Every finding on record at The Plaza at Richardson

Based on interview and record review the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of three residents reviewed for abuse and neglect. 1. The facility failed to report an allegation of abuse involving Resident #1 to the local police department immediately but no later than 24 hours on 07/21/2026. This failure could place residents at risk of abuse and neglect. Findings includedRecord review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an original admission date of 03/09/2026 and current admission date of 06/17/2026. His diagnoses included Thrombocytopenia (low blood platelet count), Cirrhosis of the liver (late stage chronic liver disease), and Acute kidney failure (sudden loss of kidney function that happens over a few hours or days). Resident #1 had a BIMS score of 0 indicating he rarely/never understood and he was dependent on oral, toileting and personal hygiene. Review of Resident #1's Care Plan dated 03/10/2026 reflected he has Tracheostomy, Goal: . Resident #1 will have clear and equal breath sounds bilaterally through the review date.Interventions: . Ensure that trach ties are secured at all times. Review of Resident # 1's direct express debit card account screenshot reflected the following unauthorized transactions: 06/06/2026 [name of sports store] $108.2506/07/2026 [name of restaurant] $87.3406/10/2026 [name of department store] $46.22. An observation on 07/21/2026 at 11:56 AM revealed Resident #1 was lying in his bed, his eyes were closed and he did not respond to any questions. A phone interview on 07/21/2026 at 10:42 AM with Resident#1's family member, she stated she noticed unauthorized transactions on Resident #1's direct express debit card account while she was reviewing the account activity on her cell phone. She stated Resident #1 had his card statement sent to the home address, but when she called the card company, they said they received a request to change the resident's address to the facility address. Resident #1's family member stated Resident #1 was non-verbal and she was certain that the change of address request and unauthorized transactions were made by the facility BOM who was the only person she had given this information. She stated she went to the facility and spoke with the BOM, he stated he had the resident's express debit card account information on file, but he did not know anything about the unauthorized transactions and address change request. Resident #1's family member stated BOM told her that he would address the issue with the social security administration and take care of it. She stated she made a follow-up visit to the facility (could not remember the date) and that was when she learned the BOM was no longer working at the facility, she notified the facility administrator about the issue. An interview on 07/21/2026 at 01:43 PM with the New BOM, stated she Resident #1's direct express card information was stored in a binder at the BOM office with the intention of collecting the monthly applied income from the resident. She stated she was not supposed to use a resident's bank/card information for personal use and doing so will put residents at risk for financial loss, mental distress and delay in paying the applied income to the facility. She stated the BOM was responsible to safeguard the resident's financial information and if Misappropriation was suspected, she would immediately notify the abuse coordinator/administrator, and the Administrator was responsible to suspend the Alleged Perpetrator, conduct investigation and notify the local police immediately. A phone interview on 07/21/2026 at 03:13 PM with the in-house Medicaid person stated she was in the process of preparing Medicaid application for Resident #1 and she learned from Resident #1's family member on 07/16/2026 about the unauthorized transaction took place in his direct express card account and that someone requested to change Resident #1's card address to the facility address. She stated she immediately reported this to the Administrator. An interview on 07/21/2026 at 04:44 PM with the administrator, he stated it was the BOM's responsibility to safeguard Resident #1's direct express card information and none of the staff were supposed to use resident financial information for personal gain. He stated he learned from Resident #1's family member on 07/16/2026 about the unauthorized transactions that took place in Resident #1's direct express card account. He stated he suspected the previous BOM would have made these unauthorized transactions, the previous BOM did not show up to work, he did not respond when attempted to contact him after this incident. He stated he was responsible for reporting suspected abuse neglect, misappropriation to the resident's responsible party, physician, state and to the police department- within 24 hours if the incident did not involve serious bodily injury. He stated he did not report this misappropriation incident to the police because his boss, the area director of operations, suggested him report it after reevaluating the situation. He stated it was important to notify the police immediately about abuse and misappropriation of property to protect the residents and their assets. An interview on 07/21/2026 at 05:10 PM with the Area Director of Operations, she stated she was aware of the alleged misappropriation of property incident involving Resident #1 and they suspected the previous BOM as the alleged perpetrator. She stated that the facility administrator was responsible for reporting suspected abuse or misappropriation to the police, unless the resident's family requested otherwise. She added that she could not recollect directing the administrator to delay reporting to the police. Record review of facility policy titled Abuse/Neglect, revision date 3/29/18: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. A report to the appropriate agency will include the following:c. The name and address of the suspected victim. d. The name and address of the suspected victim's care giver, if known.e. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of three residents (Resident #1) reviewed for pharmacy services. Med Aide B failed to ensure Resident #2's 8 AM medications were given on time on 01/07/26 according to facility policy.Med Aide B failed to document Resident #2's 8 AM medications were given late on 01/07/26. These failures placed residents at risk of not receiving medications timely and as ordered by physician. Findings included: Review of Resident #2's Consolidated Physician Orders dated 01/07/26 reflected diagnoses of hypotension (low blood pressure), Hypertensive Heart Disease with Heart Failure, Atherosclerotic Heart Disease and Type 2 Diabetes. Resident #2 had the following current medication orders:Order date 03/12/25 with start date 03/13/25 for Dapagliflozin Propanediol Oral Tablet 5 MG (Dapagliflozin Propanediol) Give 1 tablet by mouth one time a day for diabetes.Order date 03/12/25 with start date 03/13/25 for MetFORMIN HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for diabetes.Order and start dated of 09/12/25 for Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth two times a day for HypotensionOrder date 03/12/25 with start date 03/13/25 Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium)Give 1 tablet by mouth two times a day for acid refluxObservation on 01/07/26 at 10:18 AM revealed Med Aide B checked Resident #2's blood pressure using the wrist cuff which reflected 104/46. Med Aide B put Resident #2's 8 AM and 9 AM medications of 6 pills including Dapagliflozin Propanediol 5 mg tablet, Pantoprazole sodium 40 mg tablet, Metformin 1000 mg tablet and Midodrine 10 mg in a small cup. At 10:24 AM Resident #2 was given the clear cup with the 6 pills by Med Aide B and Resident #2 took the 6 pills by mouth. Review of Resident #2's Medication Administration Record for January 2026 reflected Resident #2 was given 8 AM medications electronically signed off by Med Aide B on 01/07/26 of Dapagliflozin Propanediol 5 mg, Metformin 100 mg tablet, Pantoprazole 40 mg tablet and Midocrine HCl tablet 10 mg. Review of electronic record for Resident # 2 did not reflected a note of late medication. Interview on 01/07/26 at 12:45 PM with Med Aide B revealed he did give Resident #2's 8 AM and 9 AM medications late this morning. He stated he was supposed to give medications within 1 hour before the prescribed time for Resident # 2 to 1 hour after to ensure medications were within timeframes. Med Aide B did not notify the nurse or document he had given Resident #2's medications for 8 AM and 9 AM medication in the electronic record. He stated he was not aware there was a way to document if medications late. Interview on 01/07/26 at 3:56 PM with the DON revealed she expected Med Aide B to administer 8 AM medications within the time frame on the MAR of 1 hour before and/or 1 hour after. She stated medication times are in place to ensure medications were given on time and as ordered by the physician. She stated Resident #2's pantoprazole should have been given prior to breakfast and after 10 AM Resident #2 had already eaten their breakfast. She stated Med Aide B should notify the charge nurse if Resident #2's medications were not given on time. Review of Med Aide B's Medication/Administration Competency reflected it was dated on 06/08/25 which included proper hand hygiene and medication administered at correct time. Review of facility's Policy Medication Administration and General Guidelines dated March 2025 reflected under procedure 10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise). Before or after meal orders are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation.

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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure Med Aide B performed hand hygiene while administering medication to Resident #1 on 01/07/26. 2. Med Aid B failed to sanitize the wrist blood pressure cuff prior to checking Resident #2's blood pressure and prior to putting it in the medication cart. These failures could place residents at risk for infection and cross contamination. Findings included: Observation on 01/07/26 at10:18 AM revealed Med Aide B did not sanitize the wrist blood pressure cuff nor did he wash or sanitize hands prior to checking Resident #2's blood pressure cuff on resident's wrist. Med Aide B put the blood pressure cuff on top of his medication cart. Med Aide B did not wash or sanitize hands prior to administering Resident #2's medications. Interview on 01/07/26 at 10:30 AM with Med Aide B revealed he should have sanitized or washed his hands prior to taking Resident #2's blood pressure of and before administering Resident #2's medications. He stated there was not any hand sanitizer on the medication cart or in the medication cart so he was not able to sanitize his hands before and after medication administration. He stated he should have washed or sanitized his hands to prevent cross contamination and infection. Interview on 01/07/26 at 10:40 AM with the DON revealed Med Aide B should have washed or sanitized his hands prior to checking Resident #2's blood pressure, prior to administering medications and after administering Resident #2's medications. She stated not washing or sanitizing his hands during medication administration could place residents at risk of infection control. The DON stated she expected Med Aide B to sanitize the blood pressure cuff before resident use and prior to putting it back into the medication cart. Review of Med Aide B's Medication/Administration Competency reflected it was dated on 06/08/25 which included proper hand hygiene and medication administered at correct time. Review of facility's Policy Fundamentals of Infection Control Precautions undated reflected Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice).Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident).

Based on observation, interview, and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 3 residents (Resident #2) reviewed for residents' call system. The facility failed to ensure Resident #2's call light was not accessible to the resident and within reach. This failure could place residents at risk of a delay in getting assistance and of not having a means of directly contacting staff in an emergency.Findings included: Review of Resident #2's Significant Change MDS dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, diabetes and hypertension (high blood pressure). Resident #2 was dependent on staff with ADLs for dressing, hygiene, toileting, bathing, positioning and transfers. Resident #2 was moderately impaired in daily decision making. Review of Resident #2's Comprehensive Care plan last reviewed 12/23/25 reflected Resident #2 was (High) risk for falls r/t Gait/balance problems. Intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation on 01/07/26 at 12:58 PM revealed Resident #2's call button was on the floor below Resident #2's bed while Resident #2 was lying in bed with positioning rails on both sides of bed. Interview with Resident #2 revealed she used her call button to get assistance from staff but could not reach it and was dependent on staff for assistance. Interview on 01/07/26 at 1:08 PM with CNA C revealed Resident #2's call button must have fallen off the bed, but it should be within reach of Resident #2 while she is in bed. She stated Resident #2 was dependent on staff for ADLs. Observation revealed CNA C wrapped the call button cord around the right positioning rail within Resident #2's reach. CNA C stated Resident #2 did use her call button when she needed assistance from staff. Interview on 01/07/26 at 3:56 PM with DON revealed she expected resident's call device to be within reach of resident while in the bed. She stated Resident #2 did use her call light for assistance. The facility did not have a policy for call lights per the Administrator on 01/07/26 at 3:39 PM.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed on 06/24/2025 to ensure the stand-by refrigerator opened food items were dated. 2. The facility failed to ensure the walk-in refrigerator food items were dated, labeled and securely stored. 3. The facility failed to ensure the walk-in freezer food items were dated and labeled. 4. The facility failed to ensure the dry storage food items were dated and labeled. 5. The facility failed to ensure that canned good food items were free of dents. 6. The facility failed to ensure that dishwashing protocol was followed. 7. The facility failed to ensure that prepared foods were held correctly and maintained safe temperatures. These failures could place residents at risk for foodborne illnesses and foodborne intoxication. Findings included: Observation on 06/24/2025 at 8:55AM upon entry to the kitchen revealed the following: In the stand-by refrigerator, a carton of soy milk beverage with a broken seal and a manufacturer statement of after opening . use within 7-10 day and with no opened on and use by date. Observation on 06/24/2025 of the walk-in refrigerator at 9:00AM revealed the following: A plastic bin of russet potatoes with no label and use by date. A zip closure bag of carrots with one molding carrot, no label, and no use by date. A zip closure bag of bread with no label of the type of bread and no use by date. A saran wrapped package of cinnamons rolls with no label and no use by date. A saran wrapped bag of mozzarella cheese, dated 5-29-25 with no use by date. An unsealed zip close bag of sliced cheese with condensation moisture in the bag, dated 5/4/25 with no use by date. Observation on 06/24/2025 at 9:03AM of the walk-in freezer revealed the following: A saran wrapped bag of frozen vegetable medley with no use by date. A frozen bag of sliced sausage covered in ice crystals, with no label of the type of sausage and no use by date. An unsealed bag inside a box labeled hot water cornbread and dated 5-22-25, with no use by date. Observation on 06/24/2025 at 9:07AM of the dry storage closet revealed the following: A dented can of yams dated 3-6-25. A saran wrapped bag of uncooked macaroni noodles with no use by date. A saran wrapped bag of dry cake mix dated 3-20-25 with no use by date. A saran wrapped bag of roast beef flavored gravy mix dated 4-10-25 with no use by date. An interview on 06/24/2025 at 9:10AM with the DM revealed that the saran wrapped bag of cake mix was cherry cake mix. He stated the date on the bag indicated delivery date and that he had not known when it was originally opened. The DM stated that the risk of a dented can was that the seal can become broken and the canned good can be contaminated and unsafe to eat (foodborne illness). Observation on 06/24/2025 at 11:36AM upon entry in the kitchen revealed the following: Banana pudding cups with wafer sitting on trays for lunch. Fried chicken uncovered on the steam tray line. Observation and interview on 06/24/2025 at 11:40AM of the 3-compartment sink revealed the following: The 1st compartment, for washing dishes, only contained an empty 4-quart plastic container and stainless-steel bowl sitting in it. The stainless-steel bowl had soapy water in it. The 2nd compartment, for rinsing dishes, had a 7.5-quart plastic container filled with water and a large metal serving spoon sitting in it; food particles were observed in the bottom of the 2nd compartment. The 3rd compartment was empty. At this time, the assistant dietary manager picked up the serving spoon from the bottom of the 2nd compartment and began to walk to the steam tray line. This surveyor intervened and asked what the serving spoon was going to be used for. The assistant dietary manager stated it was for stirring green beans. This surveyor asked if the serving spoon had been cleaned, and the assistant dietary manager stated that she had washed it. This surveyor further asked if she had sanitized the spoon, and she stated, not yet. This surveyor pointed out the food particles at the bottom of the sink. The assistant dietary manager proceeded to turn on the sanitizing solution dispenser and use the sanitizer solution dispenser tube to cover the serving spoon in sanitizer. This surveyor asked how the 3-compartment sink was used; the assistant dietary manager stated she washes dishes in the 1st compartment, rinses dishes in the 2nd compartment, and sanitizes dishes in the 3rd compartment. When asked if using the tube to disperse sanitizing solution on the dishes was the correct way to sanitize dishes. She explained that sanitizing solution was diluted with water and that the dip test paper strip to check sanitizing solution concentration was supposed to be yellow-green colored. At this time, the assistant dietary manager and DM placed a drain stopper in the sink and filled the sink with the sanitizing solution. A dip test strip to test the concentration; the test strip revealed a green blue color. The DM stated that he checks the sanitizing solution concentration daily. When the DM was asked what the solution concentration should be, he stated 200 ppm but the diagram says 150 ppm. The DM further stated it was expected that after rinsing, dishes should be immersed in sanitizing solution for 10 seconds. He pointed out the instructional diagrams on the wall behind the 3-compartment sink that were provided by the chemical supply company and discussed they should be utilized. Record review on 06/24/2025 at 11:57 PM of the instructional diagrams provided by the dishwashing chemical supply company posted on the wall behind the sink reflected: The Three-Compartment Sink Procedure instructed the 2nd compartment to be filled with hot water and rinse all items in clean hot water. The 3rd compartment instructed to be filled with proper sanitizer solution; completely immerse (dishes) in the sanitizer solution for at least one minute. The Sanitize Test Procedure instructed to dip test paper in sanitizing solution for 10 seconds and compare strip to color chart on test paper dispenser (color chart on dispenser to compare to quaternary ammonia sanitizing solution concentration). Further instructions reflected the test paper must read 150-400 ppm (0 ppm - red, 150 ppm - yellow-orange, 200 ppm - dark yellow, 400 ppm - yellow-green, 500 ppm - green-blue). Observation and interview on 06/24/2025 at 12:05PM with the DM revealed that he filled the 3rd compartment of the sink with the sanitizing solution and was able to show a dark yellow colored test strip result. He explained that he added water the sanitizing solution to achieve the right concentration. He further stated it's important to have the right concentration. He explained that if not enough sanitizer is used, dishes can carry pathogens; if too much sanitizer was used on dishes, it can make residents sick (foodborne intoxication). Observation and interview on 06/24/2025 at 12:13PM with the assistant dietary manager revealed the following: The assistant dietary manager had prepared to plate food from the stream tray table. This surveyor intervened and asked was going to check the holding temperatures of food items on the steam tray table before plating. She stated she had already checked food temperatures after food were cooked, but not the temperature the foods were held at. She proceeded to check the holding temperatures of the food items on the steam tray table. The temperature of the pureed pinto beans was 100°F. The temperature of the banana pudding cups with wafers was 59.7°F The assistant dietary manager stated that the holding temperature for hot foods should be 145°F. Interview on 06/24/2025 at 12:20PM with the DM revealed that holding temperatures for cold foods should be 41°F or lower. He did not know how long the banana pudding cups had sat out, and that oatmeal cream pies would be used as a substitute for the banana pudding cups. He stated the importance of foods meeting temperatures as required was for palatability, taste, and to make sure foods are properly cooked for safety. Interview on 06/26/2025 at 10:30AM with the registered dietitian revealed she had done in-service training regarding the food temperatures checks. She stated temperatures checks were expected to be done prior to serving food from the steam tray line. Hot held foods should be 135°F or hotter, and cold foods should be 41°F or less. She further explained if hot foods are not 135°F or hotter, they must be reheated to at least 165°F, and cold foods should be kept on ice. She stated the importance of meeting these temperatures was for food palatability, taste, and safety; if foods are not kept at the appropriate temperatures, they can grow bacteria, leading to foodborne illness. Interview on 06/26/2025 at 12:20PM with the DM revealed the expectation for temperature checks for foods on the steam tray table and cold foods was to be done prior to plating foods. He stated the expectation for using the 3-compartment sink was for it to be used as directed on the instructional diagrams and for dishes to be submerged in the sanitizing solution. When asked if the assistant dietary manager should have attempted to use the serving spoon, the DM stated she should not have and he expected it to sanitized prior to use. He explained these expectations are important to follow because of the bacteria risk to residents. He stated that since 06/24/2025, he in-serviced the assistant dietary manager on how to use the 3-compartment sink and temperature checks. Record review of the facility's Equipment Sanitation Policy dated 2012 reflected: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure: . 6. Pots and Pans: a. Manual dishwashing of pots, pans and equipment: Three compartment sinks should be used. b. Prior to washing, all utensils and equipment shall be pre-scraped or pre-flushed and, when necessary, pre-soaked to remove gross waste. c. Effective concentration of a suitable detergent shall be used. d. This detergent solution shall be kept reasonably clean. e. All equipment and utensils shall be thoroughly rinsed free of the detergent solution. f All equipment and utensils shall be sanitized by one of the following methods: g. Immersion for at least one-half minute in clean, hot water at a temperature of at least 180 degrees F. h. Immersion for a period of at least one minute in a sanitizing solution containing: . - Any other approved chemical-sanitizing agent containing at least 150-400 ppm of quaternary ammonia at a temperature of approximately 70 degrees F. 7. Facilities shall use an approved test kit to measure the parts per million (ppm) of the chemical solutions in pot sinks on a daily basis. Records of test results should be kept on the temperature/chemical log. Any abnormal test results shall be reported to the Dietary Service Manager, and the solution shall not be used until at the correct ppm . Record review of the facility's Food Storage and Supplies policy dated 2012 reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: . 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable . If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year . 7. According to the USDA fact sheet on Food Product dating . products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product. These dates do not indicate that the product is no longer safe after one year, but give a method to track the age of a product so that it can be evaluated for quality before service. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten . 9. Perishable and non-perishable foods are classified based on their pH and water content . These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. 10. Frozen items that should be thawed before preparation should be stored under refrigeration until thawed, and should be dated with the date removed from the freezer and used within 7 days . If a frozen food does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging . Record review of the U.S. FDA Food Code 2022 reflected the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above . (2) At 5°C (41°F) or less . 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers . 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated . 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness .A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: . (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), P (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. The facility failed to ensure Hall 200 and 400 were free of gnat flies. The facility failed to ensure the facility's only kitchen was free of gnat flies. This failure could lead infestation of pests and compromise resident health Findings included: Observation on 06/24/2025 at 8:55AM upon entry to kitchen revealed the following: 2 gnats flying around the hand washing sink. Interview on 06/24/2025 at 9:48AM with the DM revealed that there had been a gnat issue in the kitchen. He stated that pest control is coming and that staff had currently been trying to maintain pest control by pouring bleach down the drains in the kitchen. The DM stated he had put a pest control order in for maintenance. Observation on 06/24/2025 at 9:48AM in hall 200 revealed the following: 1 gnat flying around in room [ROOM NUMBER] 1 gnat flying around in the common area (activities and dining) 1 gnat flying around in the hallway Observation on 06/24/2025 at 11:36AM upon entry to the kitchen revealed the following: 3 gnats flying around the hand washing sink. When the DM moved a stainless-steel bowl with sauce in it, 3 gnats flew out of it. 1 gnat flying around near the deep fryer (12:13PM) 2 gnats flying around near the steam tray table (12:42PM) 1 gnat flying around near the steam tray table (12:47PM) 1 gnat flying around near the steam tray table (12:55PM) Observation on 06/26/2025 at 11:30AM with Resident #52 revealed 1 gnat flying around his head. This surveyor attempted to interview Resident #52; he was unable to coherently communicate. Observation and interview on 06/26/2025 at 2:26PM with Resident #40 revealed 2 gnats flying around his room upon entry. Resident #40 resides in hall 400. The resident stated that the gnats have been a problem and have been in the facility for a long time. Resident #40 stated the gnats bother him and he had complained to staff but did not know who and does not know what else to do about the gnats. The resident appeared agitated by the gnats, based on reactions to asking about the gnats and tone of voice. Observation and interview on 06/26/2025 at 2:35PM with Resident #33 revealed the resident had many gnats in her room. Resident #33 resides in hall 100. She stated she had talked to someone in the facility but was unsure of who. She further stated she wanted her family to bring traps to control the gnats since they have continued to be an issue. When asked if the gnats bothered her, she said yes and that one gnat flew in her mouth while she was eating and that she almost threw up. Interview with the ADON on 06/26/2025 at 3:10PM revealed she had seen gnats around the facility and in hall 200. She stated there were no current swarms. Interview on 06/26/2025 at 3:36PM with the maintenance supervisor revealed that he was responsible for pest control. He stated that food in a resident's room caused the gnats to populate, and he was able to locate the source of the gnats. He explained that traps were set to control the gnat population, prior to pest control treatment on 06/10/2025. He stated pest control came again on 06/25/2025 and when pest control was not in the facility, he continues to maintain gnats with traps, sprays, and pouring bleach or vinegar down drains. He stated it is important to take time to continue to manage the gnats because the facility was the resident's home and there should not be pests. Interview with the ADM on 06/26/2025 at 4:28PM revealed that maintenance overlooks pest control in the facility. He stated that the gnat problem was due to food that was in a resident's room. He explained that pest control comes to the facility once a month and does follow ups and after treatment. The ADM further stated that pest control had currently done treatment more than once a month due to the gnat issue. This surveyor asked the ADM how the facility monitors the gnats to prevent further increase in gnat population, he stated during morning meetings with staff, everyone is assigned halls to check and assess all rooms for any issues, including pests. The ADM expect staff to log and let maintenance know of pest issues, and maintenance to inform pest control. He stated that maintenance uses sprays and traps to manage the gnats. Observation during an interview with ADM on 06/26/2025 at 4:28PM revealed 1 gnat flying in front of this surveyor's face. Record review of pest control log dated 06/10/205 reflected: (the head nurse) said (room [ROOM NUMBER]) was the source of the gnats . 200 HALLWAY AND DINING ROOM EXPERENCING HEAVY GNAT PRESSURES . treatment applied to the common area and resident's room . targeted pests: gnat . Record review of the facility's Insect and Rodent Control policy dated 2012 reflected: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Procedure: 1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. 2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. 4. Deliveries of food and supplies will be monitored for prevention of insect and rodent access.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to one medication cart of four medication carts observed for medication security, and for one medication in one of two common areas observed for medication security. 1. The facility failed to keep a dialysis medication cart locked in Resident #40's room. On 6/24/25 at 4:00 pm an unlocked dialysis medication cart containing intravenous medications was observed in Resident #40's room and unlocked dialysis fluids were observed in the room. 2. The facility failed to keep one medication (Advair Diskus) secured in a common area near the nurse's station . On 6/24/25 at 9:06 am an unlocked and unattended Advair Diskus was observed in the common area This failure could affect residents by placing them at risk of injury or harm of adverse medication reactions or side effects and placing the facility at risk for possible drug diversion. Findings included: In a record review of Resident #40's Quarterly MDS dated [DATE], Resident #40 was noted with a diagnosis of End-Stage Renal Disease (kidney failure) with dependence on renal dialysis. His BIMs score was 1, indicating severe cognitive impairment. In an observation and interview on 6/24/25 at 04:00 pm, Resident #40 was observed with an unlocked medication cart in his bedroom which contained: Heparin 30,000 units per ml, 30 ml vial, 12 unopened vials and 2 opened vials Zemplar 2 mg/ml, 1 ml vial, 41 unopened vials Observed sitting on Resident #40's bedroom floor: RenalPure Liquid Acid 1 Gallon plastic jugs, 2 opened jugs and 5 unopened jugs Resident #40 reported that an outside agency had used the medication cart and dialysis fluids to provide him with in-room dialysis. He stated he had not been aware that the medications and fluids were unlocked. He stated only the dialysis nurse accessed these medications and dialysis fluids. In an interview on 6/24/25 at 04:15 pm, RN C stated he had not been aware of the unsecured medications and dialysis fluids in Resident #40's room. He reported that Resident #40 received dialysis from a contracted agency, and that the dialysis nurses as well as the facility nurses were both responsible for ensuring that the medications remained securely locked. He reported that the medications being left unlocked were a risk to residents and could hurt them but was unsure what the exact chemicals and medications might cause. In an interview on 6/24/25 at 04:20 pm, the DON stated the contract dialysis nurse, and the facility nursing staff were responsible for having kept the medications in Resident #40's room locked. She stated that she herself and the ADONs made environmental rounds in the mornings and would monitor for unsecured medications, and she believed this was an oversight. She stated any unsecured medications that were found would have been immediately secured, and in-service staff training would have been done had any unsecured medications been found. She stated that if a resident had accessed these medications, they could have been injured or had a reaction. She stated that staff had received training quarterly and as needed on the need to securely lock medications. In an interview on 6/25/25 at 09:20 a.m., LVN D reported she was the dialysis nurse for Resident #40 today (6/25/25). She reported that she had always locked Resident #40's medications and dialysis fluids, and she stated, the medications should remain locked so that another resident doesn't wander in and could get hurt. She reported that the nurses are responsible for keeping medications locked, and she had received training on this. In an observation on 6/24/25 at 09:06 a.m., an unattended, unlocked/unsecured, opened, box of Fluticasone propionate/salmeterol diskus inhalation (Advair Diskus) was observed sitting in the basket of the vital sign machine against the wall near the nurse's station. The Diskus showed 57 doses remaining. Resident label was not observed. No staff or residents were observed in the immediate area. LVN A entered the area at approximately 9:08 am. In an interview on 6/24/25 at 09:08 a.m., when LVN A was shown the unlocked and unattended Advair Diskus she stated, That should not be there and it should be locked on a cart. She reported that nurses and medication aides were responsible for keeping medications secure. She stated the risk of unsecured medications to residents is, a resident could get it. She took the medication out of the basket to place it in a medication cart. In an interview on 6/24/25 at 10:20 a.m., the ADM stated, there is no excuse for the Advair Diskus to have been left unsecured and that nurses and medications aides were responsible for maintaining the security of each of their own carts. He stated that DONs and ADONs made rounds each morning to monitor the environment, including monitoring for the presence of unsecured medications. He stated the risk to the resident would, depend on the type of medication but that, any resident could grab it and have adverse reactions. In an interview on 6/24/25 at 10:50 a.m., the DON stated that nurses and medications aides were responsible for maintaining medications in a locked manner. She stated that she made environmental rounds each morning and monitored for any unsecured medications but that she had been running today (6/24/15). She stated that the risk of an unsecured medication was that it could have been lost, and that the wrong resident could have taken it and experienced an allergic reaction. She stated that all nurses and medication aides have received training on the need to keep medications securely locked and that this training was done quarterly and as needed. In a record review of the facility policy titled, PCU027-Medication Storage in the Facility dated 2025, the policy reflected, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 1 of 20 residents (Resident #52) reviewed for environment. The facility failed to ensure Resident #52's bedroom floor was clean of regurgitated food, on 6/24/2025, after it had been on the floor from 11:50 AM to 2:40 PM. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: Record review of Resident #52's Face Sheet dated 6-26-2025 indicated a [AGE] year-old male with an initial admission date of 9-20-2023 and a re-admission date of 6-13-2025. Resident #52 had a primary diagnosis of Parkinson's Disease (a progressive degeneration of nerve cells in the brain) and secondary diagnoses of Encephalopathy (any disease or disorder that affects the function or structure of the brain, leading to altered mental status, confusion, or changes in behavior), Malignant Neoplasm of the Prostate (a cancerous tumor that develops in the prostate gland), Unspecified Dementia (a condition where cognitive decline is significant enough to interfere with daily functioning, but the specific cause or type of dementia is not clearly identified or classified), and Psychotic Disorder with Hallucinations due to known Physiological condition (a mental health condition where a person experiences hallucinations, false sensory perceptions like seeing or hearing things that aren't there, as a direct result of a recognized medical or neurological condition, and not due to a primary psychotic disorder). Record review of Resident 52's Comprehensive MDS assessment dated [DATE] revealed a BIMS Score of 15 indicating Resident #52 was cognitively intact. Section (I) of the MDS revealed Resident #52 had Dysphagia (difficulty swallowing where food or liquid could get stuck in the throat). Record review of Resident #52's Therapy MDS dated [DATE] revealed he had a cognitive decline, was being treated for Dysphagia because of coughing or choking during meals . and was on a mechanically altered diet. Record review of Resident #52's Care Plan dated 12-11-2023 revealed he was planned for Parkinson's Disease with interventions of Monitor/document/report to MD PRN any [signs] of aspiration or dysphagia: choking . In an observation and interview on 6-24-2025 at 11:50 AM, dried food regurgitation was seen on both sides of Resident #52's bed. Resident #52 was observed to be the sole resident in his room. Resident #52 was not able to communicate how long the regurgitated food was on the floor but said it made him feel nasty because it had been there a while. In an observation on 6-24-2025 at 2:40 PM, it was witnessed that the dried regurgitated food, next to Resident #52's bed, had not been cleaned up since 11:50 AM. In an interview with CNA E, on 6-24-2025 at 2:40 PM, it was learned that CNA E had worked the hallway where Resident #52 resided and had worked at the facility for 3 weeks. CNA E said she was unaware that throw-up was on the floor in Resident #52's room. CNA E said the facility had a housekeeping department that cleaned the resident's rooms every day. CNA E said the CNAs were responsible to ensure resident's rooms were kept clean and free from food or liquids on their floors. CNA E said the potential harm to residents if their floors were not kept free of regurgitated food was a slippery floor and it could cause them to feel neglected. In an interview with LVN F, on 6-26-2025 at 1:35 PM, it was learned that LVN F was working the hallway where Resident #52 resided and had worked at the facility for 1 year. LVN F said the CNAs make rounds from time-to-time to make sure resident's rooms stay clean. LVN F said the nurses made rounds to ensure the cleanliness of resident's rooms as well. LVN F said the housekeeping department made rounds in the morning to clean resident's rooms then they were on PRN standby status to respond as needed by other staff to clean resident's rooms. LVN F said she expected the CNAs to make rounds to ensure spills and throw-up messes were cleaned in resident's rooms in a timely manner. LVN F said CNAs and housekeeping were responsible to ensure resident's rooms stay clean. LVN F said the nursing staff supervised the CNA staff. In an interview with the DON, on 6-26-2025 at 4:24 PM, it was learned the DON had worked at the facility for 6 months. The DON said the facility had a housekeeping department for cleaning, however, her expectations were for CNAs and nurses to make rounds and report debris on the floors to the housekeeping department for cleaning. The DON said her expectation was for staff to clean resident's rooms as soon as they see spills or food debris on the floors. The DON said the potential risk to residents not having throw-up cleaned off their floors, in a timely manner, was it could cause a fall or become an infection control issue. In an interview with the Administrator, on 6-26-2025 at 4:38 PM, it was stated the housekeeping depart was responsible to keep resident rooms clean. The Administrator said any staff who see food or liquid on the floor, in resident's rooms, should contact the housekeeping department for cleaning. The Administrator said floor staff and managers were supposed to make rounds to ensure floors were kept clean in a timely manner. The Administrator stated that he expected floors to not have debris on them for over an hour. The Administrator said the potential risk to residents having spills or regurgitation on their floors was not having a clean and comfortable environment. The Administrator said he was going to start in-services on timely cleaning of resident rooms. Record review of the facility's Grievance Log, for the past 90 days, revealed a complaint was made regarding the condition of a resident's room on 6-23-2025. Record review of the facility's non-dated policy entitled Resident Rights stated: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-- 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible . 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .

Based on observation and interview, the facility failed to must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired gentle female intermittent catheters were removed from the facility's only medication room on [DATE]. These failures could place residents at risk for infection and possible adverse effects. Findings included: In an interview and observation on [DATE] at 09:10 a.m., expired supplies found stored in the medication room included: 75 count - Gentle Cath Female Intermittent Catheters, unopened, manufacturer expiration date of 06-01-24 LVN A was present and stated that the medication room should have been audited for expired supplies by an ADON each day and that all expired supplies should have been disposed of. She stated that the DON was responsible for monitoring to ensure that this took place. She stated that the risk to residents of expired medical supplies was infection. She then took and disposed of the expired supplies. In an interview on [DATE] at 10:20 a.m., the ADM reported that the medication room was to be audited for expired supplies and medications twice weekly by Central Supply Personnel B. He reported that on the other days the supply room was audited by the ADONs. He reported that any expired medication should have been removed and discarded immediately. The ADM reported that the facility DON monitored to ensure the auditing was completed. He reported that while he did not fully understand the risks to residents regarding expired supplies, he understands that over time materials can degrade. In an interview on [DATE] at 10:50 a.m., the DON stated medication room supplies were audited for expiration dates by Central Supply Personnel B. She stated on other days the ADONs audited the medication room for expired supplies, and that she herself as the DON monitored the overall auditing. She stated the presence of expired supplies was maybe an oversight and that she had not been aware of their presence. She stated the risk to the resident of expired supplies was, possibly side effects and stated, the manufacturer writes that date there for a reason. In an interview on [DATE] at 11:05 a.m., Central Supply Personnel B stated he was responsible for monitoring the medication room for expired supplies. He reported he did a clean sweep once a month in which he removed all expired supplies. He stated that he also monitored expired supplies twice weekly as he was ordering supplies. He stated he had not been aware of the presence of the expired supplies. He stated he threw away any expired supplies immediately. He stated, the nurses also monitor for expired supplies and nurses are in there every day. He reported that, we don't want to use compromised materials with the resident. There was a reason for the manufacturer's expiration date. We want the full effect of what we are using it for. In an interview on [DATE] at 1:13 pm, RN C reported that the facility did not have a policy that specifically covered expired medical supplies.

Based on observation and interview, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired IV/PICC supplies were removed from the facility's only medication room on [DATE]. These failures could place residents at risk for infection and possible adverse effects. Findings included: In an interview and observation on [DATE] at 09:10 a.m., expired supplies found stored in the medication room included: 1 count - Insyte Autoguard IV Catheter 24 Gauge, unopened, manufacturer expiration date of 08-2018 8 count - Insyte Autoguard IV Catheter 24 Gauge, unopened, manufacturer expiration date 12-01-21 17 count - Insyte Autoguard IV Catheter 20 Gauge, unopened, manufacturer expiration date of 03-01-22 3 count - Insyte Autoguard IV Catheter 20 Gauge, unopened, manufacturer expiration date of 02-01-24 1 count - Invision Plus Needleless IV Connector, unopened, manufacturer expiration date of 07-01-23 1 count - Invision Plus Needleless IV Connector, unopened, manufacturer expiration date of 02-01-24. 1 count - Stat Lock PICC Plus Stabilization Device, unopened, manufacturer expiration date of 04-28-24 1 count - Stat Lock PICC Plus Stabilization Device, unopened, manufacturer expiration 10-28-23 LVN A was present and stated that the medication room should have been audited for expired supplies by an ADON each day and that all expired supplies should have been disposed of. She stated that the DON was responsible for monitoring to ensure that this took place. She stated that the risk to residents of expired medical supplies was infection. She then took and disposed of the expired supplies. In an interview on [DATE] at 10:20 a.m., the ADM reported that the medication room was to be audited for expired supplies and medications twice weekly by Central Supply Personnel B. He reported that on the other days the supply room was audited by the ADONs. He reported that any expired medication should have been removed and discarded immediately. The ADM reported that the facility DON monitored to ensure the auditing was completed. He reported that while he did not fully understand the risks to residents regarding expired supplies, he understands that over time materials can degrade. In an interview on [DATE] at 10:50 a.m., the DON stated medication room supplies were audited for expiration dates by Central Supply Personnel B. She stated on other days the ADONs audited the medication room for expired supplies, and that she herself as the DON monitored the overall auditing. She stated the presence of expired supplies was maybe an oversight and that she had not been aware of their presence. She stated the risk to the resident of expired supplies was, possibly side effects and stated, the manufacturer writes that date there for a reason. In an interview on [DATE] at 11:05 a.m., Central Supply Personnel B stated he was responsible for monitoring the medication room for expired supplies. He reported he did a clean sweep once a month in which he removed all expired supplies. He stated that he also monitored expired supplies twice weekly as he was ordering supplies. He stated he had not been aware of the presence of the expired supplies. He stated he threw away any expired supplies immediately. He stated, the nurses also monitor for expired supplies and nurses are in there every day. He reported that, we don't want to use compromised materials with the resident. There was a reason for the manufacturer's expiration date. We want the full effect of what we are using it for. In an interview on [DATE] at 1:13 pm, RN C reported that the facility did not have a policy that specifically covered expired medical supplies.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for (Resident #65) one of one resident reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene while feeding lunch to Resident #65 on 06/24/25. This deficient practice could place residents at risk for infections. Findings included: Record review of Resident #65's face sheet, dated 06/25/25, reflected a [AGE] year-old male, with an admission date of 09/24/24. Resident #65 had diagnoses of Dementia (loss of memory, language, problem-solving and other thinking abilities), Muscle Wasting and Atrophy (loss of muscle mass and strength), Protein-Calorie Malnutrition (inadequate intake of food), Dysphagia (difficulty swallowing), Hypertensive Heart Disease (a condition where the heart is damaged to due to long-term high blood pressure), Cerebral Atherosclerosis (a buildup of fats, cholesterol, and other substances in the artery walls), Constipation (difficult -to-pass bowel movements), Pain (a signal in the nervous system that something may be wrong), Muscle Weakness (difficult for muscles to contract and move as they normally would), and Benign Prostatic Hyperplasia without Lower Urinary Tract (prostate gland enlarges). In an observation on 06/24/25 at 12:35 PM, CNA A was observed as she texted on her cellphone while she fed resident #65. CNA A did not apply any hand sanitizer while she fed resident #65. In an interview on 06/24/25 at 12:40 PM, CNA A stated she did not normally use her phone while she fed a resident, because staff were not supposed to have phones out when they fed residents. She stated she texted another staff member about the transportation van. CNA A stated she did not use hand sanitizer after she used her phone before she assisted resident #65. CNA A stated a risk of not using hand sanitizer was cross contamination. In an interview on 06/26/25 at 1:22 PM, the DON stated staff were expected to wash their hands or sanitize properly before feeding the residents. The DON stated staff are not allowed to use their phones while feeding the residents. The DON stated the risk of CNA A texting while feeding a resident would cause choking. Record review of the facility's undated policy titled, Hand Hygiene reflected the following: You may use alcohol-based hand cleaner or soap/water for the following .Before and after assisting a resident with meals . Record review of the facility's undated policy titled, Eating, Assistive/Complete reflected the following: (15. Constant supervision will be provided throughout the meal for complete feeders. Close supervision will be provided throughout the meal for complete feeders. Close supervision will be provided throughout the meal for assistive feeders).

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 1 of 4 residents (Resident #1) reviewed for reporting, in that: The facility failed to report the allegation of neglect for Resident #1 to the State Agency within required reporting timeframes. This failure could place residents at risk ongoing abuse or neglect. Findings included: Review of Resident #1's face sheet dated 05/13/2025 revealed an [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Admitting diagnosis of other fracture of lower end of the left femur, subsequent encounter for closed fracture with routine Healing (bone breaks, but there is no break in the skin over the injury; cast change or removal of external or internal fixation device, medication adjustment, other aftercare, and follow-up injury treatment); unspecified dementia mild, with other behavioral disturbances (dementia that doesn't fit into a specific type by has a mild severity and presents with other behavioral issues); and essential (primary) hypertension (high blood pressure where the underlying cause is unknown). Record review of Resident #1's Annual MDS (Minimum Data Sheet) dated 04/12/2025 revealed Resident #1 BIMS (Brief Interview for Mental Status) score was noted to be 02/15 indicating severe cognitive impairment. Resident #1 required total assistance with all ADL care including bed mobility and transfers. Record review of Resident #1's progress notes revealed the following: * 01/09/2025 revealed Resident #1 c/o pain on the left knee to LVN A and upon assessment the knee looks swollen. 2 Tylenol 325 mg administered for pain, vital signs taken, physician was notified and gave an order for x-ray on the left knee. Order updated in the system and waiting for the technician. DON and ADON were notified. *01/10/2025 results of x-ray received and sent to NP for review. Orders given for Resident #1 to be transferred to hospital for further evaluation. *01/15/2025, Resident #1 returned to facility from hospital with diagnosis of unspecified fracture of head of left femur with unremovable dressing, following a surgery. Record review of Resident #1's x-ray results taken on 01/10/2025 of the left knee by [company] in-house at the facility revealed a chronic fracture of distal femur (a fracture of the lower part of the thigh bone that has not healed properly or is failing to heal after a significant period of time). Record Review of Resident #1's x-ray results taken on 01/10/2025 of the left hip, left knee and left femur by [name] Hospital revealed acute oblique distal left femoral diaphyseal fracture with extension to patellar articulating surface (the patient has a new broken bone in the thigh which runs at an angle across the bone, located near the end of the femur, in the main shaft of the femur, and extends into the knee joint). Surgical procedure that was performed was a ORIF (Open Reduction and Internal Fixation) of left femur (surgical procedure used to repair a broken femur (thigh bone), specifically in the left leg). On 05/13/2025 at 3:45 pm interview with DON revealed when Resident #1 complained to nurse about her knee hurting, the facility contacted the physician and obtained orders to complete an x-ray. Resident #1 was sent to hospital for an evaluation. DON revealed the x-ray report states it was due to her age and Osteopenia. The fracture of her left femur was chronic, not acute. DON revealed that this was why the incident was not reported to the state. On 05/13/2025 at 4:00 pm interview with ADM revealed that he did not complete the Provider Investigation Report due to the changes in the Long-Term Care Provider Letter dated 08/29/2024 r/t reporting incidents. ADM revealed Resident #1 was diagnosed with an acute fracture of the femur which could be noted as an old fracture that had not healed. ADM referred to the statement in the letter and stated : A NF is not required to report to CII: o serious bodily injury or other injury that is NOT suspicious or of unknown source and that is NOT related to abuse; serious bodily injury or other injury that is NOT suspicious or of unknown source and that is NOT related to neglect, exploitation, or mistreatment. Record review of the facility's Abuse policy revised 03/29/2018 revealed in part: Facility Employees must report allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/19. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Review of Provider Letter PL 2024 - 14, issued 08/29/2024, revealed, .required reporting timeframes .neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that results in serious bodily injury .immediately, but not later than two hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury but involves .neglect, exploitation, a missing resident, misappropriation of resident property, drug theft, fire, emergency situations that pose a threat to resident health and safety, a death under unusual circumstances, and communicable disease situation that pose a threat to resident health and safety.

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 3 residents (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for discharge planning. -The facility failed to provide or document sufficient preparation for an orderly discharge of Resident #1 to a private residence and Resident #2 and Resident #3 to a nursing facility. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge, which could cause physical and emotional harm. Findings included: Record review of Resident #1's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: vascular dementia (loss of memory and thinking caused by a stroke), depressive episodes (mood disorder), heart disease, cerebral infarction (stroke), chronic kidney disease, hemiplegia and hemiparesis (partial paralysis), and muscle weakness. Record review of Resident #1's Admission MDS assessment, dated 09/02/24, reflected the resident had a BIMS score of 9 which indicated moderate cognitive impairment. The MDS assessment reflected Resident #1 was independent with most ADLs; however, the resident required moderate assistance and/or supervision with eating, hygiene, and upper body dressing. Further review reflected Resident #1 had a behavior of rejecting evaluation or care. Record review of Resident #1's care plan, dated 08/28/24, did not reflect the resident's preferences for discharge planning. Record review of Resident #1's discharge summary, dated 09/16/24, reflected in part the following: [Resident #1's] Date of discharge: 09/16/24; Condition on discharge: Good; discharged to: Home-with home health. Record review of Resident #1's progress note, dated 09/13/24 at 1:29 PM by the SW reflected: DC Date: 9/15/24 DC Time: Unknown DC Destination: [private residential address] w/[RP] PCP : The [RP] will schedule an appointment with [personal MD] on 9/16/24. Home Health: [Home Health Agency] Transportation: Arranged by the [RP] Record review of Resident #1's progress note, dated 09/12/24 at 4:56 PM by LVN A reflected: NOMNC received from Managed Care with LCD of 9/14/2024. [RP] not in [Resident#1's] room, 3 calls placed with no answer. Voicemail left informing [RP] of NOMNC with LCD right to appeal, informed that appeal must be filed by noon on 09/13/2024 to number [PHONE NUMBER], also informed that if she does not DC on 9/15/2024 financial liability begins for [Resident #1] on that date. Since unable to contact via phone, NOMNC also emailed to email address on file. Record review of Resident #2's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: dementia (loss of memory and thinking), hemiplegia and hemiparesis (partial paralysis), type II diabetes, hypertension (high blood pressure), heart disease, and non-traumatic subarachnoid hemorrhage (brain bleed). Record review of Resident #2's Quarterly MDS assessment, dated 09/17/24, reflected the resident's BIMS score was 0 which indicated severe cognitive impairment. The MDS assessment reflected Resident #2 required maximal assistance with most ADLs. Further review reflected Resident #2 had a behavior of wandering. Record review of Resident #2's care plan, dated 06/18/24, did not reflect the resident's preferences for discharge planning. Record review of Resident #2's discharge summary, dated 09/19/24, reflected in part the following: [Resident #2's] Date of discharge: 09/19/24; Condition on discharge: Good; discharged to: Other staffed facility. Record review of Resident #2's progress note, dated 08/20/24 at 01:30 PM by the SW reflected: The social worker (SW ), the Business Office Manager (BOM ) & the Administrator spoke to the daughter, [RP] on the phone & in person. The SW, the BOM & the Admin spoke to [RP] that the [Resident #2] was five days past the DC date. [RP] was informed that corporate has issued a hard DC date for 8/23/24. The SW, the BOM, & the Administrator discussed multiple options with [RP] regarding [Resident #2] safe DC. However, [RP] declined all options & refused to cooperate with the facility for the [Resident #1's] DC. Record review of Resident #2's progress note, dated 09/11/24 at 4:17 PM by the SW reflected: [SW] spoke to [RP] at [phone number]. The SW informed [RP] that [resource agency] found three group homes at [three other cities] The SW offered those choices to [RP]. [RP] stated those locations were 'too far' [sic] for [Resident #2]. Record review of Resident #2's progress note, dated 09/19/24 at 03:31 PM by the SW reflected: DC Date: 9/20/24 DC Time: Between 12 PM-2 PM DC Destination: [Nursing Facility] Transportation: Arranged by the receiving facility Family Member Informed? Yes; Left a VM for [RP] Record review of Resident #2's progress notes reflected it was not documented that the SW informed Resident #2's RP of nursing facilities that accepted her, only group homes. Record review of Resident #3's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: Parkinson's Disease (nervous system disorder), cerebral aneurysm (bulging blood vessel in brain), major depressive disorder (mood disorder), and osteoporosis (weak bones). Record review of Resident #3's Annual MDS assessment, dated 08/02/24, reflected the resident's BIMS score was 10 which indicated moderate cognitive impairment. The MDS assessment reflected Resident #3 was independent with all ADLs. Further review reflected Resident #3 did not have any behaviors. Record review of Resident #3's care plan, dated 06/18/24, did not reflect the resident's preferences for discharge planning. Record review of Resident #3's discharge summary, dated 08/26/24, reflected in part the following: [Resident #3's] Date of discharge: 08/26/24; Condition on discharge: Good; discharged to: Other staffed facility. Record review of Resident #3's progress note, dated 08/21/24 at 10:49 AM by the SW reflected: As per the [RP] request, a referral was sent & received by [Nursing Facility]. During an interview on 09/26/24 at 5:15 PM, Resident #2's RP stated the resident discharged on [DATE]. The RP stated the facility accepted Resident #1 without her having insurance in place then later admitted it was a mistake. The RP stated once the facility realized she was unable to get approved for Medicare, they began harassing her about picking the resident up; however, she explained that she was unable to care for Resident #2 at her home. The RP stated she had multiple conversations with the SW about different facility options, but they were all too far from the family or they were group homes, which she did not feel was a good fit for the resident due to her medical condition. The RP stated she felt rushed to find placement for Resident #1 because the facility wanted her to leave quickly because they were not getting paid. The RP stated before she could decide, the SW called her one day and told her to come to the facility because they were preparing to transfer Resident #2 to a different facility. The RP stated the facility chose a different nursing facility without her knowledge and it was an hour away from the family. The RP stated she felt like she had no other choice but to allow the facility to transfer Resident #2 to the facility they had chosen. The RP stated she had a care plan meeting with the facility that morning before Resident #2 discharged and they discussed her services/care. The RP stated the SW also talked about Resident #2's discharge, but the SW did not state that Resident #2 was discharging on that day, so it was a surprise when she got the call to come help move the resident later that day. During an interview on 09/26/24 at 05:21 PM, the SW stated she worked at the facility since 08/01/24. The SW stated discharge planning starts the day a resident admits to the facility. The SW stated the residents'/RP's preferences and residents' care needs were considered when planning, and clinical notes and any changes were documented throughout the residents' stay. The SW stated she knew Resident #1 from previous facilities, and they did not have a good relationship, so she decided to work in the background and not deal directly with the resident/RP. The SW stated Resident #1 had a history of being homeless and used the local hospitals and nursing facilities as shelter. The SW stated the facility discussed discharging Resident #1 because she was refusing care and was not participating in therapy, and during the planning, the insurance issued a NOMNC. The SW stated Resident #1's RP was informed about the NOMNC and told that Resident #1 had a discharge date on 09/15/24. The SW stated Resident #1/RP gave a private residence as the discharge location, and she set up home health services at that address through an agency that Resident #1 previously used. The SW stated although Resident #1 was known to be homeless, she accepted the address provided and confirmed that it was a house through an online map search. The SW initially stated she confirmed with the home health agency that they had the same address on file, then later stated they refused to disclose the address they had on file. The SW stated Resident #1/RP refused an appeal and was okay with leaving on 09/15/24. The SW stated Resident #2/RP had been issued a 30-day notice before she started working at the facility and she was working hard with the family to find safe placement; however, the RP was not cooperating. The SW stated she offered the RP several options and she refused them. The SW stated Resident #2 had a care plan meeting on 09/19/24 and a representative from a nursing facility happened to be in the building and was invited to be a part of the meeting. The SW stated she presented that nursing facility as an option to the RP and the RP stated she was okay with it. The SW stated there were 2 other nursing facilities that accepted Resident #2 and those were also presented to the RP. During an interview on 09/27/24 at 09:30 AM with the Administrator and the DON, the Administrator stated he had been at the facility for about 2 weeks and had not been a part of the discharge planning for Resident #1, #2, or #3. The Administrator stated the expectation for discharge planning was for the SW to remain in close contact with the residents/families to ensure involvement during the entire process. The DON stated she had only been at the facility for about 2 weeks also. The DON stated she was aware of Resident #1's situation because she was discharged on the day she started working; however, she was not involved in Resident #2's discharge and was not at the facility when Resident #3 discharged . The DON stated the facility's hope was that all residents were being truthful when providing them with the discharge addresses as they cannot demand proof or follow each resident to the locations. The DON stated each discharge process was case-by-case and if a resident was known to be homeless, she would take extra steps to ensure they were discharging to a safe location such as confirming last known address with previous providers, and she was not sure if the SW did that. The DON stated for all residents, the facility was responsible for collecting information from the residents/families to set up services to ensure clinical needs continue to be met. The DON stated the risk of not having a proper discharge planning meeting with the resident/RP could be an unsafe discharge and the resident's clinical needs not being met. During an interview on 09/27/24 at 10:48 AM, Resident #3's RP stated the resident discharged to a different skilled nursing facility on 08/26/24 due to her being dissatisfied with the care Resident #3 was receiving. The RP stated she was able to choose the new nursing facility; however, the discharge process was not good. The RP stated the SW did not communicate with her well during the process and she did not have a discharge meeting to go over transition process, medications, or other clinical information to provide to the new facility. The RP stated because of this, there were issues with Resident #3's medication orders when they arrived. During further interview on 09/27/24 at 01:22 PM with the SW, she stated she was a part of Resident #3's discharge process. The SW stated Resident #3's RP was upset about the resident not being showered at the times she liked, so she decided to move her to a nursing facility that the RP chose herself. The SW stated she sent out the referral and the nursing facility accepted Resident #3. The SW stated Resident #3 discharged from the facility on 08/26/24 and her RP transported her to the new facility. The SW stated she was in communication with the RP and followed the facility's discharge procedures. The SW stated they don't always have a sit-down discharge meeting, but she remained in contact at least via phone or email with the families. The SW stated the risk of discharging residents without proper planning could have a negative effect on their health and psychosocial status . During an interview on 09/27/24 at 06:15 PM, Resident #1's RP stated she was informed on 09/13/24 that the resident was being discharged due to her not wanting to socialize with anyone or take her medication because she did not trust the facility. The RP was informed that Resident #1 had to leave the facility on 09/15/24. The RP stated she was offered the option to appeal but declined due to being unhappy with the care Resident #1 was receiving and how rude the staff were. The RP stated the SW did not want to have any direct contact with her or Resident #1 from previous encounters, so she received all discharge information from another staff. The RP stated she provided the facility with a discharge address; however, they ended up at a different address. The RP stated she never contacted the facility to update ethe address and she never heard anything from a home health agency. She stated Resident #1 was currently living with another family member. Review of the facility's policy title Discharge Planning Process Policy, revised 11/28/20216, revealed in part the following: Nursing facility must complete discharge planning when you anticipate discharging a resident to a private residence, another nursing facility or skilled nursing facility, or another type of residential facility. Discharge Planning includes: A) Assessing the resident's continuing care needs, including: 1. Consideration of the resident's and family/caregiver's preferences for care; 2. How services will be accessed; . B) Developing an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility, including resident and family/caregiver education needs. .

Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on a resident's discharge goals and allowed the resident to be an active partner in the transition and development of a discharge plan for 3 residents (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for discharge planning. - The facility failed to prepare and involve Residents #1, #2, and #3 and responsible parties in an effective discharge planning process. This failure could place all residents at risk of not being an active part in their goals and discharge planning process, which could result in an unsafe discharge, and decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: vascular dementia (loss of memory and thinking caused by a stroke), depressive episodes (mood disorder), heart disease, cerebral infarction (stroke), chronic kidney disease, hemiplegia and hemiparesis (partial paralysis), and muscle weakness. Record review of Resident #1's Admission MDS assessment, dated 09/02/24, reflected the resident had a BIMS score of 9 which indicated moderate cognitive impairment. The MDS assessment reflected Resident #1 was independent with most ADLs; however, the resident required moderate assistance and/or supervision with eating, hygiene, and upper body dressing. Further review reflected Resident #1 had a behavior of rejecting evaluation or care. Record review of Resident #1's care plan, dated 08/28/24, did not reflect the resident's preferences for discharge planning. Record review of Resident #1's discharge summary, dated 09/16/24, reflected in part the following: [Resident #1's] Date of discharge: 09/16/24; Condition on discharge: Good; discharged to: Home-with home health. Record review of Resident #1's progress note, dated 09/13/24 at 1:29 PM by the SW reflected: DC Date: 9/15/24 DC Time: Unknown DC Destination: [private residential address] w/[RP] PCP : The [RP] will schedule an appointment with [personal MD] on 9/16/24. Home Health: [Home Health Agency] Transportation: Arranged by the [RP] Record review of Resident #1's progress note, dated 09/12/24 at 4:56 PM by LVN A reflected: NOMNC received from Managed Care with LCD of 9/14/2024. [RP] not in [Resident#1's] room, 3 calls placed with no answer. Voicemail left informing [RP] of NOMNC with LCD right to appeal, informed that appeal must be filed by noon on 09/13/2024 to number [PHONE NUMBER], also informed that if she does not DC on 9/15/2024 financial liability begins for [Resident #1] on that date. Since unable to contact via phone, NOMNC also emailed to email address on file. Record review of Resident #2's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: dementia (loss of memory and thinking), hemiplegia and hemiparesis (partial paralysis), type II diabetes, hypertension (high blood pressure), heart disease, and non-traumatic subarachnoid hemorrhage (brain bleed). Record review of Resident #2's Quarterly MDS assessment, dated 09/17/24, reflected the resident's BIMS score was 0 which indicated severe cognitive impairment. The MDS assessment reflected Resident #2 required maximal assistance with most ADLs. Further review reflected Resident #2 had a behavior of wandering. Record review of Resident #2's care plan, dated 06/18/24, did not reflect the resident's preferences for discharge planning. Record review of Resident #2's discharge summary, dated 09/19/24, reflected in part the following: [Resident #2's] Date of discharge: 09/19/24; Condition on discharge: Good; discharged to: Other staffed facility. Record review of Resident #2's progress note, dated 08/20/24 at 01:30 PM by the SW reflected: The social worker (SW ), the Business Office Manager (BOM ) & the Administrator spoke to the daughter, [RP] on the phone & in person. The SW, the BOM & the Admin spoke to [RP] that the [Resident #2] was five days past the DC date. [RP] was informed that corporate has issued a hard DC date for 8/23/24. The SW, the BOM, & the Administrator discussed multiple options with [RP] regarding [Resident #2] safe DC. However, [RP] declined all options & refused to cooperate with the facility for the [Resident #1's] DC. Record review of Resident #2's progress note, dated 09/11/24 at 4:17 PM by the SW reflected: [SW] spoke to [RP] at [phone number]. The SW informed [RP] that [resource agency] found three group homes at [three other cities] The SW offered those choices to [RP]. [RP] stated those locations were 'too far' [sic] for [Resident #2]. Record review of Resident #2's progress note, dated 09/19/24 at 03:31 PM by the SW reflected: DC Date: 9/20/24 DC Time: Between 12 PM-2 PM DC Destination: [Nursing Facility] Transportation: Arranged by the receiving facility Family Member Informed? Yes; Left a VM for [RP] Record review of Resident #2's progress notes reflected it was not documented that the SW informed Resident #2's RP of nursing facilities that accepted her, only group homes. Record review of Resident #3's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: Parkinson's Disease (nervous system disorder), cerebral aneurysm (bulging blood vessel in brain), major depressive disorder (mood disorder), and osteoporosis (weak bones). Record review of Resident #3's Annual MDS assessment, dated 08/02/24, reflected the resident's BIMS score was 10 which indicated moderate cognitive impairment. The MDS assessment reflected Resident #3 was independent with all ADLs. Further review reflected Resident #3 did not have any behaviors. Record review of Resident #3's care plan, dated 06/18/24, did not reflect the resident's preferences for discharge planning. Record review of Resident #3's discharge summary, dated 08/26/24, reflected in part the following: [Resident #3's] Date of discharge: 08/26/24; Condition on discharge: Good; discharged to: Other staffed facility. Record review of Resident #3's progress note, dated 08/21/24 at 10:49 AM by the SW reflected: As per the [RP] request, a referral was sent & received by [Nursing Facility]. During an interview on 09/26/24 at 5:15 PM, Resident #2's RP stated the resident discharged on [DATE]. The RP stated the facility accepted Resident #1 without her having insurance in place then later admitted it was a mistake. The RP stated once the facility realized she was unable to get approved for Medicare, they began harassing her about picking the resident up; however, she explained that she was unable to care for Resident #2 at her home. The RP stated she had multiple conversations with the SW about different facility options, but they were all too far from the family or they were group homes, which she did not feel was a good fit for the resident due to her medical condition. The RP stated she felt rushed to find placement for Resident #1 because the facility wanted her to leave quickly because they were not getting paid. The RP stated before she could decide, the SW called her one day and told her to come to the facility because they were preparing to transfer Resident #2 to a different facility. The RP stated the facility chose a different nursing facility without her knowledge and it was an hour away from the family. The RP stated she felt like she had no other choice but to allow the facility to transfer Resident #2 to the facility they had chosen. The RP stated she had a care plan meeting with the facility that morning before Resident #2 discharged and they discussed her services/care. The RP stated the SW also talked about Resident #2's discharge, but the SW did not state that Resident #2 was discharging on that day, so it was a surprise when she got the call to come help move the resident later that day. During an interview on 09/26/24 at 05:21 PM, the SW stated she worked at the facility since 08/01/24. The SW stated discharge planning starts the day a resident admits to the facility. The SW stated the residents'/RP's preferences and residents' care needs were considered when planning, and clinical notes and any changes were documented throughout the residents' stay. The SW stated she knew Resident #1 from previous facilities, and they did not have a good relationship, so she decided to work in the background and not deal directly with the resident/RP. The SW stated Resident #1 had a history of being homeless and used the local hospitals and nursing facilities as shelter. The SW stated the facility discussed discharging Resident #1 because she was refusing care and was not participating in therapy, and during the planning, the insurance issued a NOMNC. The SW stated Resident #1's RP was informed about the NOMNC and told that Resident #1 had a discharge date on 09/15/24. The SW stated Resident #1/RP gave a private residence as the discharge location, and she set up home health services at that address through an agency that Resident #1 previously used. The SW stated although Resident #1 was known to be homeless, she accepted the address provided and confirmed that it was a house through an online map search. The SW initially stated she confirmed with the home health agency that they had the same address on file, then later stated they refused to disclose the address they had on file. The SW stated Resident #1/RP refused an appeal and was okay with leaving on 09/15/24. The SW stated Resident #2/RP had been issued a 30-day notice before she started working at the facility and she was working hard with the family to find safe placement; however, the RP was not cooperating. The SW stated she offered the RP several options and she refused them. The SW stated Resident #2 had a care plan meeting on 09/19/24 and a representative from a nursing facility happened to be in the building and was invited to be a part of the meeting. The SW stated she presented that nursing facility as an option to the RP and the RP stated she was okay with it. The SW stated there were 2 other nursing facilities that accepted Resident #2 and those were also presented to the RP. During an interview on 09/27/24 at 09:30 AM with the Administrator and the DON, the Administrator stated he had been at the facility for about 2 weeks and had not been a part of the discharge planning for Resident #1, #2, or #3. The Administrator stated the expectation for discharge planning was for the SW to remain in close contact with the residents/families to ensure involvement during the entire process. The DON stated she had only been at the facility for about 2 weeks also. The DON stated she was aware of Resident #1's situation because she was discharged on the day she started working; however, she was not involved in Resident #2's discharge and was not at the facility when Resident #3 discharged . The DON stated the facility's hope was that all residents were being truthful when providing them with the discharge addresses as they cannot demand proof or follow each resident to the locations. The DON stated each discharge process was case-by-case and if a resident was known to be homeless, she would take extra steps to ensure they were discharging to a safe location such as confirming last known address with previous providers, and she was not sure if the SW did that. The DON stated for all residents, the facility was responsible for collecting information from the residents/families to set up services to ensure clinical needs continue to be met. The DON stated the risk of not having a proper discharge planning meeting with the resident/RP could be an unsafe discharge and the resident's clinical needs not being met. During an interview on 09/27/24 at 10:48 AM, Resident #3's RP stated the resident discharged to a different skilled nursing facility on 08/26/24 due to her being dissatisfied with the care Resident #3 was receiving. The RP stated she was able to choose the new nursing facility; however, the discharge process was not good. The RP stated the SW did not communicate with her well during the process and she did not have a discharge meeting to go over transition process, medications, or other clinical information to provide to the new facility. The RP stated because of this, there were issues with Resident #3's medication orders when they arrived. During further interview on 09/27/24 at 01:22 PM with the SW, she stated she was a part of Resident #3's discharge process. The SW stated Resident #3's RP was upset about the resident not being showered at the times she liked, so she decided to move her to a nursing facility that the RP chose herself. The SW stated she sent out the referral and the nursing facility accepted Resident #3. The SW stated Resident #3 discharged from the facility on 08/26/24 and her RP transported her to the new facility. The SW stated she was in communication with the RP and followed the facility's discharge procedures. The SW stated they don't always have a sit-down discharge meeting, but she remained in contact at least via phone or email with the families. The SW stated the risk of discharging residents without proper planning could have a negative effect on their health and psychosocial status . During an interview on 09/27/24 at 06:15 PM, Resident #1's RP stated she was informed on 09/13/24 that the resident was being discharged due to her not wanting to socialize with anyone or take her medication because she did not trust the facility. The RP was informed that Resident #1 had to leave the facility on 09/15/24. The RP stated she was offered the option to appeal but declined due to being unhappy with the care Resident #1 was receiving and how rude the staff were. The RP stated the SW did not want to have any direct contact with her or Resident #1 from previous encounters, so she received all discharge information from another staff. The RP stated she provided the facility with a discharge address; however, they ended up at a different address. The RP stated she never contacted the facility to update ethe address and she never heard anything from a home health agency. She stated Resident #1 was currently living with another family member. Review of the facility's policy title Discharge Planning Process Policy, revised 11/28/20216, revealed in part the following: Nursing facility must complete discharge planning when you anticipate discharging a resident to a private residence, another nursing facility or skilled nursing facility, or another type of residential facility. Discharge Planning includes: A) Assessing the resident's continuing care needs, including: 1. Consideration of the resident's and family/caregiver's preferences for care; 2. How services will be accessed; . B) Developing an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility, including resident and family/caregiver education needs. .

Based on observation, interview, and record review, the facility failed to identify a Grievance Official who was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, and leading any necessary investigations by the facility for 1 of (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure the Grievance Official was aware of a grievance for Resident #1. The Grievance Official failed to investigate a grievance for Resident #1. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Review of Resident #1's MDS quarterly assessment, dated 07/26/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 3. Her cognitive status was severely impaired. Her diagnoses included Non-Alzheimer's Dementia (decline in cognitive abilities that can affect a person's ability to think, remember, and make decisions). Review of Resident #1's Grievance Tracking Log for 08/15/24 reflected: Resident #1: Inappropriate behavior from a resident, DON notified, grievance addressed on 08/16/24. Review of Resident #1's Grievance Form, dated 08/15/24, and filled out by the SW reflected: Resident #1's Representative reported to the SW, that on 7/31, she had gone to visit Resident #1 in the Memory Care Unit. Out of nowhere, another resident sat on her lap. Resident #1's Representative had to sit there watching them since no one was around to intervene and was getting agitated with another resident sitting on her lap. Corrective Action: There will be 24-hour staff available to monitor the residents, and staff will also be present in the hallway. An observation and interview on 09/05/24 at 5:00 PM in the Memory Care Unit revealed Resident #1 was sitting on the sofa close to other residents. She said she was doing well and did not have issues with other residents. There were three other staff present. An interview on 09/05/24 at 4:20 PM with the SW, revealed it was reported to her by the Representative for Resident #1 that she had to keep watch in the Memory Care Unit because an unknown resident sat on Resident #1's lap. The SW said she told the DON and the Administrator about the grievance. She said she put an intervention in place for staff to be available 24 hours per day, but that was already required in the Memory Care unit . She said no other interventions or investigation was completed . She said she did not know who the other resident was or which day for sure that the incident occurred. An interview on 09/05/24 at 4:26 PM with the Representative for Resident #1 revealed on 08/15/24, she was visiting the resident. She said she told the SW there was a woman that kept trying to sit on Resident #1's lap. She said she did not know the exact day and she did not know who the other resident was. She said the resident wanted to sit in Resident #1's seat. She said the staff were somewhere down the hallway attending to another resident. An interview on 09/05/24 at 5:10 PM with the DON revealed for the grievance process, anyone could report it and the SW would do the investigation. The DON said he did not know who the grievance official was, and he was not notified about a grievance for Resident #1. The DON said the SW was responsible for ensuring all grievances were addressed and she was supposed to report them to the DON and Administrator. The DON said he should oversee the grievances daily and grievances were supposed to be reviewed during the morning stand-up meeting . He said there should not be an instance when he was not notified about a grievance related to nursing. He said Resident #1 was going to be assessed, staff were going to be interviewed and that there was going to be a meeting with Resident #1 and her Representative. He said there were not any residents in the Memory Care Unit who would sit on the laps of other residents. He said he did not know for sure what day the incident occurred. The DON said the resident could be negatively affected if their grievance was not addressed. An interview on 09/05/24 at 5:25 PM with the Administrator revealed for the grievance process a complaint or concern would be reported and the facility was to resolve it as soon as possible. He said the SW was to notify him as the Grievance Official of all grievances. He said the grievance could involve all departments, but that he was not made aware of the grievance for Resident #1. He said it was his responsibility to review all grievances and make sure they were addressed. Review of the facility policy for Grievances, revised 11/02/2016, reflected: .2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: o Oversee the grievance process o Receive and track grievances to their conclusion o Lead any necessary investigations by the facility o Maintain the confidentiality of all information associated with grievances o Issue written grievance decisions to the resident o Coordinate with state and federal agencies as necessary .

Based on observation, interview 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 1 (Resident #35) of 8 residents reviewed for pharmacy services. The facility failed to obtain the routine scheduled pain medication for Resident #35, who was to receive it every 4 hours, from her hospice company. Resident #35 missed 7 doses of her scheduled pain medication placing her at risk for unnecessary pain. The medications were received after surveyor inquiry. This failure could place residents who require pain medication at risk of suffering pain due to lack of medication availability. Findings included: Record review of Resident #35's Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed her diagnoses included cancer, cancer related pain, hypertension (high blood pressure), depression, and anxiety. The MDS also reflected she had severe cognitive impairment, she ambulated with a walker, received scheduled and PRN pain medication, and experienced occasional pain. Record review of Resident #35's Care Plan revealed an entry dated 07/11/23 which reflected: Focus: The resident requires pain management chronic pain r/t Malignant neoplasm [cancer] of .bronchus or lung, bil [bilateral-both sides] shoulder pain .Interventions/Tasks: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition Record review of Resident #35's Order Summary Report dated 05/08/24 revealed it included the following orders: Oxycodone HCL [narcotic pain medication] Oral Tablet 30 mg give 2 tablet by mouth every 4 hours for pain . Methocarbamol [muscle relaxer] Oral Tablet 500 mg give 2 tablet by mouth three times a day related to neoplasm related pain . Lidocaine external patch [a pain relieving patch] 4% apply to bilateral shoulders topically in the morning for pain wear for 12 hours on then 12 hours off and remove per schedule The orders also revealed orders for Morphine sulfate (narcotic pain medication) 20 mg/ml 0.25-1 ml every hour as needed for pain. Record review of Resident #35's MAR dated May 2024 revealed an entry for Oxycodone HCL Oral Tablet 30 mg give 2 tablets by mouth every 4 hours as needed for pain. The doses were scheduled to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. The doses were initialed as administered from 05/01/24 through 05/06/24 at 12:00 PM. The doses scheduled at the following dates/times were coded with a 9 indicating to see the nurses notes: 05/06/24 at 4:00 PM 05/06/24 at 8:00 PM 05/07/24 at 12:00 AM 05/07/24 at 4:00 AM 05/07/24 at 8:00 AM 05/07/24 at 12:00 PM 05/07/24 at 4:00 PM The MAR reflected Resident #35 had received morphine for pain management between 05/06/24 and 05/08/24. Record review of Resident #35's nursing Progress Notes revealed the following entries: 05/06/24 at 1:05 PM: Resident out of Oxycodone. Hospice notified reminded and promised to bring ASAP Entered by LVN D 05/06/24 at 4:47 PM: oxyCODONE HCl Oral Tablet 30 MG Give 2 tablet by mouth every 4 hours for Pain pending delivery Entered by LVN D. 05/06/24 at 11:24 PM: oxyCODONE HCl Oral Tablet 30 MG Give 2 tablet by mouth every 4 hours for Pain pending delivery Entered by LVN H. 05/07/24 at 3:17 AM: oxyCODONE HCl Oral Tablet 30 MG Give 2 tablet by mouth every 4 hours for Pain Oxycodone is on order, waiting for delivery of the medicine [sic]. Entered by LVN H. 05/07/24 at 7:25 AM: oxyCODONE HCl Oral Tablet 30 MG Give 2 tablet by mouth every 4 hours for Pain pending delivery. Entered by LVN D. 05/7/24 at 10:57 AM: [Hospice company] called in regard to resident's pain medications and notified that resident is out of medication at this time, response is that the nurse will called and medication will be sent as soon as possible Entered by DON. 05/07/24 11:42 AM: oxyCODONE HCl Oral Tablet 30 MG Give 2 tablet by mouth every 4 hours for Pain pending delivery. Entered by LVN D. Observation and interview on 05/07/24 at 10:23 AM revealed Resident #35 ambulating in the hall using her walker, she entered her room and requested to talk. Resident #35 stated she was upset with her hospice company because they have not come through with my medications for 24 hours. She stated she was missing her oxycodone. She stated she knew her roommate received medications on time from a different hospice company and she was frustrated with her company. Resident #35 stated she was receiving morphine for pain which was effective but she preferred to take the oxycodone and use her morphine for breakthrough pain. Resident #35 stated she had spoken with the DON on 5/6/24 about it and he was looking into it. She requested this surveyor to check on it for her and get the DON. Interview on 05/07/24 at 10:36 AM with the DON stated he was the acting DON for the facility and had only been there for five days. He stated the facility's usual DON was on leave due to a family emergency. When asked about Resident #35's pain medications, the DON entered her room and told her, I just checked on you this morning, you said you had a good night. Resident #35 stated she did but was upset that the hospice company had not delivered her medications yet. The DON stated they called the hospice company regarding the medications on 5/6/24 and he was not aware the medications still had not been delivered. The DON stated he would look into the situation. After leaving the room, the DON stated, after speaking with Resident #35 earlier that morning, he thought the medications had arrived and he would check her medication cart. Observation and interview on 05/07/24 at 1:20 PM revealed Resident #35 lying in bed with her eyes closed and opened them upon knocking. She stated she had received some morphine for her pain and wanted to go to sleep. She declined to discuss her pain scale. Interview on 05/07/24 at 1:25 PM with LVN D and the ADON, LVN D stated Resident #35 had run out of her oxycodone during her shift on 5/6/24. She stated she called the hospice company and was told they were working on it. She stated that was her first shift caring for her and she had been told by a previous nurse the medications had been ordered. She stated she believed either LVN E or LVN I had previously contacted the hospice company about the medications. LVN D stated she did not call the pharmacy because the hospice company was responsible for delivering the medications. She stated she did not call the resident's physician because, It's still a hospice order. She stated the resident was receiving other pain medications including morphine which was controlling her pain. LVN D stated Resident #35 rated her pain the same way whether or not she received her oxycodone and they continued to assess her. The ADON stated they did not carry oxycodone in the facility's Ekit [emergency kit of medications kept by the facility]. LVN D stated medications were usually reordered when they reached the last row on the medication card. If a resident was on hospice, they called the provider. If a resident was not on hospice, they medications were reordered through their computer software or the pharmacy could be called. The ADON stated they did not call her physician because, they would just tell us to call hospice. When asked if that was the case when a resident missed any dose of a scheduled medication, the ADON replied, I see your point and stated the physician should be called if a medication was not available and so that they would know doses were missed and could provide guidance. LVN D stated the risk for missing pain medication doses included increased pain and a change in condition. Interview on 05/07/24 at 1:45 PM, LVN E stated she had previously cared for Resident #35 but had not seen her since the previous week as she had transferred to another hall. She stated they did not typically have any issues getting medication refills and she usually called the hospice company before they ran out and they would send them STAT. She stated she had to call the hospice company for Resident #35 a few weeks prior because she was running out of her oxycodone. She stated the resident went through the supply quickly because she was getting them every 4 hours and they only sent about 45 doses at a time. She stated she recalled telling the hospice nurse the last time she saw her she needed to send more and was told she needed to call them every week. She stated the hospice nurse usually checked her cart asked them if they needed any supplies when they came to see the residents. LVN E stated the risk for missing pain medications included the resident suffering severe pain that could not be moderated, and they could possibly need to be sent to the hospital for pain control. She stated she did not typically have issues moderating Resident #35's pain because she was also on muscle relaxers and had PRN medications available. Interview with the DON on 05/07/24 at 2:33 PM, he stated he had spoken with Resident #35's hospice provider again including their Administrator and DON. He stated he also spoke with the NP for Resident #35's attending physician who was in the facility at that time. She told him Resident #35's charge nurse had called and her and she planned to visit the resident. He stated the NP planned to order some from their pharmacy as well. The DON stated he spoke with Resident #35's charge nurse on 5/6/24 and learned she was out of her oxycodone. He stated he had called them as well as the charge nurse and was told they were sending it. He was not aware if had not arrived until speaking with this surveyor and the resident that morning. Interview on 05/07/24 at 2:42 PM, NP J stated she had received a call from Resident #35's charge nurse about her running out of Oxycodone. She stated she had already called the attending physician and ordered some from the facility pharmacy. NP J stated since the medication was ordered from the resident's hospice provider, she would expect the facility staff to contact them initially if a resident ran out of medication. She stated she would expect a call if the hospice company was not providing the ordered medications. NP J stated there were concerns with her ordering the medications because they were controlled and required triplicate prescriptions and there could be a problem with the pharmacy accepting the order if duplicates were sent. NP J stated the risk for residents running out of pain medications included exacerbating the pain making it more difficult to control and they also run the risk of experiencing withdrawal symptoms. She stated, if that were the case, they should have called and let her know. NP J stated, with Resident #35, she was not as concerned because she had other medications available. She stated she was sound asleep and in no distress when she checked on her. She stated she expected the staff to use her as a back-up if they were not getting a proper response from the hospice nurse. Interview with the DON on 05/07/24 at 3:19 PM revealed he spoke with the hospice company again and was told Resident #35's oxycodone had been sent out STAT with an approximate 3 hour delivery window. He stated they never explained why the medication was not sent on 5/6/24 after they were notified. The DON stated medications should be re-ordered a minimum of 72 hours before the last dose. Observation on 05/07/24 at 3:45 PM revealed Resident #35 was ambulating in the hall with her walker following a nurse who was pushing a medication cart. Resident #35 stated she was doing fine and denied complaints. Interview with the Administrator on 05/07/24 at 4:38 PM, he stated the DON had informed him of the events surrounding Resident #35's medications. He stated his usual DON was out of the country for a family emergency and the acting DON had only been there 5 days. The Administrator stated he expected medications to be ordered 5-7 days out whether or not they were dealing with a hospice resident. He stated pain medications could take longer to arrive as they needed special prescriptions. He stated the night nurses were responsible for ensuring medications were reordered and the DON and ADON were responsible for ensuring it was done. He stated anyone could reorder medications at any time. He stated for controlled medications, the pharmacy should be called to see if refills were available and, if not, the physician should be called. The Administrator stated if the resident was on hospice, they hospice nurse should be notified and they were responsible for getting the medications to the facility. He stated he expected the nurses to leave a progress note whenever they were contacting the hospice company. He stated risks of not having pain medications available included increased pain, anxiety, a change in condition and behaviors. Observation and interview on 05/08/24 at 7:13 AM, LVN F stated Resident #35's oxycodone had arrived from hospice the evening before on 5/7/24. Two cards containing 45 doses each were observed in her medication cart. She stated the facility pharmacy had sent a supply as well and it was locked up on another cart. She stated she had received her doses as scheduled beginning at 8:00 PM on 05/07/24. Interview with the DON on 05/07/24 at 7:40 AM, revealed hospice had delivered Resident #35's medications on 5/7/24 at 6:55 PM. Interview on 05/09/24 at 5:57 AM, LVN F stated she had taken care of Resident #35 on 5/3/24 when her hospice nurse had been there to visit the resident. She had also cared for her on 5/5/24. She stated the hospice nurses usually checked the supplies but she could not recall whether they discussed her oxycodone. She stated she still had medications available but went through them quickly because they were administered every 4 hours. She stated they usually ordered the medications when they got down to last section of the card but sooner if they were getting them that often. She stated she did not always document when she communicated with the hospice nurses but would be doing so moving forward. LVN F stated the risk of not having pain medications available included pain getting out of control and the resident could end up in the hospital for relief. Interview on 05/09/24 at 8:09 AM, LVN I stated she had taken care of Resident #35 before she moved out of the secured unit on 05/03/24. She stated they would occasionally run low on medications but had never run out. She stated she made sure to check the supplies when the hospice nurses were there to see if they needed anything from them. She stated she always reordered 7 days ahead especially for pain medications because they could take longer. She did not recall if she had contacted hospice when she worked on 5/3/24 to alert them Resident #35 was within 7 days of running out. She stated the risks for running out of medications included increased pain, behaviors, blood pressure and other symptoms depending on the medications. Interview with the Hospice Administrator for Resident #35's hospice company on 05/09/24 at 9:34 AM, she stated she had spoken with the DON. She stated they were notified on 5/6/24 that Resident #35 needed a medication refill and the message was relayed to Hospice RN G. She stated Hospice RN G acknowledged the message and had stated she had been at the facility on 05/03/24 and asked if anyone needed anything. The Hospice Administrator stated Hospice RN G failed to take care of it. She stated they did not receive another call from the facility until 05/07/24. She stated their office manager sent a message that they were working on it and when she was told the ETA was going to take a while, she called their chaplain to have him drive the medications over as soon as possible. The Hospice Administrator stated the hospice nurses were responsible for checking with the facility nurses to see if they needed anything. She stated they just changed their policy and are now requiring the nurses to personally check the medication stocks for both routine and PRN medications. She stated it was both their's and the facility nurses responsibility to ensure the residents had the medications they needed. She stated the risk for not having pain medications available when needed. She stated, fortunately for Resident #35, she had an abundance of PRN pain medications available. She stated they should have known when Resident #35 was going to run out of mediations as they were scheduled. The Hospice Administrator stated she was checked her call log and could see they received a call on 05/06/24 at 4:08 AM and another at 11:00 AM. Interview with Hospice RN G on 05/09/24 at 10:00 AM, she identified herself as being Resident #35's hospice nurse. She stated she always checked with the charge nurse when she visited her residents to see if they needed anything. She stated she visited on Resident #35 on 05/03/24 and she had just moved to her new room. She stated she did check in with her new nurse but could not recall her name. Hospice RN G stated she did not check to see how many medications Resident #35 had remaining during her visit. She stated her company had just implemented a new process and they were directed to physically check the amount of medications available to the resident. When asked why she wouldn't have known the date Resident #35 would run out of a scheduled medication they provided, Hospice RN G stated they recently changed to a new computer system for ordering medications. She stated the previous system would flag if a reorder was needed but she was not used to the new system yet. She stated she did not get the message when the facility called on 5/6/24 at 4 AM. When she received the call later around 9 or 10 AM, she was working in the field and thought her Administrator had taken care of it. She stated she did not find out until the next day that it was never ordered. She stated she was unaware of Resident #35 missing any other medications, she stated she knew she had morphine available and it had been administered. Hospice RN G stated the risk for not having pain medications available would be withdrawal symptoms if no other pain medications were available for them. Record review of the facility's policy and procedure titled Medication Orders and Receipt Records dated Revised April 2007 reflected: Policy Statement: The facility shall document all medications that it orders and receives. Policy Interpretation and Implementation: 1. The Charge Nurse will maintain the medication order and receipt records .3. The Director of Nursing Services will designate individuals to be responsible for completing medication order/receipt forms. 4. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time Record review of the facility's policy and procedure titled, Hospice Program dated revised July 2017 reflected: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation: 1. Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so .5. Hospice providers who contract with this facility: a. must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and b. are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility .9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: .e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: .b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care; .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure foods in the refrigerator, freezer, and dry storage were properly stored, labeled, and dated. These failures could place residents at risk for food borne illness. Findings included: Observation of the facility's only kitchen on [DATE] at 8:37 AM, revealed the following: -1 opened jar of barbeque sauce in dry storage that had instructions to refrigerate after opening, -1 opened and exposed 25-pound bag of brown sugar, -1 plastic cup filled with peaches in the reach-in refrigerator that was covered but was not labeled or dated, -4 tomatoes in the walk-in refrigerator that appeared to be rotten with visible bruising and open holes in the flesh, -1 opened jar of jalapenos in the walk-in refrigerator that had a black substance around the lid and had a written expiration date of ,d+[DATE], -1 opened container of buttermilk in the walk-in refrigerator that had an expiration date of [DATE], and -1 container of sliced vegetables in the walk-in freezer that was covered but was not labeled or dated. During an interview with the Dietary Director on [DATE] at 8:48AM, she stated she was responsible for ensuring foods which were expired and/or rotten were thrown away. She stated she attempted to check for expired and rotten foods frequently; she said the expired jar of jalapenos, the expired container of buttermilk, and the rotten tomatoes must have been an oversight. The Dietary Director stated whichever staff member was prepping a given food was responsible for labeling any leftovers or prepared foods with the contents and the date in which the food was prepped. She stated the plastic cup filled with peaches and the sliced vegetables should have been labeled and dated. The Dietary Director also stated the barbeque sauce should have been stored in the refrigerator, as there were instructions to refrigerate after opening. The Dietary Director said the facility had ordered a storage bin for the 25-pound bag of brown sugar; however, it had not yet arrived so the bag was being stored as is, even though it had already been opened. The Dietary Director stated the potential risk of not properly labeling, dating, and storing foods included residents being infected with foodborne illnesses. Review of the facility's Food Receiving and Storage policy, dated ,d+[DATE], reflected, .foods shall be received and stored in a manner that complies with safe food handling practices . and .all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) . The Food and Drug Administration Food Code dated 2017 reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Residents #25 and #218) of eighteen residents reviewed for resident rights and dignity. 1. The facility failed to treat Resident #218 with dignity and respect during the discharge process from the facility to the resident's home. 2. The ADON failed to ensure Resident #25 was provided with a dignified dining experience, when she stood over him as she was assisting him in eating a lunch meal service. This failure could place residents at risk for a loss of dignity, decreased self-worth, and decreased self-esteem. Findings included: 1. Review of face sheet dated [DATE] documented Resident #218 was a [AGE] year-old female previously admitted on [DATE] and currently admitted on [DATE] with diagnoses of Alzheimer's disease, Anemia, Type 2 Diabetes Mellitus with diabetic neuropathy, dementia, legal blindness. Review of Resident #218's Comprehensive MDS assessment, dated [DATE], reflected not being completed. MDS Outcome Summary Report revealed it was In Progress. Review of Resident #218's care plan dated as initiated on [DATE] and revised on [DATE] revealed care areas of requested palliative care, a Full Code status, with a terminal prognosis with an elected hospice agency. Telephone interview on [DATE] at 1:43 PM with LVN A revealed she was Resident #218's Charge Nurse on the evening she was discharged home and worked from 6:00 PM to 6:00 AM that night. She stated she had only taken care of her that evening. She stated Resident #218 was fine and breathing when she left the faciity on [DATE] at around 10:30 PM and someone later called and said she was not breathing. LVN A stated Resident #218 was supposed to have been discharged earlier that day, but no one had come to pick her up. She stated she took her vital signs when she left but was not sure if she had entered them in the progress notes. She stated she was contacted by the Administrator on [DATE] and asked to provide a statement. She stated she located Resident #218's vital signs on a piece of paper she had at home. LVN A stated they often wrote resident's vital signs on a scrap piece of paper and later entered the information into the chart. She stated the resident's blood pressure was ,d+[DATE] and her pulse was 59. She said she did not know what her respiratory rate was. She stated she used a wrist blood pressure cuff and denied receiving any error readings. LVN A stated she observed the resident during her initial rounds that evening and noted she was already sleeping and was breathing. She stated she did not wake her to complete a full assessment or vital signs and they rarely did that unless there was a reason for concern, and she had moved on to another hall. She stated, when the transportation people arrived to pick her up, the resident was still sleeping. She moved her to a wheelchair with the assistance of one of the transport staff. She described Resident #218 as drowsy but able to sit up. LVN A stated she probably should have documented her vital signs in the computer. She stated she was unaware of any need to complete an assessment because she had never discharged anyone before. Interview on [DATE] at 2:00 PM with the medical transport representative, the representative revealed two of the medical transport employees on [DATE] went to a 10:30 PM scheduled transport for the discharging Resident #218 back the resident's home. Interview on [DATE] at 2:17 PM with the medical transport representative revealed they sent a wheelchair van with two employees to transport Resident # 218 home from the facility. She stated she was unsure why the van was sent so late that night. She stated she was informed by the transportation staff that they had discovered Resident #218 had expired when they arrived at her family member's home. She stated the trip was approximately a ,d+[DATE]-minute drive. When they arrived, the resident's family member questioned whether she was asleep because the resident was usually up all night and that was when they discovered she was not breathing. She stated the hospice nurse was notified who then arrived at the resident's home and confirmed her death. She stated they transported the resident to the facility for respite care on [DATE] and she travelled by stretcher at that time. She stated they were notified by her hospice company not to use a stretcher but to use a wheelchair instead because her family did not wish her to use a stretcher. Interview on [DATE] at 2:30 PM, with Resident #218's Responsible Party revealed when she arrived Resident #218 was slumped over in the wheelchair. The Responsible Party stated she knew something was wrong when she asked Medical Transporter A if Resident #218 had been giving them trouble, due to Resident #218's unusual evening behavior. Responsible Party revealed the medical transport person A stated Resident #218 had been sleeping the entire time of putting Resident #218 in the wheelchair, loading into the medical transport and during the ride home. Medical Transporter A told her she had to hold Resident#218's shoulders to keep the resident from leaning forward in the wheelchair during the transport. The Responsible Party stated it took three people to transfer Resident #218 from the wheelchair to the bed. The Responsible Party stated Resident #218's mouth was open, and her eyes were fixed. She stated Hospice Nurse A arrived at the facility and pronounced Resident #218 deceased . Interview on [DATE] at 2:45 PM with Medical Transporter A revealed she told LVN A, who was assisting to dress Resident #218, that the resident felt cold. Medical Transporter A revealed LVN A stated Resident #218 was always cold, and they would get Resident #218 another blanket. Medical Transporter revealed she asked if LVN A was going to take the resident's vitals to which LVN A went and got a wrist blood pressure cuff, but it was not working. LVN A stated Resident #218 was fine as she was sleeping. Interview on [DATE] at 3:00 PM with the Administrator revealed staff statements were taken after medical transport personnel returned to the facility on [DATE] and inquired to the Administrator about the status of Resident #218 when Resident #218 was discharged and transported on [DATE]. Interview on [DATE] at 8:24 AM with LVN D revealed she was the daytime charge nurse for Resident #218 on the day she was discharged , and she worked from 6:00 AM to 6:00 PM. LVN D stated caring for a respite patient was just like caring for any other resident. They were checked every two hours for needs such as incontinent care, assistance with food, and bathing. Vital signs were taken as required and would be flagged on their medication administration records, if none were required, they took them as needed if there were any concerns. She stated, if she had assessed her, she would have documented it in the nurses' notes. She stated she recalled Resident #218 was supposed to have gone home on her shift because someone from Admissions had told her. She stated one of her family members had called wanting to know why she was not home yet and she told them no one had arrived to pick her up. She stated the family member told her they would look into it as they were arranging transportation. LVN A stated she had taken care of Resident #218 during her previous stay, and she would often refuse meals and medications. She stated, during the most recent stay, she was much calmer at night and slept a lot. She stated she would occasionally come out to the dining room for meals and always ate in the same spot. She stated she had her paperwork ready for discharge and checked on her before she left on [DATE] and she was sleeping. She stated she had not noticed any end-of-life symptoms or anything unusual that would have prompted her to check her vital signs or perform a further assessment. She stated she passed on report that her ride had not arrived yet. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy reflected: .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . Review of facility's Transfer or Discharge Documentation policy and procedure reflected: .4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: The basis for the transfer or discharge; (1) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met; (b) this facility's attempt to meet those needs; and (c) the receiving facility's service(s) that are available to meet those needs. .b. That an appropriate notice was provided to the resident and/or legal representative. c. The date and time of the transfer or discharge. d. The new location of the resident. e. The mode of transportation. f. A summary of the resident's overall medical, physical, and mental condition. g. Disposition of personal effects. h. Disposition of medications. i. Others as appropriate or as necessary; and j. The signature of the person recording the data in the medical record. 2. Review of Resident #25's Face Sheet, dated [DATE], reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #25's MDS Assessment reflected he had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), non-Alzheimer's dementia (a more rare type of dementia), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life ). Review of Resident #25's Care Plan, dated [DATE], reflected he was unable to feed himself and required assistance for all meals. Observation of the lunch meal service in the facility's main dining room on [DATE] at 11:50 AM, revealed the ADON was feeding Resident #25. The ADON was in a standing position while assisting Resident #25 with the meal service. Interview with the ADON on [DATE] at 10:37 AM revealed she typically sat down when assisting a resident with eating, as to make the experience more personal for the resident. She said when she was assisting Resident #25 with eating on [DATE], she did not initially sit down (until the Administrator entered the dining room and reminded her that she needed to have a seat), as she was waiting on another staff member to take over for her. The ADON stated the potential risk of not sitting down when feeding a resident included a lack of dignity. Review of the facility's Assistance with Meals policy, dated [DATE], reflected: .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals . 47030

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #42) of six residents reviewed for accidents and hazards. The facility failed to ensure Resident #42 did not have access to a disposable razor. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents. Findings included: Review of Resident #42's Face Sheet, dated 05/09/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #42's MDS Assessment, dated 04/13/24, reflected she had diagnoses including stroke (damage to the brain from interruption of its blood supply), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Resident #42 was identified as being moderately cognitively impaired. Review of Resident #42's Care Plan, dated 07/21/22, reflected Resident #42 required one staff member to assist her with personal hygiene tasks. Observation of and interview with Resident #42 on 05/07/24 at 9:30 AM revealed she was lying in her bed, while shaving her chin with a disposable razor. Resident #42 stated an unknown staff member provided her with the disposable razor to shave her face. She said there were times in which facility staff would shave her face for her; however, she believed staff members were currently busy because they allowed her to shave herself. Interview with RN A on 05/07/24 at 9:42 AM revealed facility staff were responsible for shaving residents. He said residents were not supposed to have access to disposable razors, as that would put residents at risk for injury. RN A located the disposable razor in Resident #42's room and disposed of it. Interview with the Administrator on 05/09/24 at 7:22 AM revealed facility staff were responsible for shaving residents. He said residents were not supposed to have access to disposable razors, as that would put residents at risk for injury. Review of the facility's Hazardous Areas, Devices, and Equipment policy, dated July 2017, reflected, .all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible .and a hazard is defined as anything in the environment that has the potential to cause injury or illness .

Based on observations, interviews, and record reviews the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #32) reviewed for infection control. CNA C failed to perform hand hygiene while providing incontinence care to Resident #32 and between resident rooms. This failure could place the residents at risk for infection. Findings included: Record review of Resident #32's Admission Record dated 05/09/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed he had severe cognitive impairment, he had impaired range of motion of his arm and leg on one side and required maximum assistance with toileting and personal hygiene. The MDS Assessment reflected his diagnoses included hypertension (high blood pressure); peripheral vascular disease or peripheral arterial disease (reduced blood flow to arms and legs); end stage renal disease (kidneys are unable to function properly to remove waste and balance fluids); non-Alzheimer's dementia; and aphasia following cerebral infarction (disability with speech following a stroke). Record review of Resident #32's Care Plan reflected the following entry dated 3/23/23: Focus: [Resident #32] has an ADL Self Care Performance Deficit r/t impaired balance. Goal: [Resident #32] will maintain current level of function in (Bed Mobility, Transfers, Eating, Dressing, Toilet Use, and Personal Hygiene .). Interventions/Tasks: .Toilet Use: The resident requires (X1) staff participation to use toilet .Personal Hygiene: The resident requires (X1) staff participation with personal hygiene and oral care During an observation on 5/9/24 at 4:53 AM, Resident #32 was observed sitting up in bed watching television. He agreed to allow this surveyor to observe care. CNA C entered the room carrying supplies and donned gloves. He informed Resident #32 he was going to change his brief. CNA C removed the resident's blankets, lowered the resident's brief and cleaned him. The CNA assisted Resident #32 to position on his side and continued to clean him and remove his brief. CNA C replaced Resident #32's brief and bagged the trash. CNA C removed his gloves, donned a new pair and covered Resident #32 with his blankets. CNA C removed the bag of trash from the room, entered the spa room, discarded and immediately returned to the hallway. CNA C was observed retrieving a pair of gloves from his pocket, he donned the gloves without washing or sanitizing his hands. He walked down the hall and entered another resident's room. CNA C was observed moving things around the resident's room and speaking with the resident. He removed his gloves and left the room, and returned to the hallway without washing his hands or using the hand sanitizer available in the hallway. During an interview on 5/9/24 at 5:15 AM, CNA C stated he did not use hand sanitizer during or after providing incontinent care for Resident #32 because there was no hand sanitizer in the room. He stated he could just change his gloves. CNA C stated he should wash his hands between resident rooms to prevent the spread of germs. When asked why he did not wash his hands after leaving Resident #32's room and entering another resident's room, he stated he forgot but he did use gloves . During an interview with the DON on 5/9/24 at 6:07 AM, he stated, when providing incontinent care, he expected the CNAs to gather supplies, wash their hands, and put on gloves. He stated they should clean the resident and wash their hands if they became visibly soiled or use hand sanitizer if not heavily soiled. The DON stated the CNAs must wash their hands between residents because they risked spreading infections from resident to resident. During an interview on 5/9/24 at 6:42 AM, the Administrator was asked about his expectation for staff during incontinent care. He stated staff should always wash their hands, gather equipment, explain the care to the resident and don gloves. He stated they should clean the resident in the front, change gloves and sanitize their hands, and clean the back of the resident. The Administrator stated the staff should replace their gloves place a new brief, bag the soiled items, wash their hands and leave. The Administrator stated staff must always sanitize their hands between resident rooms. He stated the risks included spreading infections. The Administrator stated he was a nurse and provided in-service training himself almost every two weeks. Record review of an Inservice Training Report dated 4/17/24 revealed the subject was Perineal Care. The sign-in sheet revealed CNA C was in attendance. The facility's policy/procedure titled Perineal Care revised February 2018 was attached and reflected the following: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin conditions .Steps in the procedure 1/ Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly . 7. Put on gloves 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly.

Based on observation, interview, and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one (Resident #17) of three residents reviewed for nutrition. The facility failed to have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff was providing enteral feeding at a rate of 30 ml per hour, which was a decrease from her previous feeding rate of 65 ml per hour. Resident #17 had a significant weight loss of 16.9% over a three-month period. Findings included: Review of Resident #17's face sheet on 1/10/22 revealed she was a [AGE] year-old female with an initial admitted [DATE] and re-admitted [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS for Resident #17, dated 11/25/2021, revealed a BIMS assessment was not conducted, due to Resident #17 being severely impaired cognitively. The resident received 100% of her nutritional intake via enteral feedings and was totally dependent upon staff for nutritional intake seven days a week. It further revealed No for weight loss of 5% or more in the last month or 10% or more in the last 6 months. Record review of Resident #17's Care Plan, revised on 11/25/21, revealed the resident required tube feeding related to Dysphasia or difficulty swallowing (Fibersource 65 ml/hour x 22 hrs. continuous. Off at 10:30 a.m., on at 12:30 p.m.). The care plan goals reflected: Resident will maintain adequate nutritional and hydration status as evidenced by weight stable, no signs and symptoms of malnutrition or dehydration through review date. Review of electronic orders revealed enteral feeding order was changed to 30ml/hour x 22 hrs. on 9/24/2021 and signed by Facility Doctor. Record review of Resident #17's re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of hospital records from 10/04/21 - 10/07/21 revealed Resident #17 was hospitalized with a discharge date of [DATE] due to respiratory distress. Observation of Resident #17 on 1/10/22 at 11:52 AM revealed the resident lying in her bed. Resident #17 was observed to be hooked up to a formula pump that was running. The pump was set at a rate of 30 ml per hour. Resident #17 was unable to participate in an interview due to severe cognitive impairment. Observation on 1/11/22 at 10:15 AM of Resident #17 revealed the resident lying in bed. LVN D was observed preparing to start the resident's feeding. LVN D set the feeding pump at a rate of 30 ml/hour. Interview on 1/11/22 at 10:17 AM with LVN D revealed Resident#17 was receiving 30ml/hour of Fibersource HN nutrition at 1.2 kcal/ml continuous for 22 hours with 2 hours of downtime. LVN D informed that Resident #17 previously had an ileus (a condition where the colon can't move to push food and waste which can cause an obstruction) which caused her feeding to be decreased from 65ml/hour to 30ml/hour. There was no documentation that Resident #17 was hospitalized for this condition or that the resident's feedings were decreased for that reason. She stated the resident was hospitalized and the Ileus was corrected; however, the feeding remained at 30ml/hour per family's request. LVN D stated resident had lost a significant amount of weight since feeding was decreased. She stated there was no concern for another obstruction and it was her opinion that an increase in feeding would not increase the risk. Record review of Resident #17's electronic record revealed the following: - On 10/13/2021, the resident weighed 124 lbs. On 01/05/2022, the resident weighed 103 pounds which is a -16.94 % Loss. - On 07/01/2021, the resident weighed 122 lbs. On 01/05/2022, the resident weighed 103 pounds which is a -15.57 % Loss. Interview on 01/11/22 at 1:30 PM with the Hospice Nurse Manager revealed hospice provided nursing services for Resident #17 once a week, and the facility was responsible for daily treatment. She stated there was a decrease in the resident being able to tolerate feeding, which resulted in weight loss. She stated weight loss was expected in residents on hospice due to the body not using nutrition the same. The Hospice Nurse Manager stated hospice notes reflected inconsistencies in the rate of feedings for the resident. She stated on 12/27/21 1/5/22 the feeding was documented as running at 30ml/hour and on 1/5/22 the feeding was documented as running at 65ml/hour. The Hospice Nurse Manager stated discrepancy could have been due to orders changing when the resident was admitted into the hospital. She stated and anticipated reason for a decrease in rate of feeding could be due to increased upper respiratory infections; however, she needed to research Resident #17's case more to see if there was a documented reason. Interview continued on 01/11/22 at 2:40 PM with the Hospice Nurse Manager revealed Resident #17's rate of feeding was decreased to 30 ml/hour while she was in the hospital. There was no documentation of this found in Resident #17's records. Hospice Nurse Manager confirmed that on average, 1 out of 5 nursing notes reflected feeding was running at 65 ml/hour and other times were at 30 ml/hour. She stated it was documented that resident's family was aware the rate of feeding was decreased and wanted to titrate down from 30 ml/hour to no enteral feeding. Interview with Resident #17's family member on 1/11/21 at 2:20 PM revealed the resident was on hospice services and the family did not want any heroic life-saving measures taken. Regarding the hospitalization on [DATE], the family member stated the resident should have never been sent out to the hospital. The family member stated he visited the resident in late November 2021 and after seeing her he made the decision to request all nutrition be withheld to the DON. He stated he had only recently talked to the hospice provider about his desire to discontinue the feedings. The facility was not in agreement for all nutrition to be withheld and the family member revealed he was in the process of looking into his options. Interview on 1/12/22 at 12:21 PM with the Dietician revealed she was contracted and trained with previous dietician for only two months. She stated she had not reviewed Resident #17's chart before this date. The Dietician stated she did not have much knowledge on the resident but had heard there was conflict with the family regarding the resident's care as the family wanted to discontinue all feedings. The Dietician stated the most recent care plan reflected the rate for feeding at 65ml/hour. She stated the rate at which feedings were currently being given were at 30ml/hour and she understood it was due to the family's request. The Dietician stated based on the resident's size, 65ml/hour seemed suitable, but she would need to further investigate. She stated it was not an appropriate intervention to take the family's recommendation for a decrease in feeding rate without a statement from a doctor. She denied seeing a written statement from doctor on decreasing the resident's rate of feeding. The Dietician stated her responsibility was to ensure that nutrition was being provided, not to approve a decrease or discontinuation of feedings. The Dietician stated she would document on the resident and recommend an increase in the feeding rate. She stated approval would depend on a doctor's statement, family and facility policy. Interview on 1/12/22 at 12:48 PM with the MDS Coordinator revealed Resident #17's enteral feeding order was updated to rate of 30ml/hour X 22hrs/continuous by the DON and approved by the Facility Doctor on 1/12/22. She stated she was responsible for ensuring all orders were accurate and that care plans were updated to reflect any changes. The MDS Coordinator stated there had been discussions between management that the family wanted to discontinue Resident #17's feedings. The MDS Coordinator also stated the family did not want resident to go to hospital for interventions such as her peg tube being dislodged. Interview on 1/12/22 at 1:00 PM with the DON revealed the Facility Doctor updated Resident #17's enteral feeding order to Fibersource at rate of 30 ml/hour x 22 hrs. on 1/12/22. The DON stated she had only been employed at the facility for 2 months and could not state when the enteral feeding order was originally decreased from 65 ml/hour to 30ml/hour. The DON and the MDS Coordinator reviewed Resident #17's NAR from November 2021 and could not find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated there was an ongoing family dispute regarding the resident's feeding that The Dietician and hospice provider were aware of. The DON stated hospice agreed to keep the feeding rate at 30ml/hour. based on the family's request. The DON stated she did not agree with the rate of feeding being at 30ml/hour. She stated she could've taken her concerns about the resident not receiving enough nutrition to her corporate nurse; however, since the resident was on hospice it was expected for hospice to make those decisions. The DON stated the order should have been investigated more when concerns were brought up about Resident #17's weight loss. The DON stated the risk of the resident not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated it was the MDS Coordinator's responsibility to ensure residents orders were accurate and updated in the records and it was her responsibility to ensure it was being done. The DON stated failure to have enteral feeding orders for three months may have contributed to the resident's significant weight loss. Record review of Resident #17's current Care Plan, revised on 01/12/22, revealed the resident required tube feeding related to Dysphasia (Fibersource 30 ml/hour. x 22 hrs. continuous). The care plan goals reflected: Resident will maintain adequate nutritional and hydration status as evidenced by weight stable, no signs and symptoms of malnutrition or dehydration through review date. Review of facility's policy titled Enteral Nutrition, dated April 2006, revealed in part the following: Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents unable to consume adequate nutritional intake by mouth. Policy Interpretation and Implementation 1. A Dietician will assess residents who are dependent on tube feeding and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feeding. 2. A Dietician will assess a resident admitted with a Gastrostomy Tube (GT) or Jejunostomy Tube (JT) for initial recommendation of enteral feeding orders. If a Dietician is not available prior to the first feeding, the Dietician on call will be contacted. The Dietician will review available information with the nurse and recommend initial orders based on available admission information. 3. A Dietician will conduct a full nutritional assessment with current initial assessment timeframes. Current Standards of Practice, facility formulary, and facility policies will be the basis for the assessment and recommendations. The Dietician will confirm or modify initial orders based on the complete nutritional assessment. 4. Timing of feeding will be scheduled to enhance resident independence whenever possible (e.g. at night or during hours which do not interfere with the resident's ability to participate in facility activities). 5. Enteral feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that any necessary interruptions of feeding will not decrease volume infused: a. Pump Feeding (1) Product name (2) Type of tube (3) Rate of infusion (number of ml per day) (4) Total calories per day (5) Start time; and (6) Total daily volume to be infused (number of ml per day) 6. Fluids to be provided will be calculated by Dietician and referred to the physician for an order.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #11) of 10 residents reviewed for neglect. The facility failed to give Resident #11 her [MEDICATION NAME] (diuretic) 100 mg twice daily for seven days as ordered by her Nephrologist (kidney doctor), due to the facility's failure to transcribe the order to the resident's January 2014 MAR. Resident #11's weight increased from 242 pounds on 01/22/14 to 262.8 pounds on 01/30/14. The resident developed shortness of breath on 01/30/14, while out on pass with her family member. The family member took the resident to the hospital. Resident #11 was diagnosed with [REDACTED]. This was determined to be a PNC Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the 29 residents, residing on hall 100 receiving medications from LVN A, by placing them at risk for not being provided physician-ordered medications, which could result in exacerbation of health conditions, discomfort and hospitalization . Findings included: Resident #11's Face Sheet, dated 02/03/14, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #11's MDS assessment, dated 12/02/13, reflected she was moderately cognitively impaired, required extensive assistance with ADLs, required a wheel chair for mobility and was incontinent of bowel and bladder. The MDS assessment reflected her [DIAGNOSES REDACTED]. Resident #11's Care Plan, dated 12/02/13, reflected she was at risk for shortness of breath and [MEDICAL CONDITION] due to [MEDICAL CONDITION], with the following interventions: medication as ordered, monitor for shortness of breath and [MEDICAL CONDITION] and monitor oxygen saturations. The Care Plan reflected Resident #11 was at risk for dehydration due to being provided diuretic medication and cognitive impairment with the following interventions: assess the resident's skin and mucous membranes every shift and as needed, offer extra fluids with meals and on medication pass, monitor for [MEDICAL CONDITION], provide medications as ordered and monitor for side effects, and monitor for leg cramps and abnormal labs, report to doctor. The Care Plan also reflected she was at risk for increased [MEDICAL CONDITION], abnormal labs and a decrease in urination with the following interventions in place: notify physician of resident status change, serve extra fluids with meals, monitor labs, provide medications as ordered, and monitor skin, eyes and report any changes to the MD promptly. A review of Resident #11 Physician order [REDACTED]. A review of an Office visit report, dated 01/21/14, of Resident #11 visit to Nephrologist office, revealed Resident #11 [MEDICATION NAME] should be changed to 100 mg twice daily. Resident #11's Nurse's Note, dated 01/22/14, timed at 1:18 PM, and written by LVN A, reflected LVN A clarified the [MEDICATION NAME] order with the Nephrologist office, to give [MEDICATION NAME] 100 mg by mouth twice daily. An interview on 02/26/14 at 10:05 AM with LVN A revealed Resident #11 went to the Nephrologist on 01/21/14 and returned with new orders. She stated the nurse working the evening shift was not able to interpret the physician's handwriting and left her a note to clarify the [MEDICATION NAME] order. LVN A revealed on 01/22/14, she contacted the Nephrologist's office and was informed the order was to increase Resident #11's [MEDICATION NAME] to 100 mg twice daily. She stated she entered the medication into the computer system; however, the new order was not saved on the MARs or sent to the pharmacy to be filled; she must have forgotten to push save. She stated she checked the MAR to ensure the medication was on the MA's record and it appeared to be transferred. LVN A revealed no staff inquired why the resident's [MEDICATION NAME] was not on the medication sheet, and the resident was not provided any [MEDICATION NAME] (including the original 80 mg a day) the next seven days. The facility's 24 Hour Report, dated 01/22/14, reflected Resident #11 was to be provided [MEDICATION NAME] 100 mg twice daily, but the order was to be clarified with the Nephrologist. Resident #11's Nurse's Note, dated 01/30/14, timed at 12:16 PM and written by LVN B, reflected LVN B contacted the NP regarding the [MEDICATION NAME] order from the renal doctor, but the note did not reflect the [MEDICATION NAME] dosage, but to continue the [MEDICATION NAME]. Resident #11's Nurse's Note, dated 01/30/14 and timed at 4:00 PM, reflected her family member, who had taken the resident out on pass, called LVN B and stated she was taking the resident to the hospital due to shortness of breath. An interview on 02/28/14 at 1:20 PM with LVN B revealed on 01/30/14, Resident #11's family member asked about the resident's weight gain and then took the resident out on pass. She stated the family member called her back later and stated Resident #11 was short of breath. LVN B revealed she advised the family member to take the resident to the hospital. She stated that was when she checked Resident #11's medications and saw the resident was not being given [MEDICATION NAME] 100 mg as ordered. LVN B revealed she called the NP to clarify any orders, and to give [MEDICATION NAME] 100 mg twice daily. Resident #11's Physician Orders, dated 01/01/14 through 01/31/14, reflected to weigh the resident daily. Review of Resident #11's eMAR, dated 01/01/14 through 01/31/14, revealed on 01/22/14 her weight was 242.2 pounds, on 01/23/14 it was 252.2 pounds, on 01/28/14 it was 255.6 pounds, and on 01/30/14, the day of admission to the hospital, it was was 262.8 pounds. Review of Resident #11's MA MAR, dated 01/01/14 through 01/31/14, revealed from the evening of 01/22/14 through 01/30/14, when the resident was admitted to the hospital, she was not provided the [MEDICATION NAME] as ordered. Resident #11's hospital emergency room Records, dated 01/30/14 reflected resident was provided care for shortness of breath. The resident presented with slowly worsening volume overload and shortness of breath. Chest x-ray reflected [MEDICAL CONDITION] vascular congestion. Final assessment was resident was admitted to the hospital with [REDACTED]. The facility's Provider Investigation Report, dated 02/07/14, reflected Resident #11 was not provided [MEDICATION NAME] 100 mg twice daily as ordered by the Nephrologist on 01/21/14. The report indicated the error occurred due to the nurse not transferring the medication change to the MAR. The report reflected the nurse forgot to press save, which would have transferred the medication order to the MAR, therefore the resident did not receive [MEDICATION NAME] from 01/22/14 through 01/30/14. Further review of the Provider Investigation Report revealed the resident's weight on 01/23/14 was 252.2 pounds, on 01/28/14 and 01/29/14 her weight was 255.6 pounds, and on 01/30/14 her weight was 262.8 pounds. On 01/30/14 while Resident #11 was out on pass with her family member, she complained of shortness of breath and was taken by her family member to the hospital. Resident #11 was admitted due to [MEDICAL CONDITION]. The report reflected the facility's action taken post-investigation included: chart audit to ensure compliance, updated the resident's Care Plan and continue to monitor the resident's condition, implemented a new protocol regarding putting orders in the computer system that would prevent similar errors from reoccurring, in-serviced staff on the new procedure. The facility's current policy, "Administering Medication," dated April 2007, reflected, "Medication shall be administered in a safe and timely manner, and as prescribed... Policy Interpretation and Implementation...3. Medication must be administered in accordance with the orders, including ant required time frame...." The facility's current LTC Facility Pharmacy Services and Procedures Manual contained the policy, New Orders for Non-Controlled Substances, revised 01/01/13, which reflected, "...5. If the medication is needed before the next scheduled delivery and is not in the Emergency Medication Supply, Facility staff should: 5.1.1 Fax or transmit the order to the pharmacy. 5.1.2 Notify the pharmacy and include the exact time by which the medication is needed. 5.1.3 Facility staff should ask the pharmacist to read the order back to assure accuracy, if providing the pharmacist with a telephone order. 5.1.4 Document the following information for any necessary verbal orders or communication on the interim/telephone order form: 5.1.4.1 Date: 5.1.4.2 Time 5.1.4.3 Nurse's initials; and, 5.1.4.4 The phrase 'telephone order.'" The facility's current LTC Facility Pharmacy Services and Procedures Manual contained the policy, 4.5 Reordering, Changing, and Discontinuing Orders, revised 01/01/13, which reflected, "Applicability: This policy 4.5 sets forth procedures with respect to Facility's communication of any medication reorders, changes, or discontinuation to Pharmacy...3. Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order...Facility staff cannot alter directions on any existing prescription once it has been dispensed to the resident...3.4 Pharmacy should receive a discontinued order before a new order (that reflects a change) is filled. 3.5 If Pharmacy should receive a new order that changes the strength or dose of a medication previously ordered, and there is adequate supply on hand. 3.5.1 Pharmacy should discontinue the original order; 3.5.2 Facility Physician/prescriber should write the new order with directions and facility should enter the new order on the appropriate Medication Record forms; and...." The facility's current undated "Abuse Prohibition Management Program Identification, Investigation and Reporting Policy," reflected: Policy: All personnel, residents' family members visitors, etc., are encouraged to report actual or suspected incidents of Resident Abuse or inappropriate behavior that may lead to resident abuse. Such reports may be made without fear of retaliation from the facility or its staff. The facility will provide feedback to residents and family members and other regarding concerns that have been expressed to facility staff, in a timely manner. 1. To assist our facility's staff members, residents, families and visitors to our facility in recognizing incidents of Resident Abuse, the following definitions are provided...h) Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." It was determined these failures placed Resident #11 in an Immediate Jeopardy (IJ) situation from 01/23/14 through 01/30/14. A review of an updated Care Plan, dated 02/13/14, reflected resident was to be monitored for fluid volume, and notify doctor if a weight gain of three pounds in 24 hours, or five pounds in seven days. LVN A's Notice of Warning, dated 01/31/04, reflected she failed to transcribe Resident #11's order of [MEDICATION NAME] 100 mg twice daily. An In-Service Report, dated 01/31/14, reflected nurses were provided an in-service on transcribing doctor's orders. An undated In-Service Report reflected staff were in-serviced on Signs and Symptoms of [MEDICAL CONDITION]. An undated In-Service Report reflected staff were in-serviced on daily weights. The facility's Addendum to the Medication Administration Policy, effective 02/05/14, reflected the facility implemented the following Addendum to the current policy on Medication Transcription of physician's orders [REDACTED]. The nurse would also be required to transcribe the order onto the white paper sheet labeled "physician's orders [REDACTED]. The ADON would check for accuracy of the transcribed order in the Electronic Medical Record. Any inaccuracies or issues would be immediately clarified and rectified in the Electronic Medical Record. In addition, all new orders would be reviewed daily in the Daily Clinical Stand-up Meeting, as a "triple-check" of all new physicians' orders. Any inaccuracies/issues would be resolved immediately during the Daily Clinical Stand-up meeting. The facility's current undated Policy Changing an Existing Order, as part of their action plan, reflected the following: "Changing an Existing order: 1. Changing an existing order rules: ? You cannot write a new order unless you address the existing order. You must check the chart and be accurate! Doctors are changing orders based on what you tell them! ? The safest way is to discontinue the existing order and then rewrite the new order. ? This assures that the computer data base is accurate and that the pharmacy knows what the physician wants. 2. Existing order- [MEDICATION NAME] 20mg tab. 1 PO (by mouth) QD (daily) [MEDICAL CONDITION]. You want to increase the dose. Steps to follow: ? Write the following: D/C (discontinue) [MEDICATION NAME] 20mg tab.1 PO QD Start [MEDICATION NAME] 40mg tab. 1 PO QD - Dx. (diagnosis) [MEDICAL CONDITIONS] This makes it clear that the physician wants a total daily dose of 40 mg. If you wrote just the new order, it could mean the total daily dose is 60 mg... ? Add the Systolic and Diastolic blood pressures, pulse, [MEDICAL CONDITION] check, etc. if appropriate. This doesn't require a physician order [REDACTED]. ? Place a 'change in direction' sticker on all remaining cards of medication if current supply can be used. ? Fax the order to the pharmacy. Note on the order 'Do not send' if you have a supply of the drug on hand to use. ? Enter on 24 hour report sheet. ? Verbally report to the appropriate staff the order change and reasons. ? Document appropriately in the nurse's notes...." Interview on 02/27/14 at 12:10 PM with the Administrator revealed the incident of Resident #11 not receiving her [MEDICATION NAME] occurred because LVN A failed to save the order and ensure the order was processed to the resident's MAR and to the pharmacy. She stated she felt confident the facility now had systems in place to prevent a similar occurrence. The Administrator revealed the staff was in-serviced on medication administration, the correct procedure to ensure the medication was in the computer system, on the resident's MARs and sent to the pharmacy. Interview with the DON on 02/27/14 at 12:30 PM revealed she was confident non-compliance of the medication administration and transcription incident came about related to the fact there was no system in place for the staff to confirm if the pharmacy received the physician's orders [REDACTED]. In the Quality Assurance meeting in February of 2014 the issue of medication error was discussed related to the incident of Resident #11's [MEDICATION NAME]. She stated the nurses were in-serviced on the Pharmacy process related to transmitting new orders to the pharmacy, re-order of medication and discontinuing medication and transcribing medication on the Medication Administration Record, Treatment Record and document on the 24 hour report and must document in the Nurse's Notes. She stated in the future all medication orders including new medication, a change in any medication dosage, time or discontinued medication would be reviewed in the morning meeting. The DON revealed all new employees would be trained on the Pharmacy ordering and discontinued process as well as notifying the facility's only ADON who would follow up on all medication orders to ensure the appropriate pharmacy process was implemented. She stated when residents were weighed according to the physician's orders [REDACTED]. Interview on 02/26/14 at 1:00 PM with LVN C revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and the residents' MARs. Interview on 02/26/14 at 1:02 PM with LVN A revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to pharmacy and residents' MARs. Interview on 02/27/14 at 9:45 AM with the ADON, revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to her and she followed up to ensure the order was transferred to the pharmacy and the residents' MARs. Interview on 02/27/14 at 9:50 AM with LVN E revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. Interview on 02/27/14 at 10:00 AM with LVN F revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. Interview on 02/27/14 at 1:50 PM with LVN G revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARs, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. She would check with the MA to ensure the medication was on the MAR. Interview on 02/27/14 at 2:00 PM with LVN H revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. This was determined to be PNC Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's Form CMS-802, Roster/Sample Matrix, printed on 02/25/14, reflected 29 residents resided on Hall 100.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #11) of 10 residents reviewed for neglect. The facility failed to give Resident #11 her [MEDICATION NAME] (diuretic) 100 mg twice daily for seven days as ordered by her Nephrologist (kidney doctor), due to the facility's failure to transcribe the order to the resident's January 2014 MAR. Resident #11's weight increased from 242 pounds on 01/22/14 to 262.8 pounds on 01/30/14. The resident developed shortness of breath on 01/30/14, while out on pass with her family member. The family member took the resident to the hospital. Resident #11 was diagnosed with [REDACTED]. This was determined to be a PNC Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the 29 residents, residing on hall 100 receiving medications from LVN A, by placing them at risk for not being provided physician-ordered medications, which could result in exacerbation of health conditions, discomfort and hospitalization . Findings included: The facility's current undated "Abuse Prohibition Management Program Identification, Investigation and Reporting Policy," reflected: Policy: All personnel, residents' family members visitors, etc., are encouraged to report actual or suspected incidents of Resident Abuse or inappropriate behavior that may lead to resident abuse. Such reports may be made without fear of retaliation from the facility or its staff. The facility will provide feedback to residents and family members and other regarding concerns that have been expressed to facility staff, in a timely manner. 1. To assist our facility's staff members, residents, families and visitors to our facility in recognizing incidents of Resident Abuse, the following definitions are provided...h) Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." Resident #11's Face Sheet, dated 02/03/14, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #11's MDS assessment, dated 12/02/13, reflected she was moderately cognitively impaired, required extensive assistance with ADLs, required a wheel chair for mobility and was incontinent of bowel and bladder. The MDS assessment reflected her [DIAGNOSES REDACTED]. Resident #11's Care Plan, dated 12/02/13, reflected she was at risk for shortness of breath and [MEDICAL CONDITION] due to [MEDICAL CONDITION], with the following interventions: medication as ordered, monitor for shortness of breath and [MEDICAL CONDITION] and monitor oxygen saturations. The Care Plan reflected Resident #11 was at risk for dehydration due to being provided diuretic medication and cognitive impairment with the following interventions: assess the resident's skin and mucous membranes every shift and as needed, offer extra fluids with meals and on medication pass, monitor for [MEDICAL CONDITION], provide medications as ordered and monitor for side effects, and monitor for leg cramps and abnormal labs, report to doctor. The Care Plan also reflected she was at risk for increased [MEDICAL CONDITION], abnormal labs and a decrease in urination with the following interventions in place: notify physician of resident status change, serve extra fluids with meals, monitor labs, provide medications as ordered, and monitor skin, eyes and report any changes to the MD promptly. A review of Resident #11 Physician order [REDACTED]. A review of an Office visit report, dated 01/21/14, of Resident #11 visit to Nephrologist office, revealed Resident #11 [MEDICATION NAME] should be changed to 100 mg twice daily. Resident #11's Nurse's Note, dated 01/22/14, timed at 1:18 PM, and written by LVN A, reflected LVN A clarified the [MEDICATION NAME] order with the Nephrologist office, to give [MEDICATION NAME] 100 mg by mouth twice daily. An interview on 02/26/14 at 10:05 AM with LVN A revealed Resident #11 went to the Nephrologist on 01/21/14 and returned with new orders. She stated the nurse working the evening shift was not able to interpret the physician's handwriting and left her a note to clarify the [MEDICATION NAME] order. LVN A revealed on 01/22/14, she contacted the Nephrologist's office and was informed the order was to increase Resident #11's [MEDICATION NAME] to 100 mg twice daily. She stated she entered the medication into the computer system; however, the new order was not saved on the MARs or sent to the pharmacy to be filled; she must have forgotten to push save. She stated she checked the MAR to ensure the medication was on the MA's record and it appeared to be transferred. LVN A revealed no staff inquired why the resident's [MEDICATION NAME] was not on the medication sheet, and the resident was not provided any [MEDICATION NAME] (including the original 80 mg a day) the next seven days. The facility's 24 Hour Report, dated 01/22/14, reflected Resident #11 was to be provided [MEDICATION NAME] 100 mg twice daily, but the order was to be clarified with the Nephrologist. Resident #11's Nurse's Note, dated 01/30/14, timed at 12:16 PM and written by LVN B, reflected LVN B contacted the NP regarding the [MEDICATION NAME] order from the renal doctor, but the note did not reflect the [MEDICATION NAME] dosage, but to continue the [MEDICATION NAME]. Resident #11's Nurse's Note, dated 01/30/14 and timed at 4:00 PM, reflected her family member, who had taken the resident out on pass, called LVN B and stated she was taking the resident to the hospital due to shortness of breath. An interview on 02/28/14 at 1:20 PM with LVN B revealed on 01/30/14, Resident #11's family member asked about the resident's weight gain and then took the resident out on pass. She stated the family member called her back later and stated Resident #11 was short of breath. LVN B revealed she advised the family member to take the resident to the hospital. She stated that was when she checked Resident #11's medications and saw the resident was not being given [MEDICATION NAME] 100 mg as ordered. LVN B revealed she called the NP to clarify any orders, and to give [MEDICATION NAME] 100 mg twice daily. Resident #11's Physician Orders, dated 01/01/14 through 01/31/14, reflected to weigh the resident daily. Review of Resident #11's eMAR, dated 01/01/14 through 01/31/14, revealed on 01/22/14 her weight was 242.2 pounds, on 01/23/14 it was 252.2 pounds, on 01/28/14 it was 255.6 pounds, and on 01/30/14, the day of admission to the hospital, it was was 262.8 pounds. Review of Resident #11's MA MAR, dated 01/01/14 through 01/31/14, revealed from the evening of 01/22/14 through 01/30/14, when the resident was admitted to the hospital, she was not provided the [MEDICATION NAME] as ordered. Resident #11's hospital emergency room Records, dated 01/30/14 reflected resident was provided care for shortness of breath. The resident presented with slowly worsening volume overload and shortness of breath. Chest x-ray reflected [MEDICAL CONDITION] vascular congestion. Final assessment was resident was admitted to the hospital with [REDACTED]. The facility's Provider Investigation Report, dated 02/07/14, reflected Resident #11 was not provided [MEDICATION NAME] 100 mg twice daily as ordered by the Nephrologist on 01/21/14. The report indicated the error occurred due to the nurse not transferring the medication change to the MAR. The report reflected the nurse forgot to press save, which would have transferred the medication order to the MAR, therefore the resident did not receive [MEDICATION NAME] from 01/22/14 through 01/30/14. Further review of the Provider Investigation Report revealed the resident's weight on 01/23/14 was 252.2 pounds, on 01/28/14 and 01/29/14 her weight was 255.6 pounds, and on 01/30/14 her weight was 262.8 pounds. On 01/30/14 while Resident #11 was out on pass with her family member, she complained of shortness of breath and was taken by her family member to the hospital. Resident #11 was admitted due to [MEDICAL CONDITION]. The report reflected the facility's action taken post-investigation included: chart audit to ensure compliance, updated the resident's Care Plan and continue to monitor the resident's condition, implemented a new protocol regarding putting orders in the computer system that would prevent similar errors from reoccurring, in-serviced staff on the new procedure. The facility's current policy, "Administering Medication," dated April 2007, reflected, "Medication shall be administered in a safe and timely manner, and as prescribed... Policy Interpretation and Implementation...3. Medication must be administered in accordance with the orders, including ant required time frame...." The facility's current LTC Facility Pharmacy Services and Procedures Manual contained the policy, New Orders for Non-Controlled Substances, revised 01/01/13, which reflected, "...5. If the medication is needed before the next scheduled delivery and is not in the Emergency Medication Supply, Facility staff should: 5.1.1 Fax or transmit the order to the pharmacy. 5.1.2 Notify the pharmacy and include the exact time by which the medication is needed. 5.1.3 Facility staff should ask the pharmacist to read the order back to assure accuracy, if providing the pharmacist with a telephone order. 5.1.4 Document the following information for any necessary verbal orders or communication on the interim/telephone order form: 5.1.4.1 Date: 5.1.4.2 Time 5.1.4.3 Nurse's initials; and, 5.1.4.4 The phrase 'telephone order.'" The facility's current LTC Facility Pharmacy Services and Procedures Manual contained the policy, 4.5 Reordering, Changing, and Discontinuing Orders, revised 01/01/13, which reflected, "Applicability: This policy 4.5 sets forth procedures with respect to Facility's communication of any medication reorders, changes, or discontinuation to Pharmacy...3. Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order...Facility staff cannot alter directions on any existing prescription once it has been dispensed to the resident...3.4 Pharmacy should receive a discontinued order before a new order (that reflects a change) is filled. 3.5 If Pharmacy should receive a new order that changes the strength or dose of a medication previously ordered, and there is adequate supply on hand. 3.5.1 Pharmacy should discontinue the original order; 3.5.2 Facility Physician/prescriber should write the new order with directions and facility should enter the new order on the appropriate Medication Record forms; and...." It was determined these failures placed Resident #11 in an Immediate Jeopardy (IJ) situation from 01/23/14 through 01/30/14. A review of an updated Care Plan, dated 02/13/14, reflected resident was to be monitored for fluid volume, and notify doctor if a weight gain of three pounds in 24 hours, or five pounds in seven days. LVN A's Notice of Warning, dated 01/31/04, reflected she failed to transcribe Resident #11's order of [MEDICATION NAME] 100 mg twice daily. An In-Service Report, dated 01/31/14, reflected nurses were provided an in-service on transcribing doctor's orders. An undated In-Service Report reflected staff were in-serviced on Signs and Symptoms of [MEDICAL CONDITION]. An undated In-Service Report reflected staff were in-serviced on daily weights. The facility's Addendum to the Medication Administration Policy, effective 02/05/14, reflected the facility implemented the following Addendum to the current policy on Medication Transcription of physician's orders [REDACTED]. The nurse would also be required to transcribe the order onto the white paper sheet labeled "physician's orders [REDACTED]. The ADON would check for accuracy of the transcribed order in the Electronic Medical Record. Any inaccuracies or issues would be immediately clarified and rectified in the Electronic Medical Record. In addition, all new orders would be reviewed daily in the Daily Clinical Stand-up Meeting, as a "triple-check" of all new physicians' orders. Any inaccuracies/issues would be resolved immediately during the Daily Clinical Stand-up meeting. The facility's current undated Policy Changing an Existing Order, as part of their action plan, reflected the following: "Changing an Existing order: 1. Changing an existing order rules: ? You cannot write a new order unless you address the existing order. You must check the chart and be accurate! Doctors are changing orders based on what you tell them! ? The safest way is to discontinue the existing order and then rewrite the new order. ? This assures that the computer data base is accurate and that the pharmacy knows what the physician wants. 2. Existing order- [MEDICATION NAME] 20mg tab. 1 PO (by mouth) QD (daily) [MEDICAL CONDITION]. You want to increase the dose. Steps to follow: ? Write the following: D/C (discontinue) [MEDICATION NAME] 20mg tab.1 PO QD Start [MEDICATION NAME] 40mg tab. 1 PO QD - Dx. (diagnosis) [MEDICAL CONDITIONS] This makes it clear that the physician wants a total daily dose of 40 mg. If you wrote just the new order, it could mean the total daily dose is 60 mg... ? Add the Systolic and Diastolic blood pressures, pulse, [MEDICAL CONDITION] check, etc. if appropriate. This doesn't require a physician order [REDACTED]. ? Place a 'change in direction' sticker on all remaining cards of medication if current supply can be used. ? Fax the order to the pharmacy. Note on the order 'Do not send' if you have a supply of the drug on hand to use. ? Enter on 24 hour report sheet. ? Verbally report to the appropriate staff the order change and reasons. ? Document appropriately in the nurse's notes...." Interview on 02/27/14 at 12:10 PM with the Administrator revealed the incident of Resident #11 not receiving her [MEDICATION NAME] occurred because LVN A failed to save the order and ensure the order was processed to the resident's MAR and to the pharmacy. She stated she felt confident the facility now had systems in place to prevent a similar occurrence. The Administrator revealed the staff was in-serviced on medication administration, the correct procedure to ensure the medication was in the computer system, on the resident's MARs and sent to the pharmacy. Interview with the DON on 02/27/14 at 12:30 PM revealed she was confident non-compliance of the medication administration and transcription incident came about related to the fact there was no system in place for the staff to confirm if the pharmacy received the physician's orders [REDACTED]. In the Quality Assurance meeting in February of 2014 the issue of medication error was discussed related to the incident of Resident #11's [MEDICATION NAME]. She stated the nurses were in-serviced on the Pharmacy process related to transmitting new orders to the pharmacy, re-order of medication and discontinuing medication and transcribing medication on the Medication Administration Record, Treatment Record and document on the 24 hour report and must document in the Nurse's Notes. She stated in the future all medication orders including new medication, a change in any medication dosage, time or discontinued medication would be reviewed in the morning meeting. The DON revealed all new employees would be trained on the Pharmacy ordering and discontinued process as well as notifying the facility's only ADON who would follow up on all medication orders to ensure the appropriate pharmacy process was implemented. She stated when residents were weighed according to the physician's orders [REDACTED]. Interview on 02/26/14 at 1:00 PM with LVN C revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and the residents' MARs. Interview on 02/26/14 at 1:02 PM with LVN A revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to pharmacy and residents' MARs. Interview on 02/27/14 at 9:45 AM with the ADON, revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to her and she followed up to ensure the order was transferred to the pharmacy and the residents' MARs. Interview on 02/27/14 at 9:50 AM with LVN E revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. Interview on 02/27/14 at 10:00 AM with LVN F revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. Interview on 02/27/14 at 1:50 PM with LVN G revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARs, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. She would check with the MA to ensure the medication was on the MAR. Interview on 02/27/14 at 2:00 PM with LVN H revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. This was determined to be PNC Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's Form CMS-802, Roster/Sample Matrix, printed on 02/25/14, reflected 29 residents resided on Hall 100.

Based on interview and record review, it was determined the facility failed to ensure residents were free of any significant medication error for one (Resident #10) of 19 resident reviewed for medications. The facility failed to give Resident #11 her [MEDICATION NAME] (diuretic) 100 mg twice daily for seven days as ordered by her Nephrologist (kidney doctor), due to the facility's failure to transcribe the order to the resident's January 2014 MAR. Resident #11's weight increased from 242 pounds on 01/22/14 to 262.8 pounds on 01/30/14. The resident developed shortness of breath on 01/30/14, while out on pass with her family member. The family member took the resident to the hospital. Resident #11 was diagnosed with [REDACTED]. This was determined to be a PNC Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the 29 residents, residing on hall 100 receiving medications from LVN A, by placing them at risk for not being provided physician-ordered medications, which could result in exacerbation of health conditions, discomfort and hospitalization . Findings included: Resident #11's Face Sheet, dated 02/03/14, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #11's MDS assessment, dated 12/02/13, reflected she was moderately cognitively impaired, required extensive assistance with ADLs, required a wheel chair for mobility and was incontinent of bowel and bladder. The MDS assessment reflected her [DIAGNOSES REDACTED]. Resident #11's Care Plan, dated 12/02/13, reflected she was at risk for shortness of breath and [MEDICAL CONDITION] due to [MEDICAL CONDITION], with the following interventions: medication as ordered, monitor for shortness of breath and [MEDICAL CONDITION] and monitor oxygen saturations. The Care Plan reflected Resident #11 was at risk for dehydration due to being provided diuretic medication and cognitive impairment with the following interventions: assess the resident's skin and mucous membranes every shift and as needed, offer extra fluids with meals and on medication pass, monitor for [MEDICAL CONDITION], provide medications as ordered and monitor for side effects, and monitor for leg cramps and abnormal labs, report to doctor. The Care Plan also reflected she was at risk for increased [MEDICAL CONDITION], abnormal labs and a decrease in urination with the following interventions in place: notify physician of resident status change, serve extra fluids with meals, monitor labs, provide medications as ordered, and monitor skin, eyes and report any changes to the MD promptly. A review of Resident #11 Physician order [REDACTED]. A review of an Office visit report, dated 01/21/14, of Resident #11 visit to Nephrologist office, revealed Resident #11 [MEDICATION NAME] should be changed to 100 mg twice daily. Resident #11's Nurse's Note, dated 01/22/14, timed at 1:18 PM, and written by LVN A, reflected LVN A clarified the [MEDICATION NAME] order with the Nephrologist office, to give [MEDICATION NAME] 100 mg by mouth twice daily. An interview on 02/26/14 at 10:05 AM with LVN A revealed Resident #11 went to the Nephrologist on 01/21/14 and returned with new orders. She stated the nurse working the evening shift was not able to interpret the physician's handwriting and left her a note to clarify the [MEDICATION NAME] order. LVN A revealed on 01/22/14, she contacted the Nephrologist's office and was informed the order was to increase Resident #11's [MEDICATION NAME] to 100 mg twice daily. She stated she entered the medication into the computer system; however, the new order was not saved on the MARs or sent to the pharmacy to be filled; she must have forgotten to push save. She stated she checked the MAR to ensure the medication was on the MA's record and it appeared to be transferred. LVN A revealed no staff inquired why the resident's [MEDICATION NAME] was not on the medication sheet, and the resident was not provided any [MEDICATION NAME] (including the original 80 mg a day) the next seven days. The facility's 24 Hour Report, dated 01/22/14, reflected Resident #11 was to be provided [MEDICATION NAME] 100 mg twice daily, but the order was to be clarified with the Nephrologist. Resident #11's Nurse's Note, dated 01/30/14, timed at 12:16 PM and written by LVN B, reflected LVN B contacted the NP regarding the [MEDICATION NAME] order from the renal doctor, but the note did not reflect the [MEDICATION NAME] dosage, but to continue the [MEDICATION NAME]. Resident #11's Nurse's Note, dated 01/30/14 and timed at 4:00 PM, reflected her family member, who had taken the resident out on pass, called LVN B and stated she was taking the resident to the hospital due to shortness of breath. An interview on 02/28/14 at 1:20 PM with LVN B revealed on 01/30/14, Resident #11's family member asked about the resident's weight gain and then took the resident out on pass. She stated the family member called her back later and stated Resident #11 was short of breath. LVN B revealed she advised the family member to take the resident to the hospital. She stated that was when she checked Resident #11's medications and saw the resident was not being given [MEDICATION NAME] 100 mg as ordered. LVN B revealed she called the NP to clarify any orders, and to give [MEDICATION NAME] 100 mg twice daily. Resident #11's Physician Orders, dated 01/01/14 through 01/31/14, reflected to weigh the resident daily. Review of Resident #11's eMAR, dated 01/01/14 through 01/31/14, revealed on 01/22/14 her weight was 242.2 pounds, on 01/23/14 it was 252.2 pounds, on 01/28/14 it was 255.6 pounds, and on 01/30/14, the day of admission to the hospital, it was was 262.8 pounds. Review of Resident #11's MA MAR, dated 01/01/14 through 01/31/14, revealed from the evening of 01/22/14 through 01/30/14, when the resident was admitted to the hospital, she was not provided the [MEDICATION NAME] as ordered. Resident #11's hospital emergency room Records, dated 01/30/14 reflected resident was provided care for shortness of breath. The resident presented with slowly worsening volume overload and shortness of breath. Chest x-ray reflected [MEDICAL CONDITION] vascular congestion. Final assessment was resident was admitted to the hospital with [REDACTED]. The facility's Provider Investigation Report, dated 02/07/14, reflected Resident #11 was not provided [MEDICATION NAME] 100 mg twice daily as ordered by the Nephrologist on 01/21/14. The report indicated the error occurred due to the nurse not transferring the medication change to the MAR. The report reflected the nurse forgot to press save, which would have transferred the medication order to the MAR, therefore the resident did not receive [MEDICATION NAME] from 01/22/14 through 01/30/14. Further review of the Provider Investigation Report revealed the resident's weight on 01/23/14 was 252.2 pounds, on 01/28/14 and 01/29/14 her weight was 255.6 pounds, and on 01/30/14 her weight was 262.8 pounds. On 01/30/14 while Resident #11 was out on pass with her family member, she complained of shortness of breath and was taken by her family member to the hospital. Resident #11 was admitted due to [MEDICAL CONDITION]. The report reflected the facility's action taken post-investigation included: chart audit to ensure compliance, updated the resident's Care Plan and continue to monitor the resident's condition, implemented a new protocol regarding putting orders in the computer system that would prevent similar errors from reoccurring, in-serviced staff on the new procedure. The facility's current policy, "Administering Medication," dated April 2007, reflected, "Medication shall be administered in a safe and timely manner, and as prescribed... Policy Interpretation and Implementation...3. Medication must be administered in accordance with the orders, including ant required time frame...." The facility's current LTC Facility Pharmacy Services and Procedures Manual contained the policy, New Orders for Non-Controlled Substances, revised 01/01/13, which reflected, "...5. If the medication is needed before the next scheduled delivery and is not in the Emergency Medication Supply, Facility staff should: 5.1.1 Fax or transmit the order to the pharmacy. 5.1.2 Notify the pharmacy and include the exact time by which the medication is needed. 5.1.3 Facility staff should ask the pharmacist to read the order back to assure accuracy, if providing the pharmacist with a telephone order. 5.1.4 Document the following information for any necessary verbal orders or communication on the interim/telephone order form: 5.1.4.1 Date: 5.1.4.2 Time 5.1.4.3 Nurse's initials; and, 5.1.4.4 The phrase 'telephone order.'" The facility's current LTC Facility Pharmacy Services and Procedures Manual contained the policy, 4.5 Reordering, Changing, and Discontinuing Orders, revised 01/01/13, which reflected, "Applicability: This policy 4.5 sets forth procedures with respect to Facility's communication of any medication reorders, changes, or discontinuation to Pharmacy...3. Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order...Facility staff cannot alter directions on any existing prescription once it has been dispensed to the resident...3.4 Pharmacy should receive a discontinued order before a new order (that reflects a change) is filled. 3.5 If Pharmacy should receive a new order that changes the strength or dose of a medication previously ordered, and there is adequate supply on hand. 3.5.1 Pharmacy should discontinue the original order; 3.5.2 Facility Physician/prescriber should write the new order with directions and facility should enter the new order on the appropriate Medication Record forms; and...." It was determined these failures placed Resident #11 in an Immediate Jeopardy (IJ) situation from 01/23/14 through 01/30/14. A review of an updated Care Plan, dated 02/13/14, reflected resident was to be monitored for fluid volume, and notify doctor if a weight gain of three pounds in 24 hours, or five pounds in seven days. LVN A's Notice of Warning, dated 01/31/04, reflected she failed to transcribe Resident #11's order of [MEDICATION NAME] 100 mg twice daily. An In-Service Report, dated 01/31/14, reflected nurses were provided an in-service on transcribing doctor's orders. An undated In-Service Report reflected staff were in-serviced on Signs and Symptoms of [MEDICAL CONDITION]. An undated In-Service Report reflected staff were in-serviced on daily weights. The facility's Addendum to the Medication Administration Policy, effective 02/05/14, reflected the facility implemented the following Addendum to the current policy on Medication Transcription of physician's orders [REDACTED]. The nurse would also be required to transcribe the order onto the white paper sheet labeled "physician's orders [REDACTED]. The ADON would check for accuracy of the transcribed order in the Electronic Medical Record. Any inaccuracies or issues would be immediately clarified and rectified in the Electronic Medical Record. In addition, all new orders would be reviewed daily in the Daily Clinical Stand-up Meeting, as a "triple-check" of all new physicians' orders. Any inaccuracies/issues would be resolved immediately during the Daily Clinical Stand-up meeting. The facility's current undated Policy Changing an Existing Order, as part of their action plan, reflected the following: "Changing an Existing order: 1. Changing an existing order rules: ? You cannot write a new order unless you address the existing order. You must check the chart and be accurate! Doctors are changing orders based on what you tell them! ? The safest way is to discontinue the existing order and then rewrite the new order. ? This assures that the computer data base is accurate and that the pharmacy knows what the physician wants. 2. Existing order- [MEDICATION NAME] 20mg tab. 1 PO (by mouth) QD (daily) [MEDICAL CONDITION]. You want to increase the dose. Steps to follow: ? Write the following: D/C (discontinue) [MEDICATION NAME] 20mg tab.1 PO QD Start [MEDICATION NAME] 40mg tab. 1 PO QD - Dx. (diagnosis) [MEDICAL CONDITIONS] This makes it clear that the physician wants a total daily dose of 40 mg. If you wrote just the new order, it could mean the total daily dose is 60 mg... ? Add the Systolic and Diastolic blood pressures, pulse, [MEDICAL CONDITION] check, etc. if appropriate. This doesn't require a physician order [REDACTED]. ? Place a 'change in direction' sticker on all remaining cards of medication if current supply can be used. ? Fax the order to the pharmacy. Note on the order 'Do not send' if you have a supply of the drug on hand to use. ? Enter on 24 hour report sheet. ? Verbally report to the appropriate staff the order change and reasons. ? Document appropriately in the nurse's notes...." Interview on 02/27/14 at 12:10 PM with the Administrator revealed the incident of Resident #11 not receiving her [MEDICATION NAME] occurred because LVN A failed to save the order and ensure the order was processed to the resident's MAR and to the pharmacy. She stated she felt confident the facility now had systems in place to prevent a similar occurrence. The Administrator revealed the staff was in-serviced on medication administration, the correct procedure to ensure the medication was in the computer system, on the resident's MARs and sent to the pharmacy. Interview with the DON on 02/27/14 at 12:30 PM revealed she was confident non-compliance of the medication administration and transcription incident came about related to the fact there was no system in place for the staff to confirm if the pharmacy received the physician's orders [REDACTED]. In the Quality Assurance meeting in February of 2014 the issue of medication error was discussed related to the incident of Resident #11's [MEDICATION NAME]. She stated the nurses were in-serviced on the Pharmacy process related to transmitting new orders to the pharmacy, re-order of medication and discontinuing medication and transcribing medication on the Medication Administration Record, Treatment Record and document on the 24 hour report and must document in the Nurse's Notes. She stated in the future all medication orders including new medication, a change in any medication dosage, time or discontinued medication would be reviewed in the morning meeting. The DON revealed all new employees would be trained on the Pharmacy ordering and discontinued process as well as notifying the facility's only ADON who would follow up on all medication orders to ensure the appropriate pharmacy process was implemented. She stated when residents were weighed according to the physician's orders [REDACTED]. Interview on 02/26/14 at 1:00 PM with LVN C revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and the residents' MARs. Interview on 02/26/14 at 1:02 PM with LVN A revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to pharmacy and residents' MARs. Interview on 02/27/14 at 9:45 AM with the ADON, revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to her and she followed up to ensure the order was transferred to the pharmacy and the residents' MARs. Interview on 02/27/14 at 9:50 AM with LVN E revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. Interview on 02/27/14 at 10:00 AM with LVN F revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. Interview on 02/27/14 at 1:50 PM with LVN G revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARs, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. She would check with the MA to ensure the medication was on the MAR. Interview on 02/27/14 at 2:00 PM with LVN H revealed she was in-serviced to ensure and verify new orders from the physician were transferred to the residents' MARS, and transferred to the pharmacy. She was to follow up the next day to ensure new orders were on the residents' MARs. A copy of the order was to be provided to the ADON who followed up to ensure the order was transferred to the pharmacy and residents' MARs. This was determined to be PNC Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's Form CMS-802, Roster/Sample Matrix, printed on 02/25/14, reflected 29 residents resided on Hall 100.