder. Responsible party (RP) was contacted via phone and notified of incident. RP notified of NP order to send to ER for evaluation/treatment. Resident was transported via Emergency Medical Services (EMS) to the emergency room , RP was aware of transfer. The Director of Nursing (DON) was notified. Note made by ADON #1. Record review of CR#3's nurses notes and interviews with ADON #1, ADON #2, and DON on 1/19/19 at 11:30pm revealed no additional information or documentation concerning the above behavioral episode. An incident report was not done, and they did not consider this an incident. Record review of CR #3's history and physical from hospital visit dated 8/10/18 revealed CR #3 resided in a nursing facility where she became physically combative hitting the staff. The police department was called, and EMS brought her to the ER. She received Versed (a sedative) 5mg and 7.5 Intramuscular (IM) prior to her arrival. Resident was lethargic. Resident presented with combative and agitated behavior. EMS stated resident was somnolent (sleepy; drowsy). Blood glucose level was over 100. Family reported the resident had never been previously combative, but resident had not been happy with moving into the nursing facility. Mostly her behaviors included name calling and being angry. Resident did not remember what happened. Urinary Analysis (UA) was done and diagnosed resident with UTI. Resident was started on intravenous (IV) [MEDICATION NAME]. Record review of CR #3's progress notes dated 08/12/2018 at 09:40PM revealed CR #3 was readmitted to the facility from the hospital where she was diagnosed with [REDACTED]. CR#3's RP requested the facility administer [MEDICATION NAME] upon CR#3's arrival to the facility which was given to her. The NP verified the resident's medications, but the [MEDICATION NAME] was to be discontinued in the morning due to high dosage with [MEDICATION NAME]. Resident was to start on antibiotic Cefdnir 300 MG, one capsule twice a day (BID) for seven days for UTI. Resident was to be monitored closely and redirected as needed. Record review of CR #3's progress notes dated 08/15/2018 at 09:00PM revealed resident refused to take medication yelled at the nurse to get out of the room. RP reported that it would be best if the family did not get in touch with CR #3 via phone, so she can get adapted to her new place and to let the resident know that her family members were on vacation and will visit her when they come back. Resident continued to be monitored. Will report to the oncoming night nurse, communication for NP regarding behavioral issue is in communication log. Record review of CR #3's progress notes dated 08/16/2018 at 07:25AM revealed at the beginning of the shift, Resident was agitated, and asked staff that went into her room to assist her to get out. She refused treatments and after 2 hours the resident calmed down and rested in her bed for the remainder of the shift. Continued to monitor. Record review of CR #3's progress notes dated 08/16/2018 at 1:58PM revealed Resident ate all her meals and was brought to the nurse's station to monitor since she pulled out her first IV that was put in. New IV for [MEDICATION NAME] was put in left anterior hand. Continued to monitor. Record review of CR #3's progress notes dated 8/17/18 at 7:40AM revealed resident refused care and medication. IV [MEDICATION NAME] continued and no complaints of dysuria (painful urination) . Record review of CR #3's progress notes dated 8/17/18 at 3:01PM revealed resident pulled her IV out. RP, NP, ADON and DON notified. PRN [MEDICATION NAME] was given, and NP ordered to have the line put back in when resident calmed down. Record review of CR #3's progress notes dated 8/17/18 at 10:55PM revealed resident continued to refuse IV reinsertion. Counsel on importance of IV and medication was attempted with the resident, but she was highly confused and unable to retain information. NP gave one-time order for [MEDICATION NAME] 1GM IM and to attempt IV insertion in the morning. IM administered, and resident tolerated well. Record review of CR #3's progress notes dated 8/20/18 at 5:59PM revealed staff attempted to have a midline placed but the resident became confused and refused to have it put in. The NP was able to counsel the resident and get her to agree but shortly after the NP left the resident was confused again and did not know what was going on. After having the procedure explained to the resident several times the midline was placed in her right upper arm to receive antibiotics [MEDICATION NAME]. Record review of CR #3's progress notes dated 9/3/18 at 8:23PM revealed resident had refused her blood sugars being checked that shift. Record review of CR #3's NP progress notes dated 9/11/18 revealed a follow up from Pharmacist recommendations. Resident was said to have [MEDICAL CONDITION] with verbal outburst and the Pharmacist stated the current [DIAGNOSES REDACTED]. The NP's plan stated, continue [MEDICATION NAME] 50MG Three times a day (TID), patient has done well participation in group activities, no reports of any verbal outburst since medication was increased from BID to TID. Record review of CR #3's Physician's initial visit note dated 9/14/18 revealed CR #3 had Dementia that had become gradually worse. She had issues with behavior's and required hospitalization at a behavioral hospital for control of behaviors where she was given [MEDICATION NAME] at 40mg a day and [MEDICATION NAME] at 300mg per day. This controlled her behaviors and she became better and more functional. They were at the process or trying to peel back some of her [MEDICATION NAME]. It was noted resident was on rather significant doses of [MEDICATION NAME] and [MEDICATION NAME]. Record review of CR #3's progress notes dated 9/14/18 at 3:01PM revealed an IDT (interdisciplinary team) meeting was held to discuss residents plan of care. They decided to continue current plan of care and noted the resident had no increased behaviors and she was adjusting well to recent admission to the facility. Record review of CR #3's NP progress notes dated 9/17/18 revealed a new [DIAGNOSES REDACTED]. Record review of CR #3's NP progress notes dated 9/19/18 revealed in part, [MEDICAL CONDITION]/Depression - Nurse reported resident is sleeping most of the day, waking up late at night. Currently managed with [MEDICATION NAME] 50MG TID, [MEDICATION NAME] and Memantine. Further review the NP's plan stating, [MEDICAL CONDITION]/Dementia - Behavior for the last 2-3 weeks has been controlled, no reports of patient being physically aggressive. Plan to continue [MEDICATION NAME], Memantine and [MEDICATION NAME]. Reduce [MEDICATION NAME] to 25MG at 9AM and 2PM and continue 50MG at bedtime (HS). Continue to evaluate any changes in behavior. Record review of CR #3's progress note dated 10/4/18 at 2:26PM revealed an IDT meeting was held for the residents plan of care. Resident was to remain on anxiety medication and behavior monitoring. Resident was noted to be adjusting well to recent move. Resident was to remain on current plan of care. Record review of CR #3's NP progress notes dated 10/8/18 revealed in part, 2. Reduced [MEDICATION NAME] from 40MG to 30MG every day (QD). 3. [MEDICATION NAME] was discontinued, changed to [MEDICATION NAME] 20MG HS. 4. CR#3's family member wanted Donepezil discontinued since it normally helps in early dementia. Record review of CR #3's progress notes dated 10/20/18 at 12:01PM revealed, Resident alert and Demented. Resident stayed up all night, pushing a resident around, when resident was redirected the resident became violent with the aid, and the Nurse, calling them inappropriate names. Resident was monitored and redirected all night. Focusing on safety and explaining safety to the patient. Interventions effective. Resident left in bed, Call [NAME] in reach, ADON informed/DON informed RP contacted. Note was written by LVN #3. Record review of CR #3's NP progress notes dated 10/22/18 revealed, Follow up [MEDICAL CONDITION]/physically aggressive behavior - nurse called over the weekend, stated patient has aggressive behavior towards staff, she tried to hit her and asked her to leave her room. Explained to nurse it is how you approach the patient, nurse also reported CR#3's family member wanted her urine checked. Asked nurse to get STAT CBC, CMP, and UA C&S. Record review of CR #3's NP progress notes dated 11/2/18 revealed, Follow up [MEDICAL CONDITION]/ physically aggressive behavior - patient's family member has been concerned about patient behavior and [MEDICATION NAME] dosage. Today, discussed about possibly reducing patient PM dosage, because nurse reported patient has been sleeping until late in the morning. Further review of the note revealed a plan, [MEDICAL CONDITION]/ aggressive behavior - family member stated she is concerned about changing evening dose, because patient has history of [MEDICAL CONDITION] and behavior problems at night in the past. Plan to reduce [MEDICATION NAME] to 25MG every morning (QAM) and 50MG HS. Record review of CR #3's progress notes dated 11/13/18 at 2:05PM revealed in part, resident was confused at times and, needs supervision as she wanders, exit seeks but does not need assistance with activities of daily living (ADL's), transfers, eating, toileting, and bed mobility. Resident is able to walk around the facility with no assistance and has no difficulty. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/15/18 at 3:19PM revealed, This afternoon, CR #3 was noted to be pushing another resident's wheelchair in the common area. Staff intervention was attempted as CR #3 began yelling verbal racial slurs at staff. A female employee stood in front of the other resident's wheelchair to prevent CR#3 from pushing the resident's wheelchair. CR#3 then stated to the employee, Get away from me you Mexican! You all are a bunch of [***] es around here! CR#3 then made a fist and stuck the employee to the right-side rib cage. Note was written by the social worker. Record review of CR #3's progress notes dated 11/15/18 at 3:19PM revealed, CR #3 verbalized abusive words towards other resident and staff. CR #3 was going to bring another resident to the bathroom, the CNA tried to help the resident to the bathroom and CR #3 held tight to the resident wheel chair and verbalized abusive words towards the staff. It took three staff to get the resident out of CR #3's hands and finally helped resident to the bathroom. Note was written by LVN #13. Record review of CR #3's NP progress notes dated 11/16/18 revealed, Social worker reported today, patient was pushing another patient in her wheelchair yesterday, there was a concern that patient may accidentally hurt patient in the wheel chair, and CNA stopped the wheelchair, and patient attacked CNA physically. Informed social worker there was a steady dose reduction on [MEDICATION NAME] over the last few weeks. Patient had verbal outburst previously, but she has not attacked anyone in the past. Further review revealed a plan stating, informed social worker and nursing that patient has paranoid behavior, and something made patient afraid and she responded physically. Plan to increase [MEDICATION NAME] from 25MG in AM and 50MG in PM, to [MEDICATION NAME] 25MG 9AM, 4PM and 50MG 9PM. The end of the progress notes also revealed a conversation was held with the family discussing CR #3 plan of care, 1. Family very concerned about patient's physical response yesterday, family also concerned that patient may be removed from this facility due to her behavior. 2. Educated family that normally all measures are taken to help patient, and facility makes decision to transfer to another facility only when all measures have failed, at this moment plan to increase dose of [MEDICATION NAME] which was reduced about two weeks ago. 3. Discussed in detail, about inpatient evaluation of behavior and possibly changing medication, family stated they were not against inpatient evaluation of patient. Record review of CR #3's of progress notes dated 11/22/18 at 11:18AM revealed, Around 8 pm, Nurse was called to resident's room by CNA. Upon arrival, resident was sleeping on roommates' bed with roommate in the bed. Roommate was uncomfortable. Nurse tried to explain to resident that she had to go to her own bed as roommate wanted to sleep. Resident started screaming, yelling at nurse and two other staff that this was her house, she could go to which bed she wants. She used all sorts of profanities on staff, calling them [***] ing retards. When Nurse insisted that she had to go to her bed, she called Nurse a dumb nigger who is nothing but a piece of[***] Nurse and other staff insisted that she had to go to her bed and she finally went and ask staff to go out. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/23/18 at 3:12PM revealed, Resident was attempting to take another resident to the bathroom. Staff approached her and told her to let us help the other resident go to the bathroom. Resident said no she will take her to the bathroom, she does not need staff help. Staff insisted and explained to resident that she cannot take the other resident to the bathroom, she should let staff help her. Resident got upset, striking out and staff and calling them a bunch of [***] ing niggers who are no good. She tried hitting, kicking and punching staff. Staff stayed in the room, away from resident to ensure safety of resident and other two residents in the room. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/23/2018 at 3:24PM revealed, Resident later left the room and started walking down the hallway. NP called, and she said the manner of approach towards resident matters. She said resident lashes out only when she is approached in a confrontational manner. She asked where resident was, and Nurse said she was walking down the hallway. NP said to leave resident alone and she will calm down. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/25/2018 at 1:54 PM revealed, During Lunch time at the dinner room, writer saw resident fighting the other resident at the dinner room. The other resident poured water on resident to move away from the table that it's not her regular chair she sit at that it belongs to another resident. Writer separated them and ask what was going on, the other resident stated that resident don't suppose to sit where he is sitting that she needs to get up and go to another table. Writer spoke to resident to move from the table to another table, writer separated the two residents from each other. Writer took the other resident to her room and change her cloth, the two residents remain calm at this time. No injury or bruises from two resident. RP made aware, she thanked me and stated she will come see mother. ADON/DON made aware. Resident remain stable, will continue to monitor for any changes. Note was written by LVN #8. Record review of CR #3's progress notes dated 11/26/18 at 4:27PM revealed a quarterly note for activities. The note revealed the resident was very disruptive in activities and wanted to be the center of attention. She was noted to be demanding when she was not answered immediately and could be cruel and hateful with her words when she was angry. She lashed out at staff when she was angry by using racial slurs. She walked the halls during the day and evening and could be redirected by staff for short periods of time if she was not angry. One on one visits were done with resident if resident was not angry. Note written by the Activities Director. Record review of CR #3's progress notes dated 11/27/2018 at 11:34AM revealed, IDT met on this date to review quarterly plan of care. CR #3 had a recent gradual dose reduction (GDR) of her antipsychotic medication ([MEDICATION NAME]). The GDR had failed, behaviors began to increase once medication was titrated. NP notified and changed medication back to original dosage and RP made aware. Resident continues behavior monitoring. Resident self ambulates throughout room and corridor with a slightly unsteady gait. Enjoys conversing with other residents in the dining room and attends most meals in the dining room. CR #3 sleeps in during the morning and is usually a late riser, she then has coffee in the TV area before she begins ambulating throughout the halls. Plan of care continues. Record review of CR #3's NP progress notes dated 11/27/18 revealed she was following up on aggressive behaviors/[MEDICAL CONDITION]. The weekend nurse had told her CR #3 had hit someone. The Resident was irritated in the morning after the nurse had woke her up to give medications. She took the medications but refused to have her blood sugar and blood pressure checked. The resident was noted to have a history of verbal outbursts and recent hitting. Resident becomes more aggressive when she is argued with. The plan included to continue residents' current dose of [MEDICATION NAME] 25MG at AM, PM, and 50MG QHS. The NP also encouraged staff to speak to resident in calming manner and redirect as needed. She noted she would order labs if resident behavior continued. Record review of CR #3's progress notes dated 11/30/2018 at 2:30 PM revealed, At about 1:30pm, resident was wheeling another resident into her room, this nurse redirected her, she displayed an impulsive behavior, slapped this nurse and accidentally hit the resident in the w/c. Resident in the w/c was assessed, no apparent injury. I was finally able to get her under control. RP notified. She was very remorseful and said sorry. DON/ADON notified. Note was written by LVN #6. Record review of CR #3's progress notes dated 12/2/18 at 9:44PM revealed, After dinner time, around 6:00PM, resident was noted by staff in room [ROOM NUMBER]A trying to get another resident up from her wheel chair to her bed. This Nurse was doing rounds when she found that resident was being aggressive toward staff. Nurse redirected this resident to her room. And staff help resident in 208A with ADL. ADON, DON notified. RP was notified. Record review of CR #3's NP progress notes dated 12/3/18 revealed resident RP called the NP concerned about resident's behavior as she was informed about the resident being physically abusive towards staff. Resident was observed by NP sitting in the living area, she was upset, being verbally abusive and did not want to be disturbed. Plan of care was for labs CBC, BMP, and UA and C&S with I&O Cath to be done. Record review of CR #3's NP progress notes dated 12/4/18 revealed resident did not want to be disturbed and she was irritated by the NP was asking questions for an assessment. Resident asked to be left alone. There were no reports of aggressive behaviors from nursing staff and her behaviors were currently being controlled with Memantine and [MEDICATION NAME]. Record review of CR #3's progress notes dated 12/7/18 revealed resident was diagnosed with [REDACTED]. Record review of CR #3's progress notes dated 12/11/18 revealed resident continued to get agitated when in the TV area and the nurse would try to redirect her. The redirection would temporarily work. Record review of CR 3#'s progress notes dated 12/22/18 at 1:10AM revealed, Resident in 201A (Resident #27) reported to this writer that this resident is being loud and waking her up. This resident was in hallway standing by nursing cart and seemed confused telling staff to go home she needs to close her store. This nurse approached the resident in calm non-threating manner and remained with the resident while level of confusion is high, displayed listening and respect, answered her questions in warmth and comforting manner, resident was re-directed then became calm and agreed that nurse walks her to her bed. Note written by RN #6. Record review of CR #3's progress notes dated 12/23/18 at 7:00PM revealed resident was observed pushing another resident to her room, the resident was reeducated not to push any residents to her room. Redirection was successful. Record review of CR #3's progress notes dated 12/26/18 at 3:49PM revealed resident was diagnosed with [REDACTED]. Record review of CR #3's progress notes dated 12/31/18 at 3:26PM revealed, Writer noted CR #3 pushing another resident after Lunch on his wheelchair, writer and other staff try to stop CR #3 from pushing resident on the wheelchair around, when other staff was trying to stop CR #3, she raised her hand up to hit the staff. Writer intervene and stop resident from hitting staff, writer educate CR #3 that's not appropriate for her to do. ADON/DON made aware of behavior. RP called and explain to RP about behavior, stated she will come see her. Note was written by LVN #8. Record review of CR #3's Incident report dated 12/31/18 at 7:00PM for a behavior related incident. LVN #1 described what happened as CR #3 was pushing another resident down the hallway in his wheel chair. He tried to redirect CR #3, but she got abusive and started calling the nurse nigger and other profanities. CR #3 hit the nurse in the chest and another resident came up trying to pull the resident in the wheel chair away when CR #3 punched the other resident in the neck and chin area. Nurse was able to redirect CR #3 and got the other resident away from her. Follow up steps were taken to keep the two residents separated at all times. Education was provided to CR #3 that she could not push another resident in a wheelchair and she could not hit anyone. Both residents were evaluated with no apparent injuries noted. Incident was reported to state agency. Record review of CR #3's progress notes dated 12/31/2018 at 9:49 PM revealed, Writer noticed CR #3 pushing another resident (Resident #14) in his wheelchair. Nurse approached CR #3 and tried to redirect her not to push another resident. Resident got agitated, told staff he was nothing, but a nigger and she proceeded to hit staff in the chest. Another resident (Resident #18) came and tried to pull the other resident that CR #3 was pushing in the wheelchair away. CR #3 also hit the other resident (Resident #18) in the neck. Nurse Practitioner was called, and an order was given for CR #3 to be sent to Behavioral hospital for combative behaviors. RP was called, and she said it is ok to send her to be evaluated. Hospital was called to give a report, but no one picked up the phone. Resident is transferred to behavioral hospital via stretcher accompanied by two ambulance staff. CR# 3's family member called to be informed she was on her way. DON/ADON notified. Note was written by LVN #1. Interview on 1/18/19 at 3:23PM, LVN #1 said he had been involved in several of CR #3's behavioral episodes. He was the nurse who witnessed the incident on 12/31/18 between CR #3, Resident #18, and Resident #14. He said CR #3 was pushing Resident #14 down the hall in his wheel chair. He went to redirect CR #3 to not push Resident #14 and she became angry and started yelling and hitting him. He said Resident #18 then came up and tried to pull Resident #14 away, he tried to tell Resident #14 to leave so she would not get hurt but CR #3 swung and hit Resident #18 in the neck area. He said Resident #14 went to her room and called the police. LVN #1 said it was hard to redirect CR #3 and she was set off anytime she was not allowed to do what she wanted to do. He said sometimes she was able to be redirected and others she would explode with violent outburst of throwing things, hitting, and verbal abuse. He said she would threaten the staff and residents when she would have her behavioral episodes. He said other residents have expressed having issues with CR #3 and he thought the residents were afraid of her. LVN #1 said other residents respond to CR #3's behaviors by avoiding her and said there had been occasions where residents had called the police because they were afraid of CR #3 when she would have her behavioral episodes. Record review of CR #3's progress notes dated 1/1/19 at 3:10AM revealed resident returned to the facility via EMS and was put to bed. Record review of CR #3's progress notes dated 01/02/2019 at 03:34PM revealed, Counseling session attempted for initial evaluation of services by LCSW from a Behavioral Services organization. CR #3 was noted to be sitting in the common area of facility with other residents. LCSW informed me that she simply sat down next to resident. She asked CR #3 How are you doing? response was, not good. LCSW asked

Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse and neglect for 10 of 34 residents (CR #3, Resident #18, #27, #35, #32, #8, #14, #17, #15, and #43) reviewed for abuse and neglect. The facility failed to protect residents from CR #3 who was physically aggressive and abusive toward residents. The facility failed to implement effective interventions to protect residents from CR #3's physical and verbal abuse . The facility failed to ensure residents were free to move around the facility as desired without fear of physical attacks from CR#3. The facility failed to ensure staff were trained to address and deescalate CR#3 violent and aggressive behaviors. The facility retained CR#3 whose needs could not be met by the facility . These failures affected 10 residents who were placed at risk of abuse and neglect. Findings included: Intake # 5 CR #3 Record review of CR #3's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. with late onset, essential hypertension, [MEDICAL CONDITION], and lymphoid [MEDICAL CONDITION]. Record review of CR #3's admission MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 indicating the resident was severely impaired. Her MDS also revealed no issues with mood or behaviors. Further review of the MDS revealed CR #3 required supervision with walking on and off the unit and limited assistance with transfers. Resident used a walker or wheel chair to ambulate. The resident received antipsychotic medication 7 days, antianxiety medication 2 days, and antidepressant medication 6 days. Record review of CR #3's Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition . The MDS also revealed no mood or behaviors. The resident [DIAGNOSES REDACTED]. CR #3 required only supervision for all activities of daily living (ADL's). Resident used a walker or wheel chair to ambulate and received antipsychotic medication for 7 days and antidepressant medication 7 days during the look back period. Record review of CR #3's care plan dated 8/20/18 revealed resident receive antipsychotic medication due to behavioral disturbances. On 12/22/18 resident experienced confusion, yelling at staff and asking them, you have to leave now, I have to close the store. 12/31/18 Resident experienced behavior and being combative with residents and staff. Pushing and hitting behavior. Interventions starting on 1/1/19 were to implement a behavior management plan: during 24-hour report nurses and caregivers will discuss effective and ineffective approach by increasing visual monitoring every shift to identify and remove any triggers, physiological URI, internal or external factors. Identify contextual triggers (time, place, with specific resident/specific nurse). Identify pattern of aggressive behavior (raising hand, kicking, punching) will gather input, increase monitoring every shift and approach resident in gentle and calm tone and tell the resident, I need you to be calm. Intervention starting on 12/22/18 were to increase visual monitoring for the next 7 days and assess for any side effects of medication such as confusion/behavioral disturbances on every shift. Intervention starting on 9/12/18 was to redirect the resident when she hoards items in her bra and under her pillow. Inappropriate items will be removed. She loses her glasses in her bra. Intervention starting on 9/11/18 listed to monitor resident's behavior and response to medication. See order/Medication Administration Record [REDACTED]. Approach starting on 8/20/18 were to attempt a gradual dose reduction (GDR) in 2 separate quarters the first-year medication is received, unless clinically contraindicated. Attempt yearly GDR thereafter unless clinically contraindicated. Pharmacy consultant to review per facility standard and as needed. Record review of CR#3's care plan dated 11/26/18 revealed residents' behavioral symptoms in group programs often disrupting, distracting, and offending other residents within the activity. Interventions starting on 11/26/18 listed for staff to offer activities in which resident can succeed, that are broken into simple steps, and that involve small group or one on one activities. Staff will try activities that are short and repetitive and can be stopped if overwhelmed. Record review of CR #3's care plan dated 1/2/19 revealed resident demonstrated combative behavior towards other residents which is causing a concern for patient/staff safety. Resident had a [DIAGNOSES REDACTED]. Interventions listed included: attempt non-pharmacological interventions including physical needs met, activity programs, quiet time/rest, redirection/reassurance, increased observation, validation, consistent caregivers, psychological services, etc. Identify behaviors: combative, hitting, punching, and calling staff and other residents derogatory names. Notify Physician and family of changes in resident status. Rule out environmental causes (noises, overcrowding, new surroundings, temperature irregulates, lighting) . Record review of CR#3's admission records revealed Prescription note from a Physician's office for CR #3 dated 8/6/18 stated, Recommend long term care for Alzheimer's with delusions, not safe for patient and other patients to be at home. Record review of CR #3's progress notes dated 8/6/18 at 10:20AM revealed Resident admitted under skilled care. Resident was coming from home, she arrived via private vehicle with beside her, she provided information for resident's well-being. Resident is allergic to [MEDICATION NAME], regular diet with admitting [DIAGNOSES REDACTED]. Resident refused her vital signs to be taken, or any assessment, observed to use walker for ambulation, and verbalized, I am fine no need to put that on me and grabbed her water bottle heading towards the door. She informed the nurse she was leaving going home. Resident stated, this place stinks. She was redirected and remained calm. Record review of CR #3's progress notes dated 08/09/2018 at 09:40PM revealed a CNA reported to nurse that resident was refusing help with ADL cares. Resident became loud and cussing at the CNA. Nurse went to the room to assess the situation and resident was in the hallway yelling at other staff saying, GET OUT OF MY HOUSE. The resident was very agitated and continued to use foul language and racial slurs. Resident followed the CNA into the hallway and threatened to hurt her. The Medication aide reported all scheduled medications had been given, per orders. Resident began going into other resident rooms yelling loudly and causing a disruption in sleep. Nurse Practitioner (NP) was notified and gave orders to send resident to the emergency room (ER) for psych eval. Resident began going to other residents in TV area and yelling at them. The nurse stepped between the residents to separate and provide safety. The second resident (Resident #27) was fearful and called 911. Emergency Medical Technicians (EMT) arrived on scene and resident became more agitated and yelling became louder. Responsible party (RP) was contacted via phone and notified of incident. RP notified of NP order to send to ER for evaluation/treatment. Resident was transported via Emergency Medical Services (EMS) to the emergency room , RP was aware of transfer. The Director of Nursing (DON) was notified. Note made by ADON #1. Record review of CR#3's nurses notes and interviews with ADON #1, ADON #2, and DON on 1/19/19 at 11:30pm revealed no additional information or documentation concerning the above behavioral episode. An incident report was not done, and they did not consider this an incident. Record review of CR #3's history and physical from hospital visit dated 8/10/18 revealed CR #3 resided in a nursing facility where she became physically combative hitting the staff. The police department was called, and EMS brought her to the ER. She received Versed (a sedative) 5mg and 7.5 Intramuscular (IM) prior to her arrival. Resident was lethargic. Resident presented with combative and agitated behavior. EMS stated resident was somnolent (sleepy; drowsy). Blood glucose level was over 100. Family reported the resident had never been previously combative, but resident had not been happy with moving into the nursing facility. Mostly her behaviors included name calling and being angry. Resident did not remember what happened. Urinary Analysis (UA) was done and diagnosed resident with UTI. Resident was started on intravenous (IV) [MEDICATION NAME]. Record review of CR #3's progress notes dated 08/12/2018 at 09:40PM revealed CR #3 was readmitted to the facility from the hospital where she was diagnosed with [REDACTED]. CR#3's RP requested the facility administer [MEDICATION NAME] upon CR#3's arrival to the facility which was given to her. The NP verified the resident's medications, but the [MEDICATION NAME] was to be discontinued in the morning due to high dosage with [MEDICATION NAME]. Resident was to start on antibiotic Cefdnir 300 MG, one capsule twice a day (BID) for seven days for UTI. Resident was to be monitored closely and redirected as needed. Record review of CR #3's progress notes dated 08/15/2018 at 09:00PM revealed resident refused to take medication yelled at the nurse to get out of the room. RP reported that it would be best if the family did not get in touch with CR #3 via phone, so she can get adapted to her new place and to let the resident know that her family members were on vacation and will visit her when they come back. Resident continued to be monitored. Will report to the oncoming night nurse, communication for NP regarding behavioral issue is in communication log. Record review of CR #3's progress notes dated 08/16/2018 at 07:25AM revealed at the beginning of the shift, Resident was agitated, and asked staff that went into her room to assist her to get out. She refused treatments and after 2 hours the resident calmed down and rested in her bed for the remainder of the shift. Continued to monitor. Record review of CR #3's progress notes dated 08/16/2018 at 1:58PM revealed Resident ate all her meals and was brought to the nurse's station to monitor since she pulled out her first IV that was put in. New IV for [MEDICATION NAME] was put in left anterior hand. Continued to monitor. Record review of CR #3's progress notes dated 8/17/18 at 7:40AM revealed resident refused care and medication. IV [MEDICATION NAME] continued and no complaints of dysuria (painful urination) . Record review of CR #3's progress notes dated 8/17/18 at 3:01PM revealed resident pulled her IV out. RP, NP, ADON and DON notified. PRN [MEDICATION NAME] was given, and NP ordered to have the line put back in when resident calmed down. Record review of CR #3's progress notes dated 8/17/18 at 10:55PM revealed resident continued to refuse IV reinsertion. Counsel on importance of IV and medication was attempted with the resident, but she was highly confused and unable to retain information. NP gave one-time order for [MEDICATION NAME] 1GM IM and to attempt IV insertion in the morning. IM administered, and resident tolerated well. Record review of CR #3's progress notes dated 8/20/18 at 5:59PM revealed staff attempted to have a midline placed but the resident became confused and refused to have it put in. The NP was able to counsel the resident and get her to agree but shortly after the NP left the resident was confused again and did not know what was going on. After having the procedure explained to the resident several times the midline was placed in her right upper arm to receive antibiotics [MEDICATION NAME]. Record review of CR #3's progress notes dated 9/3/18 at 8:23PM revealed resident had refused her blood sugars being checked that shift. Record review of CR #3's NP progress notes dated 9/11/18 revealed a follow up from Pharmacist recommendations. Resident was said to have [MEDICAL CONDITION] with verbal outburst and the Pharmacist stated the current [DIAGNOSES REDACTED]. The NP's plan stated, continue [MEDICATION NAME] 50MG Three times a day (TID), patient has done well participation in group activities, no reports of any verbal outburst since medication was increased from BID to TID. Record review of CR #3's Physician's initial visit note dated 9/14/18 revealed CR #3 had Dementia that had become gradually worse. She had issues with behavior's and required hospitalization at a behavioral hospital for control of behaviors where she was given [MEDICATION NAME] at 40mg a day and [MEDICATION NAME] at 300mg per day. This controlled her behaviors and she became better and more functional. They were at the process or trying to peel back some of her [MEDICATION NAME]. It was noted resident was on rather significant doses of [MEDICATION NAME] and [MEDICATION NAME]. Record review of CR #3's progress notes dated 9/14/18 at 3:01PM revealed an IDT (interdisciplinary team) meeting was held to discuss residents plan of care. They decided to continue current plan of care and noted the resident had no increased behaviors and she was adjusting well to recent admission to the facility. Record review of CR #3's NP progress notes dated 9/17/18 revealed a new [DIAGNOSES REDACTED]. Record review of CR #3's NP progress notes dated 9/19/18 revealed in part, [MEDICAL CONDITION]/Depression - Nurse reported resident is sleeping most of the day, waking up late at night. Currently managed with [MEDICATION NAME] 50MG TID, [MEDICATION NAME] and Memantine. Further review the NP's plan stating, [MEDICAL CONDITION]/Dementia - Behavior for the last 2-3 weeks has been controlled, no reports of patient being physically aggressive. Plan to continue [MEDICATION NAME], Memantine and [MEDICATION NAME]. Reduce [MEDICATION NAME] to 25MG at 9AM and 2PM and continue 50MG at bedtime (HS). Continue to evaluate any changes in behavior. Record review of CR #3's progress note dated 10/4/18 at 2:26PM revealed an IDT meeting was held for the residents plan of care. Resident was to remain on anxiety medication and behavior monitoring. Resident was noted to be adjusting well to recent move. Resident was to remain on current plan of care. Record review of CR #3's NP progress notes dated 10/8/18 revealed in part, 2. Reduced [MEDICATION NAME] from 40MG to 30MG every day (QD). 3. [MEDICATION NAME] was discontinued, changed to [MEDICATION NAME] 20MG HS. 4. CR#3's family member wanted Donepezil discontinued since it normally helps in early dementia. Record review of CR #3's progress notes dated 10/20/18 at 12:01PM revealed, Resident alert and Demented. Resident stayed up all night, pushing a resident around, when resident was redirected the resident became violent with the aid, and the Nurse, calling them inappropriate names. Resident was monitored and redirected all night. Focusing on safety and explaining safety to the patient. Interventions effective. Resident left in bed, Call [NAME] in reach, ADON informed/DON informed RP contacted. Note was written by LVN #3. Record review of CR #3's NP progress notes dated 10/22/18 revealed, Follow up [MEDICAL CONDITION]/physically aggressive behavior - nurse called over the weekend, stated patient has aggressive behavior towards staff, she tried to hit her and asked her to leave her room. Explained to nurse it is how you approach the patient, nurse also reported CR#3's family member wanted her urine checked. Asked nurse to get STAT CBC, CMP, and UA C&S. Record review of CR #3's NP progress notes dated 11/2/18 revealed, Follow up [MEDICAL CONDITION]/ physically aggressive behavior - patient's family member has been concerned about patient behavior and [MEDICATION NAME] dosage. Today, discussed about possibly reducing patient PM dosage, because nurse reported patient has been sleeping until late in the morning. Further review of the note revealed a plan, [MEDICAL CONDITION]/ aggressive behavior - family member stated she is concerned about changing evening dose, because patient has history of [MEDICAL CONDITION] and behavior problems at night in the past. Plan to reduce [MEDICATION NAME] to 25MG every morning (QAM) and 50MG HS. Record review of CR #3's progress notes dated 11/13/18 at 2:05PM revealed in part, resident was confused at times and, needs supervision as she wanders, exit seeks but does not need assistance with activities of daily living (ADL's), transfers, eating, toileting, and bed mobility. Resident is able to walk around the facility with no assistance and has no difficulty. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/15/18 at 3:19PM revealed, This afternoon, CR #3 was noted to be pushing another resident's wheelchair in the common area. Staff intervention was attempted as CR #3 began yelling verbal racial slurs at staff. A female employee stood in front of the other resident's wheelchair to prevent CR#3 from pushing the resident's wheelchair. CR#3 then stated to the employee, Get away from me you Mexican! You all are a bunch of [***] es around here! CR#3 then made a fist and stuck the employee to the right-side rib cage. Note was written by the social worker. Record review of CR #3's progress notes dated 11/15/18 at 3:19PM revealed, CR #3 verbalized abusive words towards other resident and staff. CR #3 was going to bring another resident to the bathroom, the CNA tried to help the resident to the bathroom and CR #3 held tight to the resident wheel chair and verbalized abusive words towards the staff. It took three staff to get the resident out of CR #3's hands and finally helped resident to the bathroom. Note was written by LVN #13. Record review of CR #3's NP progress notes dated 11/16/18 revealed, Social worker reported today, patient was pushing another patient in her wheelchair yesterday, there was a concern that patient may accidentally hurt patient in the wheel chair, and CNA stopped the wheelchair, and patient attacked CNA physically. Informed social worker there was a steady dose reduction on [MEDICATION NAME] over the last few weeks. Patient had verbal outburst previously, but she has not attacked anyone in the past. Further review revealed a plan stating, informed social worker and nursing that patient has paranoid behavior, and something made patient afraid and she responded physically. Plan to increase [MEDICATION NAME] from 25MG in AM and 50MG in PM, to [MEDICATION NAME] 25MG 9AM, 4PM and 50MG 9PM. The end of the progress notes also revealed a conversation was held with the family discussing CR #3 plan of care, 1. Family very concerned about patient's physical response yesterday, family also concerned that patient may be removed from this facility due to her behavior. 2. Educated family that normally all measures are taken to help patient, and facility makes decision to transfer to another facility only when all measures have failed, at this moment plan to increase dose of [MEDICATION NAME] which was reduced about two weeks ago. 3. Discussed in detail, about inpatient evaluation of behavior and possibly changing medication, family stated they were not against inpatient evaluation of patient. Record review of CR #3's of progress notes dated 11/22/18 at 11:18AM revealed, Around 8 pm, Nurse was called to resident's room by CNA. Upon arrival, resident was sleeping on roommates' bed with roommate in the bed. Roommate was uncomfortable. Nurse tried to explain to resident that she had to go to her own bed as roommate wanted to sleep. Resident started screaming, yelling at nurse and two other staff that this was her house, she could go to which bed she wants. She used all sorts of profanities on staff, calling them [***] ing retards. When Nurse insisted that she had to go to her bed, she called Nurse a dumb nigger who is nothing but a piece of[***] Nurse and other staff insisted that she had to go to her bed and she finally went and ask staff to go out. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/23/18 at 3:12PM revealed, Resident was attempting to take another resident to the bathroom. Staff approached her and told her to let us help the other resident go to the bathroom. Resident said no she will take her to the bathroom, she does not need staff help. Staff insisted and explained to resident that she cannot take the other resident to the bathroom, she should let staff help her. Resident got upset, striking out and staff and calling them a bunch of [***] ing niggers who are no good. She tried hitting, kicking and punching staff. Staff stayed in the room, away from resident to ensure safety of resident and other two residents in the room. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/23/2018 at 3:24PM revealed, Resident later left the room and started walking down the hallway. NP called, and she said the manner of approach towards resident matters. She said resident lashes out only when she is approached in a confrontational manner. She asked where resident was, and Nurse said she was walking down the hallway. NP said to leave resident alone and she will calm down. Note was written by LVN #1. Record review of CR #3's progress notes dated 11/25/2018 at 1:54 PM revealed, During Lunch time at the dinner room, writer saw resident fighting the other resident at the dinner room. The other resident poured water on resident to move away from the table that it's not her regular chair she sit at that it belongs to another resident. Writer separated them and ask what was going on, the other resident stated that resident don't suppose to sit where he is sitting that she needs to get up and go to another table. Writer spoke to resident to move from the table to another table, writer separated the two residents from each other. Writer took the other resident to her room and change her cloth, the two residents remain calm at this time. No injury or bruises from two resident. RP made aware, she thanked me and stated she will come see mother. ADON/DON made aware. Resident remain stable, will continue to monitor for any changes. Note was written by LVN #8. Record review of CR #3's progress notes dated 11/26/18 at 4:27PM revealed a quarterly note for activities. The note revealed the resident was very disruptive in activities and wanted to be the center of attention. She was noted to be demanding when she was not answered immediately and could be cruel and hateful with her words when she was angry. She lashed out at staff when she was angry by using racial slurs. She walked the halls during the day and evening and could be redirected by staff for short periods of time if she was not angry. One on one visits were done with resident if resident was not angry. Note written by the Activities Director. Record review of CR #3's progress notes dated 11/27/2018 at 11:34AM revealed, IDT met on this date to review quarterly plan of care. CR #3 had a recent gradual dose reduction (GDR) of her antipsychotic medication ([MEDICATION NAME]). The GDR had failed, behaviors began to increase once medication was titrated. NP notified and changed medication back to original dosage and RP made aware. Resident continues behavior monitoring. Resident self ambulates throughout room and corridor with a slightly unsteady gait. Enjoys conversing with other residents in the dining room and attends most meals in the dining room. CR #3 sleeps in during the morning and is usually a late riser, she then has coffee in the TV area before she begins ambulating throughout the halls. Plan of care continues. Record review of CR #3's NP progress notes dated 11/27/18 revealed she was following up on aggressive behaviors/[MEDICAL CONDITION]. The weekend nurse had told her CR #3 had hit someone. The Resident was irritated in the morning after the nurse had woke her up to give medications. She took the medications but refused to have her blood sugar and blood pressure checked. The resident was noted to have a history of verbal outbursts and recent hitting. Resident becomes more aggressive when she is argued with. The plan included to continue residents' current dose of [MEDICATION NAME] 25MG at AM, PM, and 50MG QHS. The NP also encouraged staff to speak to resident in calming manner and redirect as needed. She noted she would order labs if resident behavior continued. Record review of CR #3's progress notes dated 11/30/2018 at 2:30 PM revealed, At about 1:30pm, resident was wheeling another resident into her room, this nurse redirected her, she displayed an impulsive behavior, slapped this nurse and accidentally hit the resident in the w/c. Resident in the w/c was assessed, no apparent injury. I was finally able to get her under control. RP notified. She was very remorseful and said sorry. DON/ADON notified. Note was written by LVN #6. Record review of CR #3's progress notes dated 12/2/18 at 9:44PM revealed, After dinner time, around 6:00PM, resident was noted by staff in room [ROOM NUMBER]A trying to get another resident up from her wheel chair to her bed. This Nurse was doing rounds when she found that resident was being aggressive toward staff. Nurse redirected this resident to her room. And staff help resident in 208A with ADL. ADON, DON notified. RP was notified. Record review of CR #3's NP progress notes dated 12/3/18 revealed resident RP called the NP concerned about resident's behavior as she was informed about the resident being physically abusive towards staff. Resident was observed by NP sitting in the living area, she was upset, being verbally abusive and did not want to be disturbed. Plan of care was for labs CBC, BMP, and UA and C&S with I&O Cath to be done. Record review of CR #3's NP progress notes dated 12/4/18 revealed resident did not want to be disturbed and she was irritated by the NP was asking questions for an assessment. Resident asked to be left alone. There were no reports of aggressive behaviors from nursing staff and her behaviors were currently being controlled with Memantine and [MEDICATION NAME]. Record review of CR #3's progress notes dated 12/7/18 revealed resident was diagnosed with [REDACTED]. Record review of CR #3's progress notes dated 12/11/18 revealed resident continued to get agitated when in the TV area and the nurse would try to redirect her. The redirection would temporarily work. Record review of CR 3#'s progress notes dated 12/22/18 at 1:10AM revealed, Resident in 201A (Resident #27) reported to this writer that this resident is being loud and waking her up. This resident was in hallway standing by nursing cart and seemed confused telling staff to go home she needs to close her store. This nurse approached the resident in calm non-threating manner and remained with the resident while level of confusion is high, displayed listening and respect, answered her questions in warmth and comforting manner, resident was re-directed then became calm and agreed that nurse walks her to her bed. Note written by RN #6. Record review of CR #3's progress notes dated 12/23/18 at 7:00PM revealed resident was observed pushing another resident to her room, the resident was reeducated not to push any residents to her room. Redirection was successful. Record review of CR #3's progress notes dated 12/26/18 at 3:49PM revealed resident was diagnosed with [REDACTED]. Record review of CR #3's progress notes dated 12/31/18 at 3:26PM revealed, Writer noted CR #3 pushing another resident after Lunch on his wheelchair, writer and other staff try to stop CR #3 from pushing resident on the wheelchair around, when other staff was trying to stop CR #3, she raised her hand up to hit the staff. Writer intervene and stop resident from hitting staff, writer educate CR #3 that's not appropriate for her to do. ADON/DON made aware of behavior. RP called and explain to RP about behavior, stated she will come see her. Note was written by LVN #8. Record review of CR #3's Incident report dated 12/31/18 at 7:00PM for a behavior related incident. LVN #1 described what happened as CR #3 was pushing another resident down the hallway in his wheel chair. He tried to redirect CR #3, but she got abusive and started calling the nurse nigger and other profanities. CR #3 hit the nurse in the chest and another resident came up trying to pull the resident in the wheel chair away when CR #3 punched the other resident in the neck and chin area. Nurse was able to redirect CR #3 and got the other resident away from her. Follow up steps were taken to keep the two residents separated at all times. Education was provided to CR #3 that she could not push another resident in a wheelchair and she could not hit anyone. Both residents were evaluated with no apparent injuries noted. Incident was reported to state agency. Record review of CR #3's progress notes dated 12/31/2018 at 9:49 PM revealed, Writer noticed CR #3 pushing another resident (Resident #14) in his wheelchair. Nurse approached CR #3 and tried to redirect her not to push another resident. Resident got agitated, told staff he was nothing, but a nigger and she proceeded to hit staff in the chest. Another resident (Resident #18) came and tried to pull the other resident that CR #3 was pushing in the wheelchair away. CR #3 also hit the other resident (Resident #18) in the neck. Nurse Practitioner was called, and an order was given for CR #3 to be sent to Behavioral hospital for combative behaviors. RP was called, and she said it is ok to send her to be evaluated. Hospital was called to give a report, but no one picked up the phone. Resident is transferred to behavioral hospital via stretcher accompanied by two ambulance staff. CR# 3's family member called to be informed she was on her way. DON/ADON notified. Note was written by LVN #1. Interview on 1/18/19 at 3:23PM, LVN #1 said he had been involved in several of CR #3's behavioral episodes. He was the nurse who witnessed the incident on 12/31/18 between CR #3, Resident #18, and Resident #14. He said CR #3 was pushing Resident #14 down the hall in his wheel chair. He went to redirect CR #3 to not push Resident #14 and she became angry and started yelling and hitting him. He said Resident #18 then came up and tried to pull Resident #14 away, he tried to tell Resident #14 to leave so she would not get hurt but CR #3 swung and hit Resident #18 in the neck area. He said Resident #14 went to her room and called the police. LVN #1 said it was hard to redirect CR #3 and she was set off anytime she was not allowed to do what she wanted to do. He said sometimes she was able to be redirected and others she would explode with violent outburst of throwing things, hitting, and verbal abuse. He said she would threaten the staff and residents when she would have her behavioral episodes. He said other residents have expressed having issues with CR #3 and he thought the residents were afraid of her. LVN #1 said other residents respond to CR #3's behaviors by avoiding her and said there had been occasions where residents had called the police because they were afraid of CR #3 when she would have her behavioral episodes. Record review of CR #3's progress notes dated 1/1/19 at 3:10AM revealed resident returned to the facility via EMS and was put to bed. Record review of CR #3'

Based on interview and record review, the facility failed promptly communicate and collaborate with hospice representatives in coordinating hospice care planning following a significant change in condition of a resident that suggest a need to alter the plan of care and transfer the resident from the facility for one of ten residents (CR#1) reviewed for hospice services. The facility failed to immediately notify CR#1's hospice agency of a fall with injury which resulted in proper assessment and delayed intervention. CR#1's Hospice agency was not promptly notified and consulted following a significant change in the resident's condition. CR#1 was found to have [MEDICAL CONDITION] two days after a fall and she passed away two days later. These failures affected one closed record and placed an additional 4 residents who received hospice services at risk of neglect and delay in treatment Findings include: Intake # 5 CR #1 Record review of CR #1's face sheet revealed an [AGE] year-old female, admitted to facility on [DATE]. CR#1 [DIAGNOSES REDACTED]. Record review of CR #1's significant change MDS dated [DATE] revealed BIMS of 8 indicating moderate cognitive impairment. Further record review of significant change MDS revealed the resident required limited assistance of one-person's physical help for locomotion. Record review of CR #1's Care Plan dated [DATE] revealed CR#1 was at risk of falls r/t impaired balance during transfers, ambulation, standing. CR#1 had a fall on [DATE] and sustained skin tear/bruise to right arm, fracture to her right arm and femur. Goal was CR#1 will be fall free from falls throughout the next review date. Approaches include fall mats at beside while in bed. Family at bedside 24hours, Monitor/document/report to MD symptoms of pain related to fall. Provide close supervision by staff. Treat and monitor skin tear and bruise per MD order. Assist CR#1 to her reclining chair when out of bed in the room. Maintain body in functional alignment when at rest. Observe the resident for signs of fatigue/pain/intolerance while up in chair. Record review of CR#1's care plan dated [DATE] revealed CR#1 required hospice as evidence by terminal illness of [MEDICAL CONDITION] and has elected to use Hospice agency effective [DATE]. Goal was dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of intervention over next 90 days. Approaches included assist resident with ADLs and provide comfort measures as needed. Monitor for decreased appetite, weight loss, skin break down, n/v. Report to hospice. Monitor for signs and symptoms of increased pain, discomfort-give meds, monitor for relief. Report decline in condition to hospice agency. Weekly skin assessments and document findings. Record review of communication form titled Situation Background Assessment and Recommendation (SBAR) written by LVN-B, dated [DATE] revealed CR#1 had skin tear, showed non-verbal signs of pain by grimace and wince. Further review of SBAR revealed pain worsen since incident occurred. Record review of CR #1's nursing notes dated [DATE] at 06:02 AM revealed at approximately 0400 hours in the morning while in the TV area on the couch, CR#1 was observed attempting to rise from a sitting position with her walker when patient lost balance and fell on her right side, CR#1 sustained a skin tear and bruises on right arm, prior to fall patient had made a couple of attempts to wander out the doors . [MEDICATION NAME] was administered, skin tear was cleaned and covered with steri strips and dry dressings. X-ray to right arm and wrist was ordered, Nurse Practitioner and Family member were notified. Note was written by LVN-A. Record review of CR #1's nursing notes dated [DATE] at 11:51 AM revealed X-ray was completed at facility. Family member requested CR#1 be sent to hospital for further evaluation. Resident was sent via ambulance to emergency room . Resident returned to facility with [DIAGNOSES REDACTED]. Record review of CR#1's hospital record dated [DATE] revealed CR#1 was seen by triage at 2:45pm. Further review of hospital record revealed CR#1 had an X-ray of her right hand which showed a fracture. CR#1's hospital records revealed CR#1 had skin avulsion to her right elbow. The avulsion was dressed in the ER however splint was applied over dressing with order to follow up with Orthopedic surgeon. Record review of CR #1's nursing notes dated [DATE] at 08:04 AM revealed hospice notified by Nurse of CR#1 complaint of pain to right leg. No swelling noted no discoloration. Pain noted with touch of right knee, and lower right leg near ankle. Note was written by LVN-C. Record review of CR #1's record revealed no order for X-ray of right leg and no pain assessment documentation from [DATE] to [DATE]. Record review of CR #1's nursing notes dated [DATE] at 09:08 AM written by LVN-C revealed results of right femur sent to doctor by nurse and called in to Hospice. Further record review of notes revealed family member was notified of result of right femur. Record review of CR #1's nursing notes dated [DATE] at 04:30 PM written by LVN -D revealed CR#1 expired and pronounced dead by Hospice nurse at 03:58 PM at the facility. In an interview on [DATE] at 10:30 AM, the Administrator stated she did not think the way staff handled situation with CR#1 was okay. The Administrator further stated staff should have sent the resident to the hospital immediately instead of waiting for X-ray and results. She said staff should have done better. In an interview on [DATE] at 11:17a.m., CR#1's family member revealed CR#1 fell on [DATE] and Hospice was not notified. Family member stated she arrived at the facility at 6:20a.m. and CR#1's arm was bandage to cover skin tear and wrist area was of an S -Shape. Family member stated every nurse that looked at the wrist of CR#1 could see it appeared broken. Family member further stated the facility would not send her out until X-ray results were received. X-ray of right leg was not done until a few days later and it was discovered CR#1 had a fracture to the hip. Family member stated treatment was delayed because although CR#1's arm was visibly broken the facility did not send her to the hospital until X-ray results came back. Family further stated she had to call hospice to notify them of the fall and that was when Hospice became involved. Hospice ordered the X-ray of the hip and leg. In an interview on [DATE] at 10:34 PM, CNA-A stated on [DATE] at 4:00am, she put CR#1 in a chair at the facility's Television room and went to answer another resident's call light. CNA-A said when she came back, CR#1 had fallen and was on the floor. CNA-A stated she did not notify Hospice. CNA-A further stated after the fall, she walked CR#1 back to her room and CR#1 did not complain of pain. CNA-A stated LVN-A assessed CR#1's upper body and she assessed CR#1's lower body. CNA-A stated CR#1 complained of pain to wrist and right side. In an interview on [DATE] at 10:36 PM, LVN-A stated he witnessed CR#1's fall because CR#1 was sitting near the nursing station. LVN-A stated he assessed CR#1 and the only visible bruising was to her wrist area. LVN-A stated X-ray was ordered, and Nurse Practitioner and Hospice were notified. LVN-A further stated CR#1 was sent to hospital before he returned to work his next 10PM to 6AM shift. LVN-A was asked what hospice agency CR#1 used but he gave an incorrect hospice agency name. LVN-A was asked who he spoke to when he contacted hospice after the fall incident on [DATE] but he said he could not recall the name of the hospice staff he contacted that night. In an interview on [DATE] at 12:07 PM, CR#1's Hospice Administrator stated based on nursing notes CR#1's family member notified Hospice on [DATE] at 05:26 PM of CR#1's fall. Hospice Administrator stated nursing notes stated facility notified hospice of the fall on [DATE] at 08:23PM. Hospice Administrator further stated based on nursing notes there was no nursing note of facility calling on-call service prior to note written on [DATE] at 08:23 PM. Record review of CR#1's picture provided by CR#1's family member dated [DATE] revealed CR#1's right hand was swollen and bruised. There were multiple bruises from the resident's elbow to her wrist. CR#1's hand was shaped like letter S. There was a bandage saturated with fresh blood applied between the right-hand elbow and mid-way to her right-hand wrist. Record review of CR#1's hospice notes dated [DATE] at 5:26pm revealed message from family member which stated CR#1 was taken to hospital due to a fall and broke arm. Record review of CR#1's Hospice notes dated [DATE] at 08:23 PM revealed Hospice nurse received a call from facility stating CR#1 fell . Record review of CR#1's hospice notes dated [DATE] at 9:24pm, revealed patient was lying in bed with eyes closed, family member at bed side. patient is status [REDACTED]. Family member reports they had just returned from the hospital ER and CR#1 had just been medicated for wrist pain. Writer noted server deformity of patient's right wrist and bandage placed from emergency room . Record review of CR#1's hospice record revealed no documentation for [DATE]. Further review of hospice notes revealed the resident was pronounced dead on [DATE] at 3:50pm. Record review of the facility's policy titled Nursing Policies and Procedures with on Hospice Care revised [DATE] revealed in part The facility has established procedures for ongoing assessment, communication and care collaboration between hospice care providers, physicians and facility staff to clarify goals and preferences regarding treatment including pain management and symptom control, treatment of [REDACTED]. The facility and hospice provider will have ongoing collaborative communication. The facility staff must immediately contact and communicate with the hospice staff, the resident's family and/or legal representative any significant changes in the resident's status, clinical complications or emergent situations. These situations may include but are not limited to changes in cognition or sudden unexpected decline in condition, a fall with a suspected fracture. Facility CMS form 672 dated [DATE] revealed 4 residents received hospice services in the facility.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for one of ten residents (CR#1) reviewed for neglect, in that: CR#1 was allowed by staff to self-ambulate to her room after a fall with injuries. CR#1 was not properly assessed after a fall with injury, CNA#A assisted LVN# A to assess the lower body of CR#1 following fall with injury to her right hand. CR#1 did not receive prompt emergency intervention following a fall with injury to her right hand despite physical deformation and her complaints of pain. CR#1 was found to have [MEDICAL CONDITION] two days after the fall. CR#1's hospice agency was not promptly notified and consulted following a significant change in the resident's condition. These failures affected one closed record and placed an additional 74 residents at risk of delay in treatment and neglect Findings include: Intake # 5 CR #1 Record review of CR #1's face sheet revealed an [AGE] year-old female, admitted to facility on [DATE]. CR#1 [DIAGNOSES REDACTED]. Record review of CR #1's significant change MDS dated [DATE] revealed BIMS of 8 indicating moderate cognitive impairment. Further record review of significant change MDS revealed the resident required limited assistance of one-person's physical help for locomotion. Record review of CR #1's Care Plan dated [DATE] revealed CR#1 was at risk of falls r/t impaired balance during transfers, ambulation, standing. CR#1 had a fall on [DATE] and sustained skin tear/bruise to right arm, fracture to her right arm and femur. Goal was CR#1 will be fall free from falls throughout the next review date. Approaches include fall mats at beside while in bed. Family at bedside 24hours, Monitor/document/report to MD symptoms of pain related to fall. Provide close supervision by staff. Treat and monitor skin tear and bruise per MD order. Assist CR#1 to her reclining chair when out of bed in the room. Maintain body in functional alignment when at rest. Observe the resident for signs of fatigue/pain/intolerance while up in chair. Record review of CR#1's care plan dated [DATE] revealed CR#1 required hospice as evidence by terminal illness of [MEDICAL CONDITION] and has elected to use Hospice agency effective [DATE]. Goal was dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of intervention over next 90 days. Approaches included assist resident with ADLs and provide comfort measures as needed. Monitor for decreased appetite, weight loss, skin break down, n/v. Report to hospice. Monitor for signs and symptoms of increased pain, discomfort-give meds, monitor for relief. Report decline in condition to hospice agency. Weekly skin assessments and document findings. Record review of communication form titled Situation Background Assessment and Recommendation (SBAR) written by LVN-B, dated [DATE] revealed CR#1 had skin tear, showed non-verbal signs of pain by grimace and wince. Further review of SBAR revealed pain worsen since incident occurred. Record review of CR #1's nursing notes dated [DATE] at 06:02 AM revealed at approximately 0400 hours in the morning while in the TV area on the couch, CR#1 was observed attempting to rise from a sitting position with her walker when patient lost balance and fell on her right side, CR#1 sustained a skin tear and bruises on right arm, prior to fall patient had made a couple of attempts to wander out the doors . [MEDICATION NAME] was administered, skin tear was cleaned and covered with steri strips and dry dressings. X-ray to right arm and wrist was ordered, Nurse Practitioner and Family member were notified. Note was written by LVN-A. Record review of CR #1's nursing notes dated [DATE] at 11:51 AM revealed X-ray was completed at facility. Family member requested CR#1 be sent to hospital for further evaluation. Resident was sent via ambulance to emergency room . Resident returned to facility with [DIAGNOSES REDACTED]. Record review of CR#1's hospital record dated [DATE] revealed CR#1 was seen by triage at 2:45pm. Further review of hospital record revealed CR#1 had an X-ray of her right hand which showed a fracture. CR#1's hospital records revealed CR#1 had skin avulsion to her right elbow. The avulsion was dressed in the ER however splint was applied over dressing with order to follow up with Orthopedic surgeon. Record review of CR #1's nursing notes dated [DATE] at 08:04 AM revealed hospice notified by Nurse of CR#1 complaint of pain to right leg. No swelling noted no discoloration. Pain noted with touch of right knee, and lower right leg near ankle. Note was written by LVN-C. Record review of CR #1's nursing notes dated [DATE] at 09:08 AM written by LVN-C revealed results of right femur sent to doctor by nurse and called in to Hospice. Further record review of notes revealed family member was notified of result of right femur. Record review of CR #1's nursing notes dated [DATE] at 04:30 PM written by LVN -D revealed CR#1 expired and pronounced dead by Hospice nurse at 03:58 PM at the facility. In an interview on [DATE] at 10:30 AM, the Administrator stated she did not think the way staff handled situation with CR#1 was okay. The Administrator further stated staff should have sent the resident to the hospital immediately instead of waiting for X-ray and results. She said staff should have done better. In an interview on [DATE] at 11:17a.m., CR#1's family member revealed CR#1 fell on [DATE] and Hospice was not notified. Family member stated she arrived at the facility at 6:20a.m. and CR#1's arm was bandage to cover skin tear and wrist area was of an S -Shape. Family member stated every nurse that looked at the wrist of CR#1 could see it appeared broken. Family member further stated the facility would not send her out until X-ray results were received. X-ray of right leg was not done until a few days later and it was discovered CR#1 had a fracture to the hip. Family member stated treatment was delayed because although CR#1's arm was visibly broken the facility did not send her to the hospital until X-ray results came back. Family further stated she had to call hospice to notify them of the fall and that was when Hospice became involved. Hospice ordered the X-ray of the hip and leg. In an interview on [DATE] at 10:34 PM, CNA-A stated on [DATE] at 4:00am, she put CR#1 in a chair at the facility's Television room and went to answer another resident's call light. CNA-A said when she came back, CR#1 had fallen and was on the floor. CNA-A stated she did not notify Hospice. CNA-A further stated after the fall, she walked CR#1 back to her room and CR#1 did not complain of pain. CNA-A stated LVN-A assessed CR#1's upper body and she assessed CR#1's lower body. CNA-A stated CR#1 complained of pain to wrist and right side. In an interview on [DATE] at 10:36 PM, LVN-A stated he witnessed CR#1's fall because CR#1 was sitting near the nursing station. LVN-A stated he assessed CR#1 and the only visible bruising was to her wrist area. LVN-A stated X-ray was ordered, and Nurse Practitioner and Hospice were notified. LVN-A further stated CR#1 was sent to hospital before he returned to work his next 10PM to 6AM shift. LVN-A was asked what hospice agency CR#1 used but he gave an incorrect hospice agency name. LVN-A was asked who he spoke to when he contacted hospice after the fall incident on [DATE] but he said he could not recall the name of the hospice staff he contacted that night. In an interview on [DATE] at 12:07 PM, CR#1's Hospice Administrator stated based on nursing notes CR#1's family member notified Hospice on [DATE] at 05:26 PM of CR#1's fall. Hospice Administrator stated nursing notes stated facility notified hospice of the fall on [DATE] at 08:23PM. Hospice Administrator further stated based on nursing notes there was no nursing note of facility calling on-call service prior to note written on [DATE] at 08:23 PM. Record review of CR#1's picture provided by CR#1's family member dated [DATE] revealed CR#1's right hand was swollen and bruised. There were multiple bruises from the resident's elbow to her wrist. CR#1's hand was shaped like letter S. There was a bandage saturated with fresh blood applied between the right-hand elbow and mid-way to her right-hand wrist. Record review of CR#1's hospice notes dated [DATE] at 5:26pm revealed message from family member which stated CR#1 was taken to hospital due to a fall and broke arm. Further record review of Hospice notes dated [DATE] at 08:23 PM revealed Hospice nurse received a call from facility stating CR#1 fell . Record review of the facility's policy titled Leadership Policies and Procedures on Abuse, Neglect and Misappropriation of property revised [DATE] revealed in part neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress Conduct/make arrangements for physical/mental examinations. Record review of the facility's policy titled Nursing Policies and Procedures on fall management revised [DATE] revealed in part the facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall and initiates any immediate medical interventions necessary . The physician and family are promptly notified, and an incident report is completed. Facility CMS form 672 dated [DATE] revealed a census of 75.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 19 residents (Resident #27 and #34) reviewed for quality of care. Resident #27 physician's orders for [MEDICATION NAME] were not followed by the facility causing continued swelling in the legs, pain, and hospitalization . Resident #34's ordered HgbAIC was done 5 months after due date. These failures affected 2 residents and placed 90 additional residents at risk of not having their physicians orders followed and causing a decline or decrease in their quality of life and quality of care. Findings include: Resident #27 Record review of Resident #27's face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #27's Admissions MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. MDS revealed that the resident does receive scheduled pain medication, PRN pain medication, and non-medication intervention for pain. MDS further revealed the resident was occasionally in pain with a moderate intensity level. The MDS revealed the resident did not use diuretics. Record review of Resident #27 care plan revealed a problem start date of 1/19/18 for the resident being at risk for decreased cardiac output related to [MEDICAL CONDITION] Fibrillation. Approaches listed were ; administer medications as ordered and to monitor for bruising and bleeding, document and report to MD and family any unusual dark brown or bloody secretions, abdominal pain or swelling, back pain, severe headache, joint pain/swelling/ blood in urine, stool, and report immediately if found. Record Review of Resident #27's original written orders written by NP included: Order written on 2/27/18 at 6:50AM 1. AM [MEDICATION NAME] 40mg to be given now? 2. [MEDICATION NAME] 2.5mg to be given a half hour later 3. Give only 20mg at 2pm Order written on 2/27/18 at 6:55AM 1. [MEDICATION NAME] 40mg in AM and 20mg at 2PM for 5 days 2. [MEDICATION NAME] 2.5mg to be given every other day to equal three doses 3. BMP in AM 4. DC current [MEDICATION NAME] orders and start [MEDICATION NAME] 40mg every day after the above order is complete. Clarification order written by NP on 3/1/18 at 11:10AM restated the order written on 2/27/18 at 6:55AM Record review of Resident #27 Progress notes from NP revealed: Note written on 2/27/18 indicating resident was complaining of [MEDICAL CONDITION] and her concern of ending up in the hospital for [MEDICAL CONDITION] exacerbation. The assessment plan in the progress note says to change [MEDICATION NAME] orders to 40mg in AM and 20mg at 2PM for 4 days, and to also add [MEDICATION NAME] 2.5mg today 30 minutes after [MEDICATION NAME] today then every other day for a total of 3 doses. BMP in AM, to restart [MEDICATION NAME] to usual dosage after current treatment. Note written on 2/28/18 indicating resident was experiencing chronic pain and Tylenol is not working. Also resident is still experiencing [MEDICAL CONDITION] to lower extremities but it is getting better, therefore continue with current treatment plan. The assessment and plan in the progress note says to change [MEDICATION NAME] from BID PRN to every 6 hours PRN. For the [MEDICAL CONDITION] continue [MEDICATION NAME] 40mg in AM and 20mg 2PM and [MEDICATION NAME] 2.5mg every other day for a total of 3 doses. Record review of Resident #27's computer physician's orders for (MONTH) (YEAR) revealed orders to treat [MEDICAL CONDITION] and heart failure that included: [MEDICATION NAME] tablet; 20mg; amt: 1, to be taken once - one time at 2:00PM with a start and end date of 2/27/18 [MEDICATION NAME] tablet; 40mg; amt: 1, to be taken once - one time at 8:00AM with a start and end date of 2/27/18 [MEDICATION NAME] tablet; 2.5mg; amt: 1, to be taken once - one time at 8:30AM with a start and end date of 2/27/18 [MEDICATION NAME] tablet; 20mg, amt: 1, to be taken once a day at 5:00PM with a start date of 2/27/18 and end date of 3/3/18 Record review of Resident #27's MAR for (MONTH) (YEAR) and (MONTH) 1st of (YEAR) revealed: [MEDICATION NAME] tablet; 40mg; amt: 1, one time administer on 2/27/18 at 8:00AM [MEDICATION NAME] tablet; 20mg; amt: 1, one time administer on 2/27/18 at 2:00PM [MEDICATION NAME] tablet; 2.5mg; amt: 1, one time administer on 2/27/18 at 8:30AM [MEDICATION NAME] tablet; 20mg; amt: 1, was administered on 2/27/18, 2/28/18, and 3/1/18 at 5:00PM Record review of Resident #27's computer Physicians orders revealed orders for [MEDICATION NAME] and [MEDICATION NAME] did not match the written physician's orders. Record review revealed orders for pain management that included: [MEDICATION NAME] tablet; 50mg; amt: 1, to be taken at 11:30PM with a start date of 1/08/18 [MEDICATION NAME] (OTC) tablet; 325mg; amt: 2, to be taken every 6 hours - PRN; PRN1, PRN2, PRN3, PRN4 with a start date of 1/2/18 and an open ended end date [MEDICATION NAME] tablet; 50mg; amt: 1, to be taken once - one time at 9:30AM with a start and end date of 2/27/18. Record review of the MAR for pain management medication revealed: [MEDICATION NAME] tablet; 50mg; amt: 1, was administered every day between the dates of 2/1/18 and 2/28/18 at 11:30PM [MEDICATION NAME] (OTC) tablet PRN; 325mg; amt: 2, was administered on 2/4/18 at 8:20PM, 2/8/18 at11:16AM, 2/26/18 at 5:10AM and 5:11PM, and 2/28/18 at 10:23AM. [MEDICATION NAME] tablet; 50mg; amt: 1, one time administer on 2/27/18 at 9:30AM [MEDICATION NAME] tablet PRN; 50mg; amt: 1, was administered on 3/1/18 at 10:28AM. Further review of the resident's (MONTH) and (MONTH) (YEAR) MAR revealed the resident only received one dose of [MEDICATION NAME] 20mg a day for two days (2/28/18 and 3/1/18), did not receive [MEDICATION NAME] 2.5mg on 3/1/18 and did not receive [MEDICATION NAME] PRN until 2/27/18. Observation and Interview on 2/27/18 at 9:31AM, Resident #27 was observed in her room sitting in a recliner with her feet up. The resident's feet and legs were swollen. Resident #27 said her legs had been swollen since yesterday but they had gone down this morning. A staff member from the Therapy department entered the resident's room to remind the resident about the therapy session and the resident had to decline therapy because her feet were swollen and she was in pain. The resident also she had back pain and she slept in her recliner because the bed hurts her back. The resident said her legs were hurting a little bit and the pain was worse last night. She stated she got medication for pain but it was some over the counter medication which she identified as Tylenol. She said she told staff that Tylenol did not work for her since her admission to the facility in (MONTH) (YEAR). Resident #27 said she was told by staff that they were finally ordering her a different pain medication. Resident told surveyor that she was always in pain. Observation and interview on 2/28/18 at 10:10AM, Resident #27 was in her room sitting in her recliner with her feet down. She was asked if she was okay because the resident was rubbing on her legs with a grimacing face. The resident responded that she was pain and pulled a blanket up that was covering her legs to expose her swollen feet and legs. The resident's skin was red and shiny on her legs. The resident further stated she told staff this morning when they came into her room that her legs were hurting and that they were leaking out fluid. She removed a sandal that was on her foot that revealed brownish fluid in the shoe. The resident said she wanted staff to wrap her leg because it was draining into her shoe. The resident asked if staff were coming back with pain medication because she was hurting really bad. Interview on 2/28/18 at 10:13AM, LPN #5 came over to Resident #27's room with the medication cart after she was informed of resident complaining of pain. After LPN #5 assessed Resident #27 and said the resident was experiencing pain from the swelling of her legs. LPN #5 confirmed the resident's swollen legs were leaking out fluid. She further stated she was searching to see if Resident #27 has a PRN medication for pain because the resident already received her scheduled pain medication. After searching the computer she revealed that the resident had PRN Tylenol that will be administered. Interview on 3/1/18 at 2:28PM, LPN #5 was asked to review Resident #27's physician's orders with the surveyor and she was asked why the resident was not getting [MEDICATION NAME] for swelling in her leg as ordered by her physician. LPN #5 said the resident was getting more than 20mg a day of [MEDICATION NAME] but the orders of [MEDICATION NAME] she found were discontinued on 2/27/18. LPN #5 also pulled up Resident #27's MAR then said it revealed that resident had only been getting 20mg of [MEDICATION NAME]. LPN #5 said NP was sending Resident #27 out to the Hospital to try and get the swelling under control and to make sure there was not something else going on causing the increased swelling. LPN #5 was also asked about Resident #27's pain medication and what she received for pain. She replied that the resident got scheduled [MEDICATION NAME] at night at 11:30PM and [MEDICATION NAME] (OTC) (Tylenol) PRN. She further said that it was not until yesterday (2/28/18) that the resident received a different order for PRN pain, medication which was [MEDICATION NAME]. Observation and Interview on 3/1/18 at 2:35PM, Resident #27 was in her room sitting in her recliner with both her legs and feet swollen, red and shiny. Her left leg was wrapped with a bandage. The residents face was observed to be red and grimacing as she rubbed on her legs and said, It feels like my legs are going to burst. Resident #27 said that she was in pain and her legs were hurting really bad. She said the swelling had not gone down and she had been hurting really bad so staff were going to send her to the hospital. The resident said she had not received any pain medication for the pain and would like to receive some before going to the hospital. The surveyor said that she would let the nurse know that she was in pain and requesting medication and the resident reminded the surveyor that she did not want Tylenol because it did not work. The nurse was informed of resident being in pain and medication request. Record review of Resident #27's notes on 3/1/18 at 3:06PM revealed that there was a new order received from NP to send patient to the hospital to evaluate and treat for [MEDICAL CONDITION] exacerbation. An additional note was made at 5:20PM revealing the resident was transferred to the hospital for evaluation and treatment. Interview on 3/2/18 at 9:39AM, after reviewing the written physician's orders and NP progress notes, the NP was asked about what medication Resident #27 should be receiving. The NP said that the morning of 2/27/18 she wrote a one-time order for [MEDICATION NAME] 40mg to be given right then and then for [MEDICATION NAME] 2.5mg to be given a half hour later, then after that to give 20mg of [MEDICATION NAME] at 2pm. She said she then wrote another order on 2/27/18 to be continued for the next 5 days that should have started on 2/28/18. She described the order as being [MEDICATION NAME] 40mg in AM and 20mg at 2PM for 5 days and also [MEDICATION NAME] 2.5mg to be given every other day to equal three doses. The NP was shown the orders in the computer and the MAR that showed the resident only got [MEDICATION NAME] 20mg on 2/28/18 and 3/1/18. The NP said that was incorrect and was not the order that she wrote. She said the resident should have been getting a total of 60mg [MEDICATION NAME] a day and that she should have also received the [MEDICATION NAME] 2.5mg on 2/28/18. The NP said she caught the error of the resident not getting [MEDICATION NAME] 2.5mg yesterday morning (3/1/18) and wrote a clarification order but the nurses told her that the resident had gotten the 60mg of [MEDICATION NAME] on 2/28/18. The NP concluded that would explain the reason why the resident's leg swelling were not going down and she confirmed the resident was sent out to the hospital because the swelling was not going down. The NP was asked if anyone had reported to her that Resident #27 was complaining of Tylenol not being effective for her. She said that 2/28/18 was the first she heard of it which was why she recently changed her PRN to [MEDICATION NAME] instead of Tylenol. The NP was informed that the Resident said she had been requesting another PRN besides Tylenol since her admission to the facility in (MONTH) (YEAR) and was also complained of back pain. The NP said she was unaware of the resident's lack of pain control. Interview on 3/2/18 at 3:15PM, Resident #27's family member said that the resident was doing okay at the hospital and that she was about to be moved to another unit where she would be getting intravenous [MEDICATION NAME]. The family member said Resident #27 had chronic pain from [MEDICAL CONDITION] and also a lot of her pain was stemming from the swelling in her legs. The family member was told about the resident being given Tylenol and requesting something else for pain and the family member replied that sounds like something she would request because Tylenol had never worked for her. She added that she was surprised the resident even took the Tylenol because usually she would not. Interview on 3/2/18 at 3:33PM, RN#8 was asked if Resident #27 has ever complained of pain to her and she said the resident had complained of pain and the resident told her told her that Tylenol was ineffective for her. RN#8 could not recall if it was on Friday or Monday when the resident complained of pain in her legs from swelling. She informed the resident that she had Tylenol PRN and the resident told her that Tylenol did not work for her. She said she told the resident to try the Tylenol and if it did not work, she would report it to the doctor so she could get something different. She said she went into Resident #27's room a little later and the resident said she was doing okay and did not say she was in pain. Interview on 3/2/18 at 4:00PM, the DON was asked about Resident #27's medication errors for her [MEDICATION NAME] on 2/27/18, 2/28/18, 3/1/18, and [MEDICATION NAME] on 2/28/18. The DON reviewed the written orders, computer order, and MAR and said she did see the error and that the Resident only got 20mg of [MEDICATION NAME] a day when it should have been 60mg. DON also said [MEDICATION NAME] was never given. She agreed the written order was not accurately transferred into the computer. Resident #34 Record review of Resident #34's Face Sheet revealed a [AGE] year old female admitted on [DATE] and re-admit on 12/25/17. Her [DIAGNOSES REDACTED]. Record review of Resident #34's Annual MDS dated [DATE] revealed BIMS score of 12 indicating moderately impaired cognition. Record review of Resident #34's physician order revealed HgbA1C due 9/14/17. Record review of Resident #34's Pharmacy Review dated 10/3/17 revealed recommendation that lab order for HgbA1C was due 9/14/17. Further review revealed recommendation was approved and not completed. Record review of Resident #34 's physician order revealed order for HgbA1C on 1/22/18 and on 2/5/18 a new order was given . Record review of Resident #34's Pharmacy Review dated 2/3/18 revealed lab order for HgbA1C had not been completed. Record review of Resident #34's lab result revealed HgbA1C was completed on 2/7/18. Further review of HgbA1C results revealed value of 11.2% with a reference range of 4.5 to 5.7. Record review of Resident #34's ordered labs from 8/3/17 to 2/7/18 revealed HgbA1C was ordered on [DATE]. Record review of Resident #34's Blood Sugars logs revealed blood sugar recorded on 1/22/18 as 513, on 1/23/18 as 537 and 1/24/18 as 502. Further review of log revealed Nurse Practitioner saw Resident #34 on 1/24/18 and nurse reported the resident's blood sugars had been high. Interview on 2/27/18 at 9:15 AM., Resident #34 stated the Nurse Practitioner was coming to see her foot because it was hurting. Interview with ADON #25 on 03/02/18 at 01:17 PM., she stated HgbA1C for Resident #34 should have been done. Interview with LPN #10 on 03/02/18 at 03:46PM via phone, she stated that she has never been told about parameters in the facility and did not know about the policy on calling the doctor about high blood sugars. Resident #34 tend to run high sugars, but after a few times over 500 she did let the Nurse Practitioner know. They did change her medications. Record review of Blood Glucose Monitoring from Physiological Basis for Nursing Practice states in part . protocol calls for laboratory confirmation testing of very high or very low results . and . report levels of target range and take appropriate action . Record review of the facility policy for physicians orders (complete revision 7/1/16) revealed in part, The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines. The facility's CMS-672 dated 2/27/18 revealed census of 92 residents.

Based on observation, record review and interview, the facility failed to ensure resident were free from neglect for one of 19 Residents (Resident #27) reviewed for neglect, in that; Resident #27 was not provided effective pain management and did not receive medications for leg swelling as ordered. Resident #27 was transferred to hospital due to increased leg swelling and ineffective pain management. These failures affected one resident and placed 42 additional residents who are on a pain management program at risk of neglect and diminished quality of life. Findings include: Resident #27 Record review of Resident #27's face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #27's Admissions MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. MDS revealed that the resident does receive scheduled pain medication, PRN pain medication, and non-medication intervention for pain. MDS further revealed the resident was occasionally in pain with a moderate intensity level. The MDS revealed the resident did not use diuretics. Record review of Resident #27 care plan revealed a problem start date of 1/19/18 for the resident being at risk for decreased cardiac output related to [MEDICAL CONDITION] Fibrillation. Approaches listed were ; administer medications as ordered and to monitor for bruising and bleeding, document and report to MD and family any unusual dark brown or bloody secretions, abdominal pain or swelling, back pain, severe headache, joint pain/swelling/ blood in urine, stool, and report immediately if found. Record Review of Resident #27's original written orders written by NP included: Order written on 2/27/18 at 6:50AM 1. AM [MEDICATION NAME] 40mg to be given now? 2. [MEDICATION NAME] 2.5mg to be given a half hour later 3. Give only 20mg at 2pm Order written on 2/27/18 at 6:55AM 1. [MEDICATION NAME] 40mg in AM and 20mg at 2PM for 5 days 2. [MEDICATION NAME] 2.5mg to be given every other day to equal three doses 3. BMP in AM 4. DC current [MEDICATION NAME] orders and start [MEDICATION NAME] 40mg every day after the above order is complete. Clarification order written by NP on 3/1/18 at 11:10AM restated the order written on 2/27/18 at 6:55AM Record review of Resident #27 Progress notes from NP revealed: Note written on 2/27/18 indicating resident was complaining of [MEDICAL CONDITION] and her concern of ending up in the hospital for [MEDICAL CONDITION] exacerbation. The assessment plan in the progress note says to change [MEDICATION NAME] orders to 40mg in AM and 20mg at 2PM for 4 days, and to also add [MEDICATION NAME] 2.5mg today 30 minutes after [MEDICATION NAME] today then every other day for a total of 3 doses. BMP in AM, to restart [MEDICATION NAME] to usual dosage after current treatment. Note written on 2/28/18 indicating resident was experiencing chronic pain and Tylenol is not working. Also resident is still experiencing [MEDICAL CONDITION] to lower extremities but it is getting better, therefore continue with current treatment plan. The assessment and plan in the progress note says to change [MEDICATION NAME] from BID PRN to every 6 hours PRN. For the [MEDICAL CONDITION] continue [MEDICATION NAME] 40mg in AM and 20mg 2PM and [MEDICATION NAME] 2.5mg every other day for a total of 3 doses. Record review of Resident #27's computer physician's orders for (MONTH) (YEAR) revealed orders to treat [MEDICAL CONDITION] and heart failure that included: [MEDICATION NAME] tablet; 20mg; amt: 1, to be taken once - one time at 2:00PM with a start and end date of 2/27/18 [MEDICATION NAME] tablet; 40mg; amt: 1, to be taken once - one time at 8:00AM with a start and end date of 2/27/18 [MEDICATION NAME] tablet; 2.5mg; amt: 1, to be taken once - one time at 8:30AM with a start and end date of 2/27/18 [MEDICATION NAME] tablet; 20mg, amt: 1, to be taken once a day at 5:00PM with a start date of 2/27/18 and end date of 3/3/18 Record review of Resident #27's MAR for (MONTH) (YEAR) and (MONTH) 1st of (YEAR) revealed: [MEDICATION NAME] tablet; 40mg; amt: 1, one time administer on 2/27/18 at 8:00AM [MEDICATION NAME] tablet; 20mg; amt: 1, one time administer on 2/27/18 at 2:00PM [MEDICATION NAME] tablet; 2.5mg; amt: 1, one time administer on 2/27/18 at 8:30AM [MEDICATION NAME] tablet; 20mg; amt: 1, was administered on 2/27/18, 2/28/18, and 3/1/18 at 5:00PM Record review of Resident #27's computer Physicians orders revealed orders for [MEDICATION NAME] and [MEDICATION NAME] did not match the written physician's orders. Record review revealed orders for pain management that included: [MEDICATION NAME] tablet; 50mg; amt: 1, to be taken at 11:30PM with a start date of 1/08/18 [MEDICATION NAME] (OTC) tablet; 325mg; amt: 2, to be taken every 6 hours - PRN; PRN1, PRN2, PRN3, PRN4 with a start date of 1/2/18 and an open ended end date [MEDICATION NAME] tablet; 50mg; amt: 1, to be taken once - one time at 9:30AM with a start and end date of 2/27/18. Record review of the MAR for pain management medication revealed: [MEDICATION NAME] tablet; 50mg; amt: 1, was administered every day between the dates of 2/1/18 and 2/28/18 at 11:30PM [MEDICATION NAME] (OTC) tablet PRN; 325mg; amt: 2, was administered on 2/4/18 at 8:20PM, 2/8/18 at11:16AM, 2/26/18 at 5:10AM and 5:11PM, and 2/28/18 at 10:23AM. [MEDICATION NAME] tablet; 50mg; amt: 1, one time administer on 2/27/18 at 9:30AM [MEDICATION NAME] tablet PRN; 50mg; amt: 1, was administered on 3/1/18 at 10:28AM. Further review of the resident's (MONTH) and (MONTH) (YEAR) MAR revealed the resident only received one dose of [MEDICATION NAME] 20mg a day for two days (2/28/18 and 3/1/18), did not receive [MEDICATION NAME] 2.5mg on 3/1/18 and did not receive [MEDICATION NAME] PRN until 2/27/18. Observation and Interview on 2/27/18 at 9:31AM, Resident #27 was observed in her room sitting in a recliner with her feet up. The resident's feet and legs were swollen. Resident #27 said her legs had been swollen since yesterday but they had gone down this morning. A staff member from the Therapy department entered the resident's room to remind the resident about the therapy session and the resident had to decline therapy because her feet were swollen and she was in pain. The resident also she had back pain and she slept in her recliner because the bed hurts her back. The resident said her legs were hurting a little bit and the pain was worse last night. She stated she got medication for pain but it was some over the counter medication which she identified as Tylenol. She said she told staff that Tylenol did not work for her since her admission to the facility in (MONTH) (YEAR). Resident #27 said she was told by staff that they were finally ordering her a different pain medication. Resident told surveyor that she was always in pain. Observation and interview on 2/28/18 at 10:10AM, Resident #27 was in her room sitting in her recliner with her feet down. She was asked if she was okay because the resident was rubbing on her legs with a grimacing face. The resident responded that she was pain and pulled a blanket up that was covering her legs to expose her swollen feet and legs. The resident's skin was red and shiny on her legs. The resident further stated she told staff this morning when they came into her room that her legs were hurting and that they were leaking out fluid. She removed a sandal that was on her foot that revealed brownish fluid in the shoe. The resident said she wanted staff to wrap her leg because it was draining into her shoe. The resident asked if staff were coming back with pain medication because she was hurting really bad. Interview on 2/28/18 at 10:13AM, LPN #5 came over to Resident #27's room with the medication cart after she was informed of resident complaining of pain. After LPN #5 assessed Resident #27 and said the resident was experiencing pain from the swelling of her legs. LPN #5 confirmed the resident's swollen legs were leaking out fluid. She further stated she was searching to see if Resident #27 has a PRN medication for pain because the resident already received her scheduled pain medication. After searching the computer she revealed that the resident had PRN Tylenol that will be administered. Interview on 3/1/18 at 2:28PM, LPN #5 was asked to review Resident #27's physician's orders with the surveyor and she was asked why the resident was not getting [MEDICATION NAME] for swelling in her leg as ordered by her physician. LPN #5 said the resident was getting more than 20mg a day of [MEDICATION NAME] but the orders of [MEDICATION NAME] she found were discontinued on 2/27/18. LPN #5 also pulled up Resident #27's MAR then said it revealed that resident had only been getting 20mg of [MEDICATION NAME]. LPN #5 said NP was sending Resident #27 out to the Hospital to try and get the swelling under control and to make sure there was not something else going on causing the increased swelling. LPN #5 was also asked about Resident #27's pain medication and what she received for pain. She replied that the resident got scheduled [MEDICATION NAME] at night at 11:30PM and [MEDICATION NAME] (OTC) (Tylenol) PRN. She further said that it was not until yesterday (2/28/18) that the resident received a different order for PRN pain, medication which was [MEDICATION NAME]. Observation and Interview on 3/1/18 at 2:35PM, Resident #27 was in her room sitting in her recliner with both her legs and feet swollen, red and shiny. Her left leg was wrapped with a bandage. The residents face was observed to be red and grimacing as she rubbed on her legs and said, It feels like my legs are going to burst. Resident #27 said that she was in pain and her legs were hurting really bad. She said the swelling had not gone down and she had been hurting really bad so staff were going to send her to the hospital. The resident said she had not received any pain medication for the pain and would like to receive some before going to the hospital. The surveyor said that she would let the nurse know that she was in pain and requesting medication and the resident reminded the surveyor that she did not want Tylenol because it did not work. The nurse was informed of resident being in pain and medication request. Record review of Resident #27's notes on 3/1/18 at 3:06PM revealed that there was a new order received from NP to send patient to the hospital to evaluate and treat for [MEDICAL CONDITION] exacerbation. An additional note was made at 5:20PM revealing the resident was transferred to the hospital for evaluation and treatment. Interview on 3/2/18 at 9:39AM, after reviewing the written physician's orders and NP progress notes, the NP was asked about what medication Resident #27 should be receiving. The NP said that the morning of 2/27/18 she wrote a one-time order for [MEDICATION NAME] 40mg to be given right then and then for [MEDICATION NAME] 2.5mg to be given a half hour later, then after that to give 20mg of [MEDICATION NAME] at 2pm. She said she then wrote another order on 2/27/18 to be continued for the next 5 days that should have started on 2/28/18. She described the order as being [MEDICATION NAME] 40mg in AM and 20mg at 2PM for 5 days and also [MEDICATION NAME] 2.5mg to be given every other day to equal three doses. The NP was shown the orders in the computer and the MAR that showed the resident only got [MEDICATION NAME] 20mg on 2/28/18 and 3/1/18. The NP said that was incorrect and was not the order that she wrote. She said the resident should have been getting a total of 60mg [MEDICATION NAME] a day and that she should have also received the [MEDICATION NAME] 2.5mg on 2/28/18. The NP said she caught the error of the resident not getting [MEDICATION NAME] 2.5mg yesterday morning (3/1/18) and wrote a clarification order but the nurses told her that the resident had gotten the 60mg of [MEDICATION NAME] on 2/28/18. The NP concluded that would explain the reason why the resident's leg swelling were not going down and she confirmed the resident was sent out to the hospital because the swelling was not going down. The NP was asked if anyone had reported to her that Resident #27 was complaining of Tylenol not being effective for her. She said that 2/28/18 was the first she heard of it which was why she recently changed her PRN to [MEDICATION NAME] instead of Tylenol. The NP was informed that the Resident said she had been requesting another PRN besides Tylenol since her admission to the facility in (MONTH) (YEAR) and was also complained of back pain. The NP said she was unaware of the resident's lack of pain control. Interview on 3/2/18 at 3:15PM, Resident #27's family member said that the resident was doing okay at the hospital and that she was about to be moved to another unit where she would be getting intravenous [MEDICATION NAME]. The family member said Resident #27 had chronic pain from [MEDICAL CONDITION] and also a lot of her pain was stemming from the swelling in her legs. The family member was told about the resident being given Tylenol and requesting something else for pain and the family member replied that sounds like something she would request because Tylenol had never worked for her. She added that she was surprised the resident even took the Tylenol because usually she would not. Interview on 3/2/18 at 3:33PM, RN#8 was asked if Resident #27 has ever complained of pain to her and she said the resident had complained of pain and the resident told her told her that Tylenol was ineffective for her. RN#8 could not recall if it was on Friday or Monday when the resident complained of pain in her legs from swelling. She informed the resident that she had Tylenol PRN and the resident told her that Tylenol did not work for her. She said she told the resident to try the Tylenol and if it did not work, she would report it to the doctor so she could get something different. She said she went into Resident #27's room a little later and the resident said she was doing okay and did not say she was in pain. Interview on 3/2/18 at 4:00PM, the DON was asked about Resident #27's medication errors for her [MEDICATION NAME] on 2/27/18, 2/28/18, 3/1/18, and [MEDICATION NAME] on 2/28/18. The DON reviewed the written orders, computer order, and MAR and said she did see the error and that the Resident only got 20mg of [MEDICATION NAME] a day when it should have been 60mg. DON also said [MEDICATION NAME] was never given. She agreed the written order was not accurately transferred into the computer. Record review of the facility provided policy for abuse, neglect, and misappropriation of property (Last revised 3/8/17) revealed in part, 6. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review of the facility policy for physicians orders (complete revision 7/1/16) revealed in part, The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines. Record review of the facility's CMS-672 dated 2/27/18 revealed 43 residents on a pain management program and a total census of 92 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 well-being, consistent with the resident's comprehensive assessment and plan of care for one of six residents (Resident#1) reviewed for services in that: The facility failed to provide prompt medical intervention to Resident #1 who suffered a fall with a fracture of her lumbar vertebrae #1. An X-ray was not ordered for 8 hours and it took an additional 7 hours for it to be completed. Resident was sent to the ER 28 hours after the fall with fracture. This failure affected one resident and placed 27 other residents on one of four units at risk of neglect and a decline in health from not receiving prompt interventions following falls with injuries. Findings include: Intake # 4 Record review of Resident #1's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly assessment MDS dated [DATE] revealed a BIMS score of 12, indicating moderately impaired cognition, she was independent with all ADLs, but had range of motion limitation on both sides of her lower extremities. This MDS further revealed Resident #1 had no falls since admission or prior assessment. Record review of Resident #1's care plan dated 3/11/17 revealed the resident had the following fall history: 4/28/17 - lost balance in bathroom with no injury. 5/2/15 - clothes got tangled up and fell sustained right head hematoma. 5/10/17 - lost balance in bathroom and sustained a bruise to left ear. 6/7/17 - observed on floor in bathroom sustained hairline fracture of right femur. 6/14/17 - observed lying on floor by bed with no injuries noted. The goal of the care plan was for Resident #1 to not experience injuries from falls over the next 90 days. The approaches included: provide nonskid socks, over the toilet seat riser in bathroom, start voiding diary to determine toilet pattern, anticipate needs, assure lighting is adequate and areas are free of clutter, encourage resident to ask for assistance, ensure call light is in reach while in bed, therapy to evaluate and treat per orders. Record review of Resident #1's incident report, completed by RN #1 and dated 6/7/17 at 4:50am revealed observed patient on the floor - laying on left side of face, left hip in bathroom near shower area. She stated I lost my balance, I have [MEDICAL CONDITION] and it makes me do that. Patient had wheelchair near her, she was getting off toilet and fell . Record review of Resident #1's progress notes revealed the following note dated 6/7/17 at 7:54am at about 4am nurse observed resident on the floor in the bathroom laying on her left side of face and on left hip near the shower area. She stated I lost my balance as I was getting off the toilet; my Parkinson makes me have problems with my balance. Resident did not use call light nor did she ask for assistance to the bathroom. At this time she had no injuries. The right groin continues to give her problems in which she complained of pain 8/10. NP in house and she is aware of the situation and the pain in the groin, no new order at this time. Patient has been re-educated about importance of calling for assistance for all transfers. She was instructed she is a high risk for fall and needs help with toileting and transferring. She verbalized understanding. Family aware, neurochecks are intact and she had no change in condition. Record review of Resident #1's physician order [REDACTED]. Record review of Resident #1's progress notes revealed a note dated 6/7/17 at 12:52pm new order for X-Ray of hip and spine due to pain. Record review of Resident #1's X-Ray result dated 6/7/17 at 8:06pm revealed there is an acute compression fracture of lumbar vertebrae 1. There is no evidence of acute displaced fracture and no evidence of dislocation. If pain persists, CT should be obtained to rule out acute non-displaced fracture. Record review of Resident #1's progress notes revealed a note dated 6/8/17 at 3:40am 11pm NP notified of the X-Ray result of spine. Showed [MEDICAL CONDITION] changes with acute compression fracture of Lumbar vertebrae 1. X -Ray of hip was negative for fracture, at this time, no new orders were received. Patient has been resting well. Alert and oriented X 3. Record review of Resident #1's progress notes revealed a note dated 6/8/17 at 9:40am Resident was sent to ER to have CT scan done per NP orders due to result of right Hip X-ray. Transportation scheduled and resident left facility at 8:55am, family and NP aware. Record review of Resident #1's MAR/TAR dated June 2017 for pain assessment revealed no documentation. Observation and interview on 6/22/17 at 9:56am, revealed Resident #1 was in bed in her room, alert and oriented. Resident #1 gave an account of her falls and explained she had many falls due to unsteady gait. She said she was getting therapy sessions to help her get stronger. Resident #1 said these falls were not the facility's fault. Resident #1 expressed she had a lot of pain to her leg when she fell in her bathroom but was better now. Interview on 6/22/17 at 12:42pm, the DON was asked why it took the facility 8 hours after Resident #1's fall to order an X-ray despite her complaints of pain at a level of 8 on a scale of 10 (10 is the most severe pain). The DON said her understanding was that the NP was notified of the incident and did not order the X-ray immediately. The DON said she could call the NP to have the NP explain the reason behind her decisions and orders. When the DON was asked why it took 8 hours for an ordered X-Ray to be completed, she said the facility had concerns about the lab company's timeliness and were working on addressing it. She agreed 8 hours for labs to be ordered and 8 hours for ordered labs to be completed was too long for someone in pain with fractures to wait. Interview on 6/22/17 at 1:29pm, the NP said she was not in the facility at the time of Resident #1's fall but was called by the nurse and informed that Resident #1 had a fall. The NP said she ordered a STAT X-Ray when she was called. She said she went in to the facility about 6:30am and saw the results of the X-ray, which suggested a CT scan should be completed and Resident #1's pain was probably severe. The NP further said when she called Resident #1's responsible party and discussed the incident, the Responsible party suggested transferring the resident to the ER. When the NP was asked about the documented time on Resident #1's progress notes and Lab result indicating the X-Ray was not done until about 8:00pm on 6/7/17, the NP said it could be a documentation error. The NP agreed a lab should not have taken 8 hours to be done and Resident #1 should have received prompt intervention following her fall instead of having to wait in the facility for more than 24 hours. Interview on 6/22/17 at 2:30pm, the DON was asked for contact information for RN #1 who was Resident #1's Nurse on the night of 6/7/17 during Resident #1's fall incident. This information was not provided prior to exit. Interview on 6/22/17 at 3:00pm, the Administrator said she was waiting for the lab company to send her their policy. She explained the policy she had at hand only had a line which read STAT lab orders should be completed in not more than 4 hours. She said she would fax over the policy when available. The Administrator also acknowledged the facility had concerns with their current lab company and they were looking for alternatives to address the residents' lab needs. Record review of the Facility's Policy on abuse and neglect revised 3/8/2017 revealed .Abuse also includes the deprivation by an individual including caregiver, of good or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. Neglect is the failure of the facility, its' employee or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish or emotional distress. Facility census dated 6/22/17 listed 28 residents resided on Unit 2.